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APPLICATION FOR PAYMENT NO. 14 (Final) <br />Original Contract Amount: $1,549,732.38 <br />vvlaterial Suitably Stored on Site, Not Incorporated into Work: <br />Change Order No. _1_ : $27,419.41 <br />Change Order No. _2_ $8,503.90 <br />Change Order No. <br />Total Amount Earned: $1,545,808.04 <br />Change Order % Complete 100% <br />Change Order % Complete 100% <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 />$27,419.41 <br />$8,503.90 <br />$1,581,731.35 <br />$1,581,731.35 <br />($1,486,155.49) <br />$95,575.86 <br />CONTRACTOR'S AFFIDAVIT <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: Legacy at Woods Edge - Phase 3 Streetscape, Planting and Irrigation Plans <br />Jay Bros., Inc. <br />(Contractor) <br />COUNTY OF <br />STATE OF 1�. <br />) SS <br />3- 10 — Oct <br />(Date) <br />(Name and Title) <br />Before me on this »� ` day of 14 00ielti , 20 0 cl personally appeared <br />M: CI- V. 4 ,e, l amy. , known to be, who being duly sworn did depose and say that he /she is the <br />C� E. ) / of the Contractor above mentioned that he /she executed the above Application for <br />Payment and Affidavit on behalf of said Contractor and that all of the statements contained therein are true, correct, and <br />complete. <br />My commission expires: 1 --6 \ -C) i C5 <br />RUTH A. HOGLUND <br />(No <br />My Commission Expires 1 -31 -2010 <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 full all of his/her obligations in connection with the work by all prior Applications for Payment. <br />Short Elliott Hendrickson Inc. <br />Approved by: <br />.ity of Lino L,p <br />(Signature <br />(Signature) <br />By <br />Date <br />By <br />Date <br />U S Prig AA /-5 0 <br />(Name and Title) <br />PR/ Jc4 PAL_ <br />AA, C (glue ( /44 6-"C hwl� e.1) <br />sit /(,)7 <br />3535 Vadnais Center Drive <br />1 t Paul MN SS1111 <br />(Name and Title) <br />Summary Page <br />