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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 />Name:Name: <br />179,624.12$ <br />Date: <br />By: <br />Title: <br />By: <br />Title: <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 for <br />Payment, will 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); <br />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 />Hydro-Klean, LLC <br />Contractor's Certification <br />Amount due this application <br />Contractor: <br />Balance to finish, including retainage (Line 3 - Line 4) <br />Date: <br />Signature: <br />Work Completed <br />Stored Materials <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% $ 53,849.60 <br /> $ - <br />2,692.48$ <br />-$ <br />51,157.12$ <br />2,692.48$ <br />51,157.12$ <br />Contractor: <br />Engineer: <br />Project: <br />0C1.127373 <br />Contractor's Application for Payment <br />Application No.:1 <br />City of Little Canada <br />Hydro-Klean, LLC <br />Bolton & Menk, Inc. <br />2022 Sewer Lining Project <br />Owner's Project No.: <br />Engineer's Project No.: <br />Agency's Project No.: <br />Application Period: <br />Contract: <br />Owner: <br />8/1/2022 <br />Application Date:8/10/2022 <br />233,473.72$ <br />-$ Net change by Change Orders <br />7/1/2022 to <br />Original Contract Price <br />53,849.60$ <br />233,473.72$ <br />Retainage <br />Current Contract Price (Line 1 + Line 2) <br />Total Work completed and materials stored to date <br />(Sum of Column G Lump Sum Total and Column J Unit Price Total) <br />Date: <br />Title: <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: 8B3F47DB-96E0-48E7-A412-77BC7CB02240 <br />Accounts Receivable Coordinator <br />August 10, 2022 <br />Amber Ogren <br />Mitch Hoeft <br />Project Manager <br />August 10, 2022 <br />Bill Dircks <br />August 10, 2022 <br />Public Works Director