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Application for Payment (continued)
<br />Total Contract Amount $ 6,671,414.00
<br />Contract Change Order No.
<br />Contract Change Order No,
<br />Contract Change Order No.
<br />Contract Change Order No.
<br />AFP No, 1:
<br />AFP No, 2:
<br />AFP No. 3:
<br />AFP No. 4:
<br />AFP No. 5:
<br />1 $130,116.38
<br />2 $141,608.93
<br />3 $124,765.45
<br />4 $88,998.37
<br />Total Contract with Chabge Orders
<br />Less Previous Applications:
<br />$735,690.78
<br />$2,136,706.33
<br />$1,234,000.14
<br />$696,347,59
<br />$876,170.98
<br />AFP No. 6:
<br />AFP No. 7:
<br />AFP No. 8:
<br />AFP No. 9:
<br />$7,156,903.13
<br />627,558.75
<br />503, 712.89
<br />Total Amount Earned
<br />Material Suitably Stored on Site, Not
<br />Incorporated into Work
<br />Percent Complete
<br />Percent Complete
<br />Percent Complete
<br />Percent Complete
<br />GROSS AMOUNT DUE
<br />LESS 1 % RETAINAGE
<br />AMOUNT DUE TO DATE
<br />LESS PREVIOUS APPLICATIONS
<br />AMOUNT DUE THIS APPLICATION
<br />$ 7,178,231.10
<br />$ 7,178,231.10
<br />$ 71,782,31
<br />$ 7,106,448.79
<br />$ 6,810,187.45
<br />$ 296,261.34
<br />CONTRACTOR'S AFFIDAVIT
<br />The undersigned Contractor hereby swears under penalty of perjury that (1) all previous progress payments received from the
<br />Owner on account of work performed under the Contract referred to above have been applied by the undersigned to discharge in
<br />full all obligations of the undersigned incurred in connection with work covered by prior Applications for
<br />Payment under said contract, Water Treatment Plant Trunk Water Main Improvements, City of Ramsey, MN and (2) all material
<br />and equipment Incorporated In said Project or otherwise listed in or covered by this Application for Payment and free and clear of
<br />all liens, claims, security interests and encumbrances,
<br />Date �)2)
<br />COUNTY OF tJJ(4N-E.
<br />STATE OF InifIrvcADD
<br />, 20 Northdate Construction Co., Inc.
<br />(Contractor)
<br />By 7 l C(/)(' (11.4v1=6'(� /) (inn I)) A'l(ctlre910_1'
<br />SS (Name and Title)
<br />Before me on this 2144" day of 1,A002-mbe.r , 20 21- personally appeared
<br />t'i Lr if t=00 loci known to be, who being duly sworn did depose and say
<br />that he is the O.drrki r 17r6j. Mo�a�oe.( (office) of the Contractor above mentioned that he executed the above
<br />Application for Payment and Affidavit on behalf of said Contractor; and that all of the statements contained therein are true,
<br />correct and complete.
<br />,.0�"1;.1, KRISTINE R CHRISTENSON
<br />1d' v =�o
<br />., Notary Public
<br />My Commission expiresMinnesota
<br />My Commission Expires ,
<br />Jan 31, 2029
<br />2 C tin3cr
<br />(Notary Public)
<br />The undersigned has checked the on actors pp icaticn or ayment shown above. A part of this Application is the
<br />Contractor's Affidavit stating that all previous payments to him under this contract have been applied by him to discharge in full all
<br />of his obligations in connecting with the work by all prior Applications for Payment.
<br />In accordance with the Contract, the undersigned recommends approval of payment to the Contractor for the Amount due.
<br />By
<br />City of Ramsey, MN
<br />161.4,1
<br />Date tZs3 2c>2cj
<br />Short Elliott Hendrickson Inc.
<br />By
<br />Dave Hutton, PE (Lic. MN, ND, WI)
<br />Date 11/26/2024
<br />Page 4 of 4
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