Committee of the Whole
Regular MeetingAmery, WI · June 21, 2022
Minutes
CITY OF AMERY
COMMITTEE OF THE WHOLE PROCEEDINGS
June 21st, 2022
The Committee of the Whole of the City of Amery met on Tuesday – June 21st, 2022 at City Hall. Council President, Sarah Flanum called
the meeting to order at 5:55 P.M.
Present: Council President, Flanum; Mayor, Chad Leonard; and Alderpersons, Tim Strohbusch; Rick Van Blaricom; Mykaela Thompson;
Mike Manor and Eric Elkin.
Absent: None
Staff Present: City Administrator, Patty Bjorklund; City Clerk-Treasurer, Ben Jansen; Deputy Clerk, Taylor Larson; Police Chief, Tom
Marson; Interim Fire Chief, Chuck Frohn; Library Director, Rachel Thomas.
Staff Absent: None
Others Present: Erik Henningsgard and Jeremiah Wendt – S.E.H.
Department Head Reports – Reports were heard from Administrator, Bjorklund; Clerk-Treasurer, Jansen; Deputy Clerk, Larson; Chief,
Marson; Interim Chief, Frohn; Director, Thomas.
Waste Water Treatment Plant Upgrade Discussion – Jeremiah Wendt of S.E.H. had a Powerpoint prepared to show the Council the
current state of the Sewer Plant and the proposed upgrade including costs and design specifics. Most of the funding would be through
the Clean Water Fund Loan Program where it is anticipated additional infrastructure funding from the Feds will be coming.
Motion by Strohbusch; seconded by Elkin; to table the discussion of the Waste Water Treatment Plant until the next Committee
of the Whole Meeting.
Ayes – 6 Nays – 0 Motion Carried.
Discussion of Budget Priorities/ARPA Funding – Administrator Bjorklund began the discussion with suggestions of where the City
could use some of its ARPA funding from the Feds. She stated that she believed the installation of a bathroom at Soo Line Park and the
repair of the bathrooms at Michael Park to make them ADA compliant. Clerk-Treasurer Jansen then took the time to ask the Council to
start thinking about what priorities they would like to stress in the Budget for next year. Van Blaricom stated he would like to see a
warning siren installed downtown. Administrator Bjorklund said that one project she will have done is wayfinding signs throughout the
City.
Public Transportation Discussion – Van Blaricom asked for this to be on the agenda as he has been approached by many people
regarding the lack of public transportation within the City. He did not expect the City to fill the void but rather is hoping that by putting this
discussion in the public forum that some interested parties will hopefully step forward to fill this need.
Pay Application 3 for S. Industrial Park Project – S.E.H. has brought this forward and recommended that it be paid. This application
is for additional water and sewer lines and other materials that have gone into the project.
Motion by Leonard; seconded by Manor; to recommend Pay Application 3 to Council as presented.
Ayes – 6 Nays – 0 Motion Carried.
Strategic Planning Discussion – Strohbusch requested that this be put on the agenda as he feels like it would be a good thing for
Department Heads and Elected officials to start thinking about. Several years ago the City did a similar training which helped facilitate
discussion and identified everyone’s role within the City. City staff was instructed to set up the training with the same group who did the
previous training.
Fire Department Capital Expenses – Several large potential expenses have come forward from the last Fire Committee meeting. Fire
Chief Frohn spoke at length during his report about the condition of Tender 2 and that he recommends taking it completely out of service.
Engine 2 will also be going in for refurbishment soon but Chief Frohn does not have solid numbers on the cost at this time but the
estimate is in excess of $100,000. Chief Frohn also informed the Council that the generator at the Fire Hall is not functioning like it is
supposed to at this time. He has an estimate from Hunt Electric of $15,000 to fix the generator and bring it up to code. Van Blaricom
stressed that the City needs to authorize the Fire Committee to make a purchase IMMEDIATELY rather than wait a month for the next
meeting as the inventory that the Fire Department needs is very fluid and sells fast.
1
Motion by Van Blaricom; seconded by Strohbusch; to recommend to Council that the Fire Committee be given the authority to
purchase a tanker truck up to a cost of $200,000. City staff will also need to start the process to get borrowing done.
Ayes – 6 Nays – 0 Motion Carried.
Public Comment – The only comment heard was from Van Blaricom stating that residents on the south end of town need
to keep up with their lawn mowing because it is extremely long.
