07-12-2023 Council Packet - Laserfiche WebLink

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From 1. 2. 3. 4. 5. a. X b. X c. 6. 7. 8. 9. Name:Eric Seaburg Name: Date: Title: 41,440.00$ 1,664,371.72$ Retainage Current Contract Price (Line 1 + Line 2) Total Work completed and materials stored to date (Sum of Column G Lump Sum Total and Column J Unit Price Total) 6/30/2023 Application Date:7/5/2023 1,618,064.22$ 46,307.50$ Net change by Change Orders 6/1/2023 to Original Contract Price Contractor's Application for Payment Application No.:1 City of Little Canada OMG Midwest, Inc. Minnesota Paving & Materials Bolton & Menk, Inc. Twin Lake Boulevard Improvements Owner's Project No.: Engineer's Project No.: Agency's Project No.: Application Period: Contract: Owner: Contractor: Engineer: Project: 23-04 0N1.125376 2,072.00$ -$ 39,368.00$ 2,072.00$ 39,368.00$ Work Completed Stored Materials Total Retainage (Line 5.a + Line 5.b) Amount eligible to date (Line 4 - Line 5.c) Less previous payments 5% $ 41,440.00 $ - Date: Principal Engineer Signature: OMG Midwest, Inc. dba Minnesota Paving & Materials Contractor's Certification Amount due this application Contractor: Balance to finish, including retainage (Line 3 - Line 4) 1,622,931.72$ Date: By: Title: By: Title: Approved by City Little Canada The undersigned Contractor certifies, to the best of its knowledge, the following: (1) All previous progress payments received from Owner on account of Work done under the Contract have been applied on account to discharge Contractor's legitimate obligations incurred in connection with the Work covered by prior Applications for Payment; (2) Title to all Work, materials and equipment incorporated in said Work, or otherwise listed in or covered by this Application for Payment, will pass to Owner at time of payment free and clear of all liens, security interests, and encumbrances (except such as are covered by a bond acceptable to Owner indemnifying Owner against any such liens, security interest, or encumbrances); and (3) All the Work covered by this Application for Payment is in accordance with the Contract Documents and is not defective. Recommended by Bolton & Menk, Inc. Name: EJCDC C-620 Contractor's Application for Payment (c) 2018 National Society of Professional Engineers for EJCDC. All rights reserved. DocuSign Envelope ID: 62EB781B-4474-4B9B-B6F8-972E47F901F6 Project ManagerLuke Tulip July 6, 2023 July 6, 2023 Bill Dircks July 6, 2023 Public Works Director