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OMG Midwest, Inc. Minnesota Paving & Materials <br />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:Eric Seaburg Name: <br />Date: <br />Title: <br />1,706,334.35$ <br />1,705,430.86$ <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 />10/31/2023 <br />Application Date:11/1/2023 <br />1,618,064.22$ <br />87,366.64$ Net change by Change Orders <br />9/29/2023 to <br />Original Contract Price <br />Contractor's Application for Payment <br />Application No.:6 <br />City of Little Canada <br />Bolton & Menk, Inc. <br />Twin Lake Boulevard Improvements <br />Owner's Project No.: <br />Engineer's Project No.: <br />Application Period: <br />Contract: <br />Owner: <br />Contractor: <br />Engineer: <br />Project: <br />23-04 <br />0N1.125376 <br /> $ 1,706,334.35 <br /> $ - <br />Date: <br />Principal Engineer <br />Signature: <br />OMG Midwest, Inc. dba Minnesota Paving & Materials <br />85,316.72$ <br />-$ <br />344,025.35$ <br />1,276,992.28$ <br />85,316.72$ <br />1,621,017.63$ <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% <br />Contractor's Certification <br />Amount due this application <br />Contractor: <br />Balance to finish, including retainage (Line 3 - Line 4)(903.49)$ <br />Date: <br />By: <br />Title: <br />By: <br />Title: <br />Approved by City 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 <br />for 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 />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: 8A3ECF1B-B2B5-4B94-939B-BC37027CA07D <br />Luke Tulip Project Manager <br />November 2, 2023 <br />November 2, 2023 November 2, 2023 <br />Bill Dircks <br />Public Works Director