02/23/1998 Council Packet - Laserfiche WebLink

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Application For Payment - Partial Payment Number 2 Project: LAURENE AVENUE LIFT STATION MODIFICATIONS City of Lino Lakes Contractor: Great Western Corporation 8101 Scandia Trail Forest Lake, Minnesota 55025 Work Started: Work Completed: Material Suitably Stored on Site, Not Incorporated into Work Contract Change Order No. Contract Change Order No. Contract Change Order No. Total Contract Amount Total Amount Earned Percent Complete Percent Complete Percent Complete GROSS AMOUNT DUE LESS 5% RETAINAGE AMOUNT DUE TO DATE $51,052.00 $42,094.00 $0.00 $0.00 $0.00 $0.00 $42,094.00 $2,104.70 $39,989.30 LESS PREVIOUS APPLICATION $14,139.80 AMOUNT DUE THIS APPLICATION $25,849.50 v 4 osio- 406-cjCO <A( Contractors 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 refereed 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 Application 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 COUNTY OF STATE OF (Contractor) By: (Name and Title) Before me on this day of , 19 personally appeared known to me, who being duly sworn, did depose and say that he is the of the Contractor mentioned above: that he executed th above Application for Payment and Affidavit on behalf of said Contractor; and that all of the statements contained therein are true, correct and complete. My Commission Expires: (Notary Public) The undersigned has checked the Contractor's Application For Payment shown above. We hereby recommend payment of this voucher Signed: ' `��/ J ,i/, ' /L ' Signed: Construction Obsdrver City Engineer