Motion by Leonard; seconded by Strohbusch to go into Closed Session at 7:33 P.M. under Wis. Stat. §19.85(1)(c)
– Potential Police Lieutenant Position; Potential Police Administration Position; Fire Chief; Deputy Clerk-Treasurer.
Considering employment, promotion, compensation or performance evaluation data of any public employee over which the
governmental body has jurisdiction or exercises responsibility.
Roll Call Vote
Ayes – Strohbusch; Van Blaricom; Thompson, Flanum; Leonard; Manor; Elkin
Nays – None
Motion Carried.
Motion by Leonard; seconded by Thompson to reconvene into Open Session at 8:05 P.M.
Roll Call Vote
Ayes – Strohbusch; Van Blaricom; Thompson; Flanum; Leonard; Manor; Elkin.
Nays – None
Motion Carried.
Motion by Strohbusch; seconded by Van Blaricom; to name Taylor Larson as the Deputy Clerk-Treasurer.
Ayes – 6 Nays – 0 Motion Carried.
Motion by Elkin; seconded by Strohbusch; to adjourn at 8:07 P.M.
Ayes – 6 Nays – 0 Motion Carried
Respectfully Submitted,
Ben Jansen
Clerk-Treasurer
June 23rd, 2022
2
Agenda
City of Amery
COMMITTEE OF THE WHOLE AGENDA
Pursuant to Wisconsin Statutes 19.84, Notice is hereby given to the public that a meeting of the Committee of the Whole of the City
of Amery will be held on Tuesday-June 21st, 2022 at 104 Maple St. W, Amery, WI IMMEDIATELY FOLLOWING SPECIAL COUNCIL.
�� 188
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Call to Order
Roll Call
Order of AGENDA ITEMS
Items
1 Department Head Reports - City Administrator, Clerk-Treasurer, Police Chief, Fire Chief, Library Director, Director of
Public Works, Deputy Clerk-Treasurer.
2 Wastewater Treatment Plant Upgrade Discussion - S.E.H.
3 Discussion of Budget Priorities/ARPA Funding
4 Public Transportation Discussion
5 Pay Application 3 for S. Industrial Park Project
6 Strategic Planning Discussion
7 Fire Department Capital Expenses
8 Public Comment**
Closed Session - Wis. Stat. §19.85(1)(c) - Potential Police Lieutenant Position; Potential Police Administration Position;
Fire Chief; Deputy Clerk-Treasurer. Considering employment, promotion, compensation or performance evaluation data
of any public employee over which the governmental body has jurisdiction or exercises responsibility.
10
Adjournment
** Although the public may speak on any item that is not included on this agenda as a "Public Hearing or Forum". In accordance with open meeting laws, the
Committee may not respond or discuss the issue brought forward at this time. In accordance with open meeting laws the Committee must notice an item on the
agenda to allow discussion on that matter. Your comments will be considered and may be placed on a future agenda for further discussion. Any person wishing to
submit a public comment digitally may email them to cityhall@amerywi.gov until noon of the day of the meeting. Although your comments will be presented to the
Committee they may or may not be read aloud or discussed during the meeting. The Public Comment Portion will be limited to 10 minutes total for speakers present
at the meeting.
Respectfully Submitted;
Ben Jansen, MPA
City Clerk-Treasurer
**Posted: Thursday-June 16th, 2022, on the City Website (www.amerywi.gov); and at Amery City Hall, Amery Public Library, and the Amery Police Department.
The City of Amery docs not discriminate on the basis of race, color, national origin, sex, religion, age or disability in employment or provision of services,
programs or activities.
NOTE: Upon reasonable notice, the City of Amery will accommodate the needs of disabled individuals through aids or services. For additional information or
to request this service, contact the Clerk-Treasurer's office at (715) 268-7486 by Noon the previous day so that arrangements can be made.
Patty Bjorklund
City City Administrator/WCMC, CMC, CMTW
Administrator 104 South Maple St., Suite A
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Amery, WI 54001
patty.bjorklund@amerywi.gov
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www.amery.gov
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715-268-3411
Monthly Report - June 21, 2022
2023 Budget: Ben and I are working on the Budget for 2023. We would like to start Budget Meetings in July. I will keep everyone
on Council apprised on this.
South Industrial Park: I heard from Erik Henningsgard that South Industrial Park progress is moving along. Curb and gutter will go in
shortly. The area needs to dry up and preparation will begin for that process.
Cell Tower Decommission: Removal of all infrastructure relative to the cell service on the Water Tower is moving along and should
be complete by months' end. There is a cage located on the ground that was agreed upon years ago to stay which belonged to
Nextel/Sprint. I am working with SEH to complete all processes and T-Mobile/Sprint will pay the lease to cover the expense to
decommission the site and bring it back to its prior state per the lease.
