03/13/2000 Council Packet - Laserfiche WebLink

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Application For Payment - continued Total Contract Amount: $ 1.787 810 00 Total Amount Earned $ /7/7/,5-"Y,(k i "'Material Suitably Stored on Site, Not Incorporated into Work $ Contract Change Order No. Percent Complete $ Contract Change Order No. Percent Complete $ Contract Change Order No. Percent Complete $ GROSS AMOUNT DUE $ LESS 0 % RETAINAGE $ AMOUNT DUE TO DATE $ s c, /7,?/0 'ifUc� LESS PREVIOUS APPLICATION $ AMOUNT DUE THIS APPLICATION Contractor's Affidavit The undersigned Contractor hereby swears under penalty of perjury that (1) all previous progress payments received from the Owner on account of work performed under the contract referred to above have been applied by the undersigned to discharge in full all obligations of the undersigned incurred in connection with work covered by prior Applications for Payment under said contract, and (2) all materials and equipment incorporated in said Project or otherwise listed in or covered by this Application for Payment are free and clear of all liens, claims, security interests and encumbrances. Dated / 19 i7 Dresel Contracting Inc. COUNTY OF 1/-cV.dee STATE OF SS (Contractor) By: /..e (Name and Title) Before me oo this 14 . day of , 19 i personally appeared /2a''- . kn n to me, who being my sworn, did depose and say that he is the of the Contractor mentioned above; that he executed the above Application for (Office) Payment , is Al'•.VI .p correct a My Com half aid Contractor; and that all of the statements contained therein are true, IetHERYL BENaTSON NOTARY PUBLIC - MINNESOTA 1IltEAran. Exp. Jan. 31, 20001 (Notary Pu ) The undersigned has checked the Contractor's Application for Payment shown above. A part of this Application is the Contractor's Affidavit stating that all previous payments to him under this'Contract have been applied by him to discharge in full all of his obligations in connection with the work covered by all prior Applications for Payment. In accordance with the Contract, the undersigned approves payment to the Contractor of the Amount Due. • Date By Page 4 of 4 LINOL9716.02 SHORT E TT HENDRICKSON INC.