2009 12-15 CCP - Laserfiche WebLink

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Application for Payment (continued) AFP No, 1: AFP No. 2: AFP No: 3: AFP No. 4: AFP No. 5: Total Cvntraet Amount. $ 138,603:10: Contract ChangeOrder No. Contract Change Order No. Contract Change Order No, Less Previous Applications: 148,399.74 1 AFP No. 6: AFP No. 7: AFP No. 8: AFP No..9: Total Amount Earned Material Suitably Stored on Site, Not Incorporated :into Work Percent Complete 100 Percent Complete 100 Percent Complete GROSS AMOUNT DUE LB.SS 0 % RETAINAGE AMOUNT DUE TO DATE LESS PREV IOUS APPLICATIONS. AMOUNT DUE THIS APPLICATION: 146,281.90 0 $3,099.64 87,386.75 $ 156,768.25 $ 0.00 $: 156,768.25 $ 148,399.74 $. 8,368.51 CONTRACTOR'S AFFIDAVIT The undersigned Contractor hereby swears under penalty of perjury that (1) all previous progress payments received from the Owner. on account of work performed under the Contract referred to above have been applied by the undersigned to discharge in full all obligations of the undersigned incurred in connection with work covered by prior. Applications for Payment under said contract, Scheuneman Road Improvements, Gem Lake, Minnesota, and (2) all material and equipment incorporated in. said Project or Otherwise listedin or covered by this Application for Payment and free and clear of al! liens, claims, security interests and encumbrances. Date COUNTY OF Ar i ��.� STATE OF t Before tneonthis ao day of r- - is the Payment an My Co �O Livy The undel i-ee i l c$ ck ra or: p wagon for Payment shown above. A part of this Application is the Contractor's Affidavit stating: that all previous payments to him under this contract have been applied by him to discharge in full all of his. obligations in connecting withthe work by all prior Applications for Payment. I JR7 J 20 ) SS By T.A. Schifsky & Sons, Inc. (Contractor) ?eV,et: MAnagee (Name an 'Ale) `J , 20�, personally appeared known to be, who being duly sworn did depose and say that he (office) of the Contractor above nientioned that he executedthe above Application for and that all of the statements contained therein are true, correct: and complete. iorie {l ry Public) G Y R TZER: P1 Tr N OTA MY COMMISSION EXPIRES JN'IUAP.Y.31, 2010. In.accordance with the. Contract, the undersigned recommends approval of paymcntto the Contractor for: the Amount due. Sh ortn.Elliott. Hendrickson Inc. By e .44) c(cY) Date fo" 1471CJ7 City of Gem Lake, Minnesota By Date Page a of 3.