Street Pole Banners: I have been working with Signation who did all of our signs inside of the Amery City Center. They are putting
together very attractive Street Pole Banners that will go through the permitting process and will be approved shortly. The Amery
Community Club has offered to pay for½ the cost of the banners which will cost approximately $3,000. This is the start of the
process of doing Wayfinding Signs that will be prominent throughout the City.
Bowmar Appraisal: The push to finish the valuations of all property is happening with the City Assessors. The focus is on Residential
properties in the city. This is our final year for valuations of property and we will have costs for that ready at Board of Review which
is moved out to October. If anyone sees vehicles looking at their property, these are most likely the City Assessors.
Developers in the City: I have been working closely with a few prospective Developers who are interested in doing projects within
the city and its outskirts. When the projects materialize, I will keep everyone posted.
Wisconsin Department of Revenue: American Rescue Plan Act (ARPA) - Local Fiscal Recovery Funds (LFRF): Tonight, I would like to
discuss potential uses of the ARPA funds that the City of Amery received dating back to last year with the first installment. The 2 nd
installment is set to arrive next Monday.
Airport Manager: Public Works Director, Jeff Mahoney and myself will be sharing duties as Airport Manager. The day-to-day
operations of the airport grounds, (fuel, maintenance, courtesy car, etc.) will fall to Jeff. The Administration portion (grants, filings,
payments, etc.) will fall to me. We had an Airport Commission Meeting last week, and we will continue to keep council informed
with status updates regarding the Amery Municipal Airport.
Lieutenant Position: Police Chief, Tom Marson as well as myself and outside agency Police staff will start the interview process for
Lieutenant on: Monday - June 27, 2022.
Wisconsin City/County Manager Association (WCMA) & International City/County Management Association (ICMA) Summer
Conference: I attended the Summer Conference held in Fontana, WI for combined training from the WCMA and ICMA. The training
is beneficial for City Administrators like myself. It's a good way for all of us to share thoughts and ideas as well as help each other
face challenges relative to the job. We also walk away learning something new.
Upcoming Events:
July 4, 2022- Monday- Independence Day (City Offices Closed)
July 6, 2022 - Council Meeting@ 5:00 PM
July 11, 2022 - July 15, 2022 - Clerk/Treasurer & Deputy Clerk/Treasurer Training
July 13, 2022 - Coffee with the Mayor (City Center) @ 4:00 PM
July 19, 2022 - Committee of the Whole Meeting @ 5:00 PM
C
Executive Summary
The City of Amery's Wastewater Treatment Plant (WWTP) currently consists of fine screening, grit
.._ removal, an anaerobic selector tank, a two-ring oxidation ditch, one final clarifier, ultraviolet (UV)
disinfection, sludge storage, centrate storage, and sludge thickening. Most of the WWTP was
constructed in the mid-1940s to late 1960s with significant upgrades occurring in 1995, and still
achieves good treatment. The influent flow and biochemical oxygen demand (BOD) loading to the
plant is approaching design conditions.
As discussed in Section 5, the Amery WWTP has several unit processes that have either exceeded
their useful life, are operating over design capacity, or experience operational issues. Alternatives for
ensuring reliable treatment into the future are developed in this section. Multiple options for WWTP
Improvements were analyzed, including a no-improvement alternative, relocating to new site, and
upgrading at the existing location.
It is recommended, based on the monetary and non-monetary evaluations and owner preference,
that the City of Amery select Alternative 4a: Upgrading the Existing WWTP utilizing a Sequencing
Batch Reactor (SBR). This alternative will provide reliable treatment and allow for future growth.
The new WWTP would consist of similar unit processes as the existing plant, including a new fine
screen and grit removal, an SBR, rehabilitation of the existing UV disinfection system, and retrofit of
existing tankage for sludge and centrate storage. A new preliminary treatment building will also be
constructed to house the new fine screen and grit removal
The preliminary layout of the proposed SBR is composed of two square basins, each having a length
--
and width of 40 feet, where equalization, primary clarification, biological treatment and clarification
can all be achieved in a single reactor vessel, eliminating the need for clarifiers. Details of the SBR
design will be further developed during the design phase.
The opinion of probable construction cost for Alternative 4a is $7,689,000.00. This includes
construction costs with 25 percent construction contingency, and design and construction
engineering.
