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APPLICATION FOR PAYMENT - Continued <br />*Total Contract Amount $289,920.01 Total Amount Earned $288,018.17 <br />Material Suitably Stored on Site, Not Incorporated into Work $0.00 <br />Contract Change Order No. _ Percent Complete $0.00 <br />Contract Change Order No. _ Percent Complete $0.00 <br />Contract Change Order No. _ Percent Complete $0.00 <br />GROSS AMOUNT DUE $288,018.17 <br />LESS 0% RETAINAGE $0.00 <br />AMOUNT DUE TO DATE $288,018.17 <br />LESS PREVIOUS APPLICATIONS ($271,189.06) <br />AMOUNT DUE THIS APPLICATION $16,829.11 <br />CONTRACTOR'S Ali r1DAVIT <br />The undersigned Contractor hereby swears under penalty of perjury that (1) all previous progress payments received from the <br />Owner on account of work performed under the Contract referred to above have been applied by the undersigned to discharge <br />in full all obligations of the undersigned incurred in connection with work covered by prior Applications for Payment under <br />said contract, Black Duck Pumping Station, City of Lino Lakes, Minnesota, and (2) all material and equipment incorporated <br />in said Project or otherwise listed in or covered by this Application for Payment and free and clear of all liens, claims, <br />security interests and encumbrances. <br />Date <br />',COUNTY OF <br />STATE OF <br />20 6 4 <br />Northdale Construction Company, Inc. <br />By _a-� -- <br />CuL <br />(Name) <br />(Title) <br />Before me on this / ( day of i - ' i'YL_Ii.. 'L' , 20 ()a , personally appeared, lttp) Cc U <br />known to be, who being duly sworn did depose and say that he/she is the owner of the Contractor above mentioned that <br />he/she executed the above Application for Payment and Affidavit on behalf of said Contractor, and that all of the statements <br />contained therein are true, correct and complete. <br />My commission expires: <br />113i)oq <br />d rmn,nnA AA.JAAWn <br />A. GELLEY <br />`"," 1 , . .. t IC- MINNESOTA <br />9.;./•, 1 ;;!res Jan.31, 2007 <br />112 VVVONYVV,ANWWvv•VVVVVVV.11 <br />(Notary Public) <br />The undersigned has checked the Contractor's Application for Payment shown above. A part of this Application is the <br />Contractor's Affidavit stating that all previous payments to him under this contract have been applied by him to discharge in <br />full all of his obligations in connection with the work by all prior Applications for Payment. <br />In accordance with the Contract, the undersigned recommends approval of payment to the Contractor for the amount due. <br />• <br />SEH <br />3535 Vadnais Center Drive <br />SHORT ELLIOTT HENDRICKSON, INC. <br />By te• ets <br />Date <br />/VoV /7, •o11 <br />St - 5 8 - Iinnesota 55110 Summary Page <br />