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tc'1 <br />I <br />Contractor's Application for Payment <br />Owner: City of Ramsey <br />Engineer: Bolton & Menk, Inc. <br />Contractor: Dave Perkins Contracting, Inc. <br />Project: Oickenson's Mississippi Estates Reconstruction <br />Contract: <br />Application No.: 3 <br />Application Period: From <br />Owner's Project No.: C.P. 25-04 <br />Engineer's Project No.: 24X.135503 <br />Agency's Project No.: <br />Application Date: 10/9/2025 <br />9/1/2025 to 9/30/2025 <br />1. Original Contract Price $ <br />2. Net change by Change Orders $ <br />3. Current Contract Price {Line 1 + Line 2) $ <br />4. Total Work completed and materials stored to date <br />(Sum of Column G Lump Sum Total and Column J Unit Price Total) $ <br />5. Retainage <br />a. 5% X $ 576,081,33 Work Completed $ <br />b. X $ - Stored Materials $ <br />c. Total Retainage (Line 5.a + Line 5.b) $ 28,804.07 <br />6. Amount eligible to date (Line 4 - Line 5.c) $ 547,277.26 <br />7. Less previous payments $ 259,976.12 <br />8. Amount due this application 287,301.14 <br />9. Balance to finish, including retainage (Line 3 - Line 4) $ 103,112.91 <br />Contractor's Certification <br />The undersigned Contractor certifies, to the best of its knowledge, the following: <br />(i) All previous progress payments received from Owner on account of Work done under the Contract have been applied on <br />account to discharge Contractor's legitimate obligations incurred in connection with the Work covered by prior Applications for <br />Payment; <br />(2) Title to all Work, materials and equipment incorporated in said Work, or otherwise fisted in or covered by this Application for <br />aPayment, wild pass to Owner at time of payment free and clear of all liens, security interests, and encumbrances (except such as <br />are covered by a bond acceptable to Owner indemnifying Owner against any such liens, security interest, or encumbrances); and <br />(3) Ali the Work covered by this Application for Payment is in accordance with the Contract Documents and is not defective, <br />Contractor: Darkins "qtracting, Inc. <br />Signature: <br />Name: <br />Recommended by Bolton & Menk, Inc. <br />Name: Zach Lingl P <br />Title: Project Manager <br />Date: 10/9J2025 <br />Date: <br />Title: <br />Approved by City of Ramsey <br />By: <br />Narne: <br />Title: <br />Date: <br />672,350.11 <br />6,844.13 <br />679,194.24 <br />576,081.33 <br />28,804.07 <br />1�—;W--;►.5 <br />kt,L-(t <br />EJCDC C-620 Contractor's Application for Payment <br />(c) 2018 National Society of Professional Engineers for EJCOC, All rights reserved <br />