A setback distance of 500 feet is required for any mechanical treatment facility, per Wisconsin
Administrative Code Section NR 110.15. The City of Amery's current WWTP site does not meet this
requirement, so the waiver provisions within NR 110.15(3)(d)2 would need to be utilized. The City will
make reasonable attempts to execute agreements with property owners within 500 feet of the
WWTP, indicating their consent to the construction and operation of the WWTP on the current site.
The City will also enact a zoning ordinance which prohibits future construction within the applicable
separation distances to prevent future encroachment.
The City of Amery intends to apply for funding from the Clean Water Fund Program to finance these
upgrades. This program allows municipalities to receive financial assistance in the form of subsidized
loans, additional subsidy to reduce the size of a loan or a combination of the two to keep project costs
low.
Initial sampling indicates that the current WWTP (and the proposed WWTP) is capable of meeting the
proposed E. Coli limits that are outlined in the current WPDES permit. As such, no additional
compliance schedule milestones should be necessary for that specific requirement.
-
SEH is a registered trademark of Short Elliott Hendrickson Inc.
FACILITY PLAN AMERY 160422
-
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SEH
Building a Better World
for All of us�
June 16, 2022 RE: City of Amery
South Industrial Park Road-Application
for Payment
SEH No. AMERY 153333 14.00
Patty Bjorklund - WCMC, CMC, CMTW
City Administrator
City of Amery
104 Maple Street W. - Suite A
Amery, WI 54001
Dear Mrs. Bjorklund:
Albrightson Excavating Inc. (Albrightson) has submitted an application for payment for the work
completed on the South Industrial Park Road project. The application for payment includes water and
sewer main extensions, storm sewer installation, and other miscellaneous items.
The contract price for the project is $1,508,152.30. The contract is paid by unit price, therefore
Albrightson is paid at a unit price for the total units of bid items installed/completed. Albrightson has
completed $927,610.29 of the project, less 5% in retainage and previous payment, and is requesting
payment of $234,442.81.
Contract Amount $1,508,152.30
Work Completed to Date $927,610.29
Less 5% Retainage $46,380.51
Less Previous Pavment $646,786.97
Payment Request $234,442.81
We have reviewed Application for Payment No. 3 and would recommend authorization of payment.
If you have any questions please let us know.
Sincerely,
SHORT ELLIOTT HENDRICKSON INC.
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Erik Henningsgard, PE
Project Manager
(Lie. MN, WI)
Engineers I Architects I Planners I Scientists
Short Elliott Hendrickson Inc., 156 High Street, Suite 300, New Richmond, WI 54017-1128
715.246.9906 I 888.881.4281 I 888.908.8166 fax. I sehinc.com
SEH is 100% employee-owned I Affirmative Action-Equal Opportunity Employer
Patty Bjorklund - WCMC, CMC, CMTW
June 16, 2022
Page 2
Attachment: Application for Payment No. 3
c: Ben Jansen, City Clerk-Treasurer, Zoning Administrator
Jeff Mahoney, Director of Public Works
Adam Hensel, Albrightson Excavating Inc.
l\sehnr\projects\aela\amery\15333317-const-svcsl73-app-pymtlafp312022.0616_amery153333_ap3.docx
Application for Payment
� (Unit Price Contract)
SEH No. 3
Eng. Project No.: AMERY 153333 Location: Amery, Wisconsin
Contractor Albrightson Excavating Inc. Contract Date November 5, 2021
345 Southside Drive
Woodville, WI 54028 Contract Amount $ 1,508,152.30
Contract for South Industrial Park Road
Application Date 6/8/22 For Period Ending 6/5/22
Quantity
Item No.
