2009-075 Council Resolution - Laserfiche WebLink

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Total Amount Earned: Material Suitably Stored on hange Order No. 1 : Change Order No. 2 : Change Order No. 3 : Change Order No. 4 : Change Order No. 5 : Change Order No. 6 : APPLICATION FOR PAYMENT NO. 11 (Final) $480,379.70 Site, Not Incorporated into Work: $3,065.00 $132,737.07 $14,401.88 $2,811.44 $2,625.31 $(34,667.12) Original Contract Amount: $483,135.84 Change Order % Complete Change Order % Complete Change Order % Complete Change Order % Complete Change Order % Complete Change Order % Complete Gross Amount Due: Less Retainage: Amount Due to Date: Less Previous Applications: Amount Due This Application: 100% 100% 100% 100% 100% 100% $3,065.00 $132,737.07 $14,401.88 $2,811.44 $2,625.31 ($34,667.12) $604,109.42 $604,109.42 ($635,765.77) ($31,656.35) 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 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 H Response tractor COUNTY OF (/) t STATE OF Before me on this Payment and Affidaviton-be complete. ) SS day of , known to be, w of the Contractor above half of said Contractor and that all My commission expires: 1121 zoto (Date) Si74/0' � C/ - (Name and title) m , 47 _a4L PETER J. LARSON I Notary Public Minnesota My Commission Expires January 31, 2010 , 20 O9ck personally appeare y sworn did depose and say that he /she is the mentioned that he /she executed the above Application for of the state �• nts 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 Mott Hendrickson Inc. pproved by: ity of Lino Lakes (Signature) SEH By Date By Date S I3/ 0 1 (Name and Title) (Name and Title) 3535 Vadnais Center Drive St. Paul, MN 55110 Summary Page