10/26/2009 Council Packet - Laserfiche WebLink

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APPLICATION FOR PAYMENT NO. 11 (Final) STotal Amount Earned: $480,379.70 Material Suitably Stored on Site, Not Incorporated into Worlc Change Order No. Change Order No. Change Order No. Change Order No. Change Order No. Change Order No. 1: 2: 3: 4: 5: 6: $3,065.00 $132,737.07 $14,401.88 $2,811.44 $2,62531 $(34,667.12) Original Contract Amount: $483,135.84 Change Order % Complete 100% $3,065.00 Change Order % Complete 100% $132,737.07 Change Order % Complete 100% $14,401.88 Change Order % Complete 100% $2,811.44 Change Order % Complete 100% $2,62531 Change Order % Complete 100% ($34,667.12) Gross Amount Due: $604,109.42 Less Retain age: Amount Due to Date: $604,109.42 Less Previous Applications: ($635,765.77) Amount Due This Application: ($31,656.35) CONTRACTOR'S AleHDAVIT 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 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 2 Street Lighting COUNTY OF k) C 11I,.t N STATE OFv-saa"' Before me on this Payment andVAvrfiZrZb complete. ) SS day of , known to be, w. o . e of the Contractor above ehalf of said Contractor and that all z✓ My commission expires: 11211 zoio /7 (Date) S,74, 6/4-ev- (Name and 1 ine) O -00A_ PETER J. CARSON ► Notary Public ► Minnesota My Commission Expires January 31, 2010 ► , 20 0ck personally appease d y sworn did depose and say that he/she is the mentioned that he/she executed the above Application for of the sta is contained therein are true, correct, and (Notary Public) 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 all of his/her obligations in connection with the work by all prior Applications for Payment. Sho I'oft Hendrickson Inc. (S pproved by City of Lino Lakes (Signature) By Date By ` 0* M D- J Ri. r`l cs P tcti-.- (Name and Title) S 1 1 Date -75- 3535 Vadnais Center Drive (Name and Title)