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APPLICATION FOR PAYMENT - Continued <br /> <br />Total Contract Amount $173,237.44 <br />Material Suitably Stored on Site, Not Incorporated into Work <br />.Contract Change Order Nol 1 $1,243.84 <br />Contract Change Order No. $816.00 <br />Contract Change Order No. <br /> <br />Total Amount Earned <br /> <br />Percent Complete - 100% <br /> <br />Percent Complete - 100% <br /> <br />Percent Complete <br /> <br />GROSS AMOUNT DUE <br /> <br />LESS 5% RETAINAGE <br /> <br />AMOUNT DUE TO DATE <br /> <br />LESS PREVIOUS APPLICATIONS <br /> <br />AMOUNT DUE THIS APPLICATION <br /> <br />$ 161,315.t~° <br /> <br />$0.00 <br />$t,243.84 <br />$816.00 <br />$0.00 <br /> <br />$ 163,375.?~?¥ <br /> <br />$8,168.79 <br /> <br />$155,206~_~.qff' <br /> <br />86,155.59 <br /> <br />$69,051.3'43b <br /> <br /> CONTRACTOR'S AFFIDAVIT <br />The undersig-ned Contractor hereby swears under penalty of perj uxy that (i) all previous progress payments received from the Owner on <br />account of work performed under the Contract referred to above have been applied by the undersigned to discharge in full all obligations <br />' of the undersig-ned incurred in connection with work covered by prior Applications for Payment under said contract, TH 61/10th Street <br />Intersection Improvements, Hastings, Minnesota, and (2) all material and equipment ingorporated in sm'd Project or otherwise listed in <br />or covered by this Application for Payment and free and clear of all liens, claims, security interests and encumbrances. <br /> <br />Date December 9, 2003 <br /> <br />COUNTY OF Durra ) <br /> ) ss <br />STATE OF Wisconsin ) <br /> <br /> Pember Excavating,, Inc. <br /> <br />pr~, e~ct Manager <br /> (Name and Tide) <br /> <br /> ~ A~.-CtZ-e.- ~'-'~.'"'~ , known to <br />Before me on this 6~ day of ~,,,~---'----~ , 20 )~ , personally appeared <br />be, who being duly sworn did depose and say that he/she is the owner of the Contractor above mentioned that he/she executed the above <br />Application for Payment and Affidavit on behalf of said Contractor; and that all of the statements contained therein are true, co,oct and <br /> <br />My commission expires: ~ <br /> <br />The undersigned has checked the Contractor's Application for Payment shown above. A part of this Application is the Contractor's <br />Affidavit stating that all previous payments to him un'der this contract have been applied by him to discharge in full all of his obligations <br />in connection with the work by all prior Application~ for Payment. <br /> <br />In accordance with the Contract, the undersigned reconunends approval of payment to the Contractor for the amount due. <br /> <br />SHO.~,~,~IOTT~~ON, INC. <br /> <br />3535 Vadnais Center Drive <br /> <br />St. Paul, Minnesota 55110 <br /> <br />Summary Page <br /> <br /> <br />