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From <br />1. <br />2. <br />3. <br />4. <br />5. <br />a.X <br />b.X <br />c. <br />6. <br />7. <br />8. <br />9. <br />By: <br />Name: <br />Title: <br />Date:Date: <br />By: <br />Title: <br />Name: <br />Amount due this application <br />1,145,924.49$ <br />Approved by City of Little Canada <br />The undersigned Contractor certifies, to the best of its knowledge, the following: <br />(1) 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 listed in or covered by this Application <br />for Payment, will pass to Owner at time of payment free and clear of all liens, security interests, and encumbrances (except <br />such as are covered by a bond acceptable to Owner indemnifying Owner against any such liens, security interest, or <br />encumbrances); and <br />(3) All the Work covered by this Application for Payment is in accordance with the Contract Documents and is not defective. <br />Recommended by Bolton & Menk, Inc. <br />Name: <br />OMG Midwest Inc., dba Minnesota Paving & Materials <br />Contractor's Certification <br />Signature:Date: <br />Title: <br />Total Retainage (Line 5.a + Line 5.b) <br />Amount eligible to date (Line 4 - Line 5.c) <br />Less previous payments <br />5% $ 183,286.45 <br /> $ - <br />Work Completed <br />Stored Materials <br />Contractor: <br />Engineer: <br />Project: <br />22-02, 22-03, 22-04, 22-05 <br />0N1.125241 <br /> <br />N.:1 <br />City of Little Canada <br />OMG Midwest Inc., dba Minnesota <br />Paving & Materials <br />Bolton & Menk, Inc. <br />2022 Street Improvements <br />Owner's Project No.: <br />Engineer's Project No.: <br />Agency's Project No.: <br />Application Period: <br />Contract: <br />Owner: <br />Balance to finish, including retainage (Line 3 - Line 4) <br />5/24/2022 <br />Application Date:5/26/2022 <br />1,329,210.94$ <br />-$ <br />183,286.45$ <br />1,329,210.94$ <br />Retainage <br />Current Contract Price (Line 1 + Line 2) <br />Net change by Change Orders <br />to <br />Original Contract Price <br />Total Work completed and materials stored to date <br />(Sum of Column G Lump Sum Total and Column J Unit Price Total) <br />5/2/2022 <br />9,164.32$ <br />-$ <br />174,122.13$ <br />9,164.32$ <br />174,122.13$ <br />EJCDC C-620 Contractor's Application for Payment <br />(c) 2018 National Society of Professional Engineers for EJCDC. All rights reserved. <br />DocuSign Envelope ID: 5D72E17F-2AF9-4804-871E-38455659CC43 <br />May 26, 2022 <br />Dan Lobello Project Manager <br />May 26, 2022 <br />Eric Seaburg <br />PM Public Works Director <br />May 26, 2022 <br />Bill Dircks