12/20/2004 Council Packet - Laserfiche WebLink

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APPLICATION FOR PAYMENT - Continued Total Contract Amount $289,920.01 Total Amount Earned $288,018.17 Material Suitably Stored on Site, Not Incorporated into Work $0.00 Contract Change Order No. _ Percent Complete $0.00 Contract Change Order No. _ Percent Complete _ $0.00 Contract Change Order No. _ Percent Complete $0.00 GROSS AMOUNT DUB $288,018.17 LESS 0% RETAINAGE $0.00 AMOUNT DUE TO DATE $288,018.17 I PAS PREVIOUS APPLICATIONS (5271,189.06) AMOUNT DUE THIS APPLICATION $16,829.11 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, Black Duck Pumping Station, City of Lino Lakes, Minnesota, and (2) aII material and equipment incorporated in said Project or otherwise listed in or covered by this Application for Payment and free and clear of all liens, claims, security interests and encumbrances. Date 103 , C 20 0 COUNTY OF STATE OF ) SS .B Northdale Construction (Name) Before me on this / 7 clay of I L6 I,itAlt-li••ai . 20 f'a . personally appeare&L/t(Y -LU known to be, who being duly swan did depose and say that he/she is the owner of the Contractor above mentioned that he/she executed the above Application for Payment and Affidavit on behalf of said Contractor, and that all of the statements contained therein are true, correct and complete. • A-I 1 /7 My commission experts: _ /,z,. Petra ■ c • Cfr LA.GEUEY • .: ,.- ��jc -M NNESOTh •,:y ,,: ».C: ^ires Jan. 31,4007 ■ 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 by all prior Applications for Payment. In accordance with the Contract, the undersigned recommends approval of payment to the Contractor for the amount due. SEH 3535 V ednals Center Drive SHORT ELLIOTT HENDRICKSON, INC. By . S �'e�a vri Daze Nov. 17, 2.00y SI - 5 8 -innosota 55110 Surranary Page