01 21 00
I Item
Contingency ($25,000)
I Unit
LS
I au��\itv I
1
to Date
I Unit Price I
$25,000.00
Total Price
01 55 25.1 Maintenance of Traffic LS 1 0.5 1,800.00 $900.00
01 71 13.1 Mobilization LS 1 0.55 20,425.00 $11,233.75
02 41 33.1 Remove and Salvage Hydrant and
Valve Each 1 1 550.00 $550.00
02 41 33.2 Remove Culvert LS 1 1 600.00 $600.00
02 41 33.3 Remove Existing Asphalt Pavement SY 71 71 3.00 $213.00
02 41 33.4 Remove Existing Culvert Each 2 1 500.00 $500.00
02 41 33.5 Remove and Replace Storm Sewer Each 3 3 800.00 $2,400.00
31 11 00.1 Clearing & Grubbing Acre 5.9 3 3,500.00 $10,500.00
31 23 10.1 Common Excavation - Roadway (P) CY 10873 5436.5 6.85 $37,240.03
31 23 10.2 Common Excavation - Stormwater
Pond (P) CY 7494 7494 7.85 $58,827.90
30 23 10.3 Excavation Below Subgrade CY 100 200 38.00 $7,600.00
31 23 19.1 Dewatering LS 1 0.5 1,600.00 $800.00
31 23 30.1 Granular Backfill, Grade 1, WisDOT
209 CY 6390 395 12.60 $4,977.00
31 25 10.1 Silt Fence Delivered, Maintained and
Installed LF 3497 4170 1.40 $5,838.00
31 25 10.2 Erosion Mat Class I, Type B SY 5857 1.10
31 25 10.3 Erosion Mat Class II, Type C SY 280 4.00
31 25 10.4 Inlet Protection Each 9 0 50.00
31 25 10.5 Sediment Control Log LF 96 6.00
31 25 10.6 Tracking Pad Each 1 1 800.00 $800.00
31 34 15.1 Geotextile Fabric, Type SAS SY 9585 555 1.75 $971.25
31 37 00.1 Riprap, Light Ton 4 65.00
31 37 00.2 Riprap, Medium Ton 578 725.4 53.45 $38,772.63
32 11 14.1 Testing Rolling STA 14.5 25.00
32 11 26.1 Crushed Aggregate Base Course Ton 9090 60.44 13.75 $831.05
32 11 26.2 Gravel Road Base Ton 214 232.15 13.75 $3,192.06
32 12 18.1 Asphaltic Pavement, 4 MT 58-34 S Ton 927 90.35
32 12 18.2 Asphaltic Pavement, 3 MT 58-28 S Ton 1622 85.65
32 12 18.3 Asphaltic Surface (Driveway Mix) (3-
inch) SY 68 46.75
32 12 18.3 Adjust Manhole Casting Each 6 250.00
32 12 18.4 Adjust Valve Box Each 13 180.00
Short Elliott Hendrickson Inc. Page 1 of 4
Est. Quantity
Item No. I Item Unit
Quanti
Unit Price Total Price
to Date
32 12 50.1 Saw Cut Pavement LF 721 181 3.30 $597.30
32 16 30.1 Concrete Curb and Gutter, 30-inch
Type D LF 2765 12.25
32 16 30.2 Concrete Flume Each 2 400.00
32 17 23.1 Pavement Marking Line Epoxy, 4-inch
Yellow LF 352 1.65
32 17 23.2 Pavement Marking Line Epoxy, 4-inch
White LF 1056 1.65
32 17 23.3 Pavement Marking Arrow Epoxy,
White Each 4 225.00
32 17 23.4 Pavement Marking Line Epoxy, 18-inch
White LF 36 10.00
32 17 23.5 Remove Pavement Marking LF 409 1.50
32 92 12.1 Turf Establishment SY 15590 8000 1.70 $13,600.00
32 92 12.2 Wetland Seed Mix, MNDOT Mix 34-
171 SY 3270 3270 1.70 $5,559.00
33 11 00.1 Connect to Existing Water Main Each 2 2 1,200.00 $2,400.00
33 11 00.2 6-inch DIP Water Service LF 211 167.5 57.65 $9,656.38
33 11 00.3 8-inch DIP Water Main LF 2175 2198.5 57.10 $125,534.35
33 11 00.4 10-inch DIP Water Main LF 2462 2462 66.90 $164,707.80
33 11 00.5 6-inch Gate Valve with Box Each 12 12 1,615.00 $19,380.00
33 11 00.6 8-inch Gate Valve with Box Each 15 15 2,135.00 $32,025.00
33 11 00.7 10-inch Gate Valve with Box Each 10 9 2,980.00 $26,820.00
33 11 00.8 Fire Hydrant Each 14 13 4,835.00 $62,855.00
33 11 00.9 Insulation, 2-inch SF 2800 6400 4.10 $26,240.00
33 31 00.1 Connect to Existing Sanitary Manhole Each 1 1 1,420.00 $1,420.00
33 31 00.2 6-inch Sanitary Service Pipe LF 245 253 35.50 $8,981.50
33 31 00.3 8-inch PVC Sanitary Sewer LF 2513 2462 34.05 $83,831.10
33 31 00.4 48-inch Sanitary Manhole - 8-foot
depth Each 9 9 3,900.00 $35,100.00
33 31 00.5 Excess Manhole Depth VF 22 11 147.00 $1,617.00
33 31 00.6 Sanitary Sewer 8-inch by 6-inch Wye Each 6 5 365.00 $1,825.00
