08-09-2023 Council Packet - Laserfiche WebLink

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OMG Midwest, Inc. dba. Minnesota Paving & Materials From 1. 2. 3. 4. 5. a.X b.X c. 6. 7. 8. 9. Signature:Signature: Name:Name: Date: Title:Title: Approved by City of Little CanadaRecommended by Bolton & Menk, Inc. Date: Amount due this application Contractor: Balance to finish, including retainage (Line 3 - Line 4)49,456.93$ 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. Name: Signature: OMG Midwest, Inc. dba. Minnesota Paving & Materials Contractor's Certification Date: Title: Less previous payments 5% $ 783,645.24 $ - Work Completed Stored Materials Total Retainage (Line 5.a + Line 5.b) Amount eligible to date (Line 4 - Line 5.c) Contractor: Engineer: Project: 23-01, 23-02, 23-03, 23-05 0N1.127995 Contractor's Application for Payment Application No.:3 City of Little Canada Bolton & Menk, Inc. 2023 Street Improvements Owner's Project No.: Engineer's Project No.: Agency's Project No.: Application Period: Contract: Owner: 7/31/2023 Application Date:7/31/2023 833,102.17$ -$ Net change by Change Orders 7/1/2023 to Original Contract Price 833,102.17$ 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) 783,645.24$ 39,182.26$ -$ 303,404.11$ 441,058.87$ 39,182.26$ 744,462.98$ EJCDC C-620 Contractor's Application for Payment (c) 2018 National Society of Professional Engineers for EJCDC. All rights reserved. DocuSign Envelope ID: C994DA10-F5B2-401B-A955-E395C1A77BBC Luke Tulip Project Manager August 1, 2023 PM August 1, 2023 Eric Seaburg Bill Dircks August 1, 2023 Public Works Director