HomeMy WebLinkAbout4.j. Approve Application for Payment #3, Contract #1988-8, Lift Station No. 5 ' .Z-�-�� .J
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APPGICJ►TI �R+O P1IYMSNI'
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GITY PROJECT NO: � gZ_ SEH FILE NO; V9Of0
PROJECT: ,�,I FT �'j'�}�"lON �� �t�ll�.> ��
CONTRACTOR: C�2�2 �rUS�UGT1oN CONTRACT DATE: �"�Z'9��
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/3o z� P�d�� t�tc. APPLICATION DATE• _ rE7��0��,9 �
. �EN �i�NRJ6�,/l�Irl.SS347 FOR PERIOD ENDING; O �4 c�9 _
Total Con,tract Amount 3$��Z4O °p Total Amount Earned S 8 �, 700
Material Suitably Stored on Site,
Not Incorporated into Work S
Contract Change Order No. � Percent Complete ��byo $ �OA �O9 '
Contract Change Order No. Percent Cornpiete g
Contract Change Order No. Percent Complete $
99,s 4
( � vRoss �ov�rr uvg . . . . . . . . . . . . . . . . .. . . , . g o
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�BSS S� RBTAINI►�(3B . . . . . . . . . . . . . . . . . . . 9 '¢97S �'
: AMOUNT DUB TO D11TB . . . . . . . . . . . . . . . . . . . . 8— 9 �iS 39
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j L�SS PREVIOVS AFPI,ZCATIONS . . , . . . . . . . . . $ ?,f,�Zs'�`�.
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� AMOUNT DUE THIS APPLICATION . . . . . . . . . . . IS� Z�jp,--
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�-� -�' � f � �y