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Original Contract Amount: <br />Change Order No. _ <br />Change Order No. _ <br />Change Order No. <br />APPLICATION FOR PAYMENT NO. 2 (FINAL) <br />$99,585.15 <br />Total Amount Earned: <br />Change Order % Complete <br />Change Order % Complete <br />Change Order % Complete <br />Gross Amount Due: <br />Less Retainage: <br />Amount Due to Date: <br />Less Previous Applications: <br />Amount Due This Application: <br />$93,282.31 <br />$93,2823 1 <br />($79,318.92) <br />$13,963.39 <br />CONTRACTOR'S A}FWAVIT <br />The undersigned Contractor hereby swears under penalty of perjury that (1) all previous progress payments received from <br />the Owner on account of work performed under the Contract referred heretofore have been applied by the undersigned to <br />discharge in full all obligations of the undersigned incurred in connection with work covered by prior Applications for <br />Payment under said contract (indicated below), and (2) all material and equipment incorporated in said Project or otherwise <br />listed in or covered by this Application for Payment and free and clear of all liens, claims, security interests and encumbrances. <br />Contract for Lino Lakes Regional Trail <br />W.B. Miller Inc. <br />STATE OF irr.e r+&... <br />Qom' <br />) <br />) SS <br />) <br />q - <br />(Date) <br />1 E /- icaI1'l PCZ EsiDE4 <br />(Name and litie) <br />n Before me on this day of J ci r1 , 20 b $ personally appeared <br />U.49 4-kol,,- , /mown to be, who bern duly sworn did depose and say that he/she is the <br />'--Pi,,.,r tetc o( of the Contractor above mentioned that he /she executed the above Application for <br />Payment and Affidavit on behalf of said . i m , or and that all of the statements contained therein are true, correct, and <br />comp/ <br />LINDA HOLM <br />on ekiliglltic - rntesota <br />My Commission Wes 01 -31 -2010 <br />Y=.21.r:::Li-i..--e <br />(Notary Public) <br />• <br />The undersigned has checked the Contractor's Application for Payment shown above. A part of this Application is <br />the Contractor's Affidavit stating that all previous payments to him/her under this contract have been applied by him/her to <br />discharge in frill all of his/her obligations in connection with the work by all prior Applications for Payment. <br />Short Elliott Hendrickson Inc. <br />(signature) <br />Approved by <br />City of Lino Lakes <br />(Signature) <br />SEH <br />By <br />Date <br />By <br />Date <br />(Name and Title) <br />(Name and Title) <br />• <br />3535 VadpCenter Drive <br />St. Pa N 55110 Summary Page <br />