33 31 00.7 Sanitary Sewer Termination Box Each 6 3 250.00 $750.00
33 41 00.1 Class Ill RCP Storm Sewer, 18-inch LF 1053 1044 46.05 $48,076.20
33 41 00.2 Class Ill RCP Storm Sewer, 30-inch LF 8 6 108.00 $648.00
33 41 00.3 Class Ill RCP Storm Sewer, 36-inch LF 65 64 116.00 $7,424.00
33 41 00.4 Class Ill RCP Endwall, 18-inch Each 4 4 1,440.00 $5,760.00
33 41 00.5 Class Ill RCP Endwall, 30-inch Each 1 1 2,940.00 $2,940.00
33 41 00.6 Class Ill RCP Endwall, 36-inch Each 1 1 3,920.00 $3,920.00
33 41 00.7 2-foot by 3-foot Catch Basin with
Casting Each 3 3 2,290.00 $6,870.00
33 41 00.8 Storm Sewer Manhole, 48-inch
Diameter with Casting Each 4 4 2,900.00 $11,600.00
33 41 00.9 Storm Sewer Manhole, 72-inch
Diameter with Casting Each 2 2 5,600.00 $11,200.00
33 41 00.10 Pond Outlet Structure LS 1 1 6,730.00 $6,730.00
33 41 00.11 Storm Sewer Bulkhead, 18-inch Each 2 2 600.00 $1,200.00
33 42 20.1 CMP Culvert, 15-inch LF 40 40 57.00 $2,280.00
33 42 20.2 CMP Culvert, 24-inch LF 5 5 200.00 $1,000.00
33 42 20.3 CMP AEW, 15-inch Each 2 2 225.00 $450.00
33 42 20.4 Connect to Existing Culvert Each 1 1 835.00 $835.00
33 42 20.5 Remove and Reinstall AEW Each 1 0.5 750.00 $375.00
Short Elliott Hendrickson Inc. Page 2 of 4
Est. Quantity
Item No. I Item I Unit I Unit Price Total Price
Quanti to Date
33 42 20.6 18-inch RCP Culvert, Class IV LF 123 128 52.00 $6,656.00
34 41 40.1 Signs SF 26.75 75.00
34 41 40.2 Street Name Sign Each 1 400.00
Total Contract Amount $927,610.29
Short Elliott Hendrickson Inc. Page 3 of 4
Application for Payment (continued)
Total Contract Amount $ 1,508,152.30 Total Amount Earned $ 927,610.29
Material Suitably Stored on Site, Not
Incorporated into Work
Contract Change Order No. ---- Percent Complete
Contract Change Order No. ---- Percent Complete
Contract Change Order No. ____ Percent Complete _
Less Previous Applications: GROSS AMOUNT DUE $ 927,610.29
AFP No. 1: 333,562.82 AFP No. 6: ---- LESS 5 % RETAINAGE $ 46,380.51
AFP No. 2: 313,224.15 AFP No. 7: ---- AMOUNT DUE TO DATE $ 881,229.78
AFP No. 3: _____ AFP No. 8: ____ LESS PREVIOUS APPLICATIONS $ 646,786.97
AFP No. 4: _____ AFP No. 9: ____ AMOUNT DUE THIS APPLICATION $ 234,442.81
AFP No. 5:
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
Payment under said contract, South Industrial Park Road, Amery, Wisconsin, and (2)all material and equipment
incorporated in said Project or otherwise listed in or covered by this Application for Payment and free and clear of all
liens, claims, security interests and encumbrances.
Date ------------ , 20 Albrightson Excavating Inc.
(Contractor)
COUNTY OF ___________ ) By ________
STATE OF _ __________ )SS (Name and Title)
Before me on this ___ day of _____________� 20_ .__, personally appeared
_________________________ known to be, who being duly sworn did depose and
say that he is the ______________ (office)of the Contractor above mentioned that he executed the
above Application for Payment and Affidavit on behalf of said Contractor; and that all of the statements contained therein
are true, correct and complete.
My Commission expires
(Notary Public)
The undersigned has checked the Contractor's Application 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 with the work by all prior Applications for Payment.
In accordance with the Contract, the undersigned recommends approval of payment to the Contractor for the Amount
due.
Short Elliott Hendrickson Inc.
By
Date _________________
City of Amery
By ____ ___ ___ __ ______
Date
Page 4 of4
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