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To (Owner): City <br />Application for Payment <br />Facility Improvements 2014 <br />Change Order Summary <br />Application Period To, <br />From (Contractor): Rice Lake <br />Contract: All Construction <br />Contractor's Project No.: 1422 <br />Approved Change Orders <br />Number Additions Deductions <br />1 $ 259,991.59 <br />TOTALS <br />$259,991.59 $0.00 <br />NET CHANGE BY <br />CHANGE ORDERS $259,991.59 <br />Contractor's Application For Payment No. 14 <br />1/1/2016 1APPlication Date: 11512016 <br />Menk, Inc. <br />t. ORIGINAL CONTRACT PRICE <br />2, Net change by Change Orders <br />3. CURRENT CONTRACT PRICE (Line 1 t 2) <br />!. TOTAL COMPLETED AND STORED TO DATE <br />(Column F on Progress Estlmata) <br />5. RETAINAGE: <br />a. 5% x $12,126,250.86 Work Completed <br />b. 50/. x $0.00 Stored Materials <br />c, Total Retainage (Line 5a + Line 5b) <br />3. AMOUNT ELIGIBLE TO DATE (Line 4 - Line 5c) <br />t. LESS PREVIOUS PAYMENTS (Line 6 from prior Application) <br />3. AMOUNT DUE THIS APPLICATION <br />il. BALANCE TO FINISH, PLUS RETAINAGE <br />(Column G on Progress Estimate + Line 5 above) <br />Contractor's Certification <br />The undersigned Contractor certifies that (1) all previous progress <br />Payment of <br />payments received from Owner on account of Work done under the <br />Contract have been applied nn account to discharge Contractors <br />legitimate obligations incurred in connection with Work covered by prior <br />Applications for Payment; (2) title of al Work, materials and equ}pment <br />is recommended by - <br />incorporated in said Work or otherwise listed in or covered by this <br />Appiicatron for Payment wi@ pass to Owner at time of payment free and <br />clear of all Liens, security interests and encumbrances (except such as are <br />covered by a Bond acceptable to Owner indemnifying Owner against any <br />such Liens. security interest or encumbrances), and (3) 2tl Work covered <br />Payment of: <br />by this Application for Payment is in accordance with the Contract <br />Documents and is not defective. <br />is approved by: <br />Approved by <br />$322,886.00 <br />(Line 8 or other - attach explanation of other amount) <br />(Engineer) <br />$322,886.00 <br />(Line 8 or other - attach explanation of other amount) <br />(Finance Director) <br />Funding Agency (if applicable) <br />rJCDC No. C-620 (2oo2 P.ditian) <br />