09/22/2008 Council Packet - Laserfiche WebLink

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APPLIC TION FOR PAYMENT NO. 10 (FINAL) Original Contract Amount $2,231,503.85 Material Suitably Stored on Site, Not Incorporated into Work Change Order No. 1 Change Order No. 2 Change Order No. 3 Change Order-No. 4 $385,410.00 $8,470.00 $6,300.00 $10,600.98 Total Amount Earned: CO Percent Complete: 100% CO Percent Complete: 100% CO Percent Complete: 100% CO Percent Complete: 100% Gross Amount Due: Less Retainage: Amount Due to Date: Less Previous Applications Amount Due This Application: $2,151,563.43 $385,410.00 $8,470.00 $6,300.00 $10,601.98 $2,562,344.41 $2,562,344.41 ($2,416,751.27) $145,593.14 CONTRACTOR'S AFFIDAVIT The undersigned Contractor hereby swears under penalty of perjury that (I) all previous progress payment received from the Owneron account of work performed under the Contract referred heretofore 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 (indicated below), and (2) all 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. Contract For. Legacy at Woods Edge - Phase 1 Lino Lakes, Minnesota lens Rebbein Companies (Contracl (ignatmre) COUNTY O ) SS STATE OF,z2•C) �-� Before me on this day of _ o , known to be, ' +o 'ern art} M 4 nee ei1..c� of the Contractor above aytent and Affidavit on behalf of said Contractor and that ail complete. g- (8 -o8 (Date) 7AUIO C . fitol (Name and 'htle) Duna J Sche Knenlerger Notary Pub Minnesota My Commission boars ,hmtuy 31,2013 My commission expires: , 20 personally appeared y sworn did dep se and say that he/she is the mentioned that he/she executed the above Application for of the statements contained therein are true, correct, and • 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/her under this contract have been applied by him/her to discharge in full•ali of his/her obligations in connection with the work by all prior Applications for Payment Short Elliott Hendrickson Inc. Wit," 1.4 LI Ii E4 _ (Signatdre) Approved by City of Lino Lakes jig S H (Signature) By Date By Date M MA o-N (Name and Title) j olvaos 1 1 (Name and Title) 3535 Vadnais Center Drive St. Paul, Minnesota 5511D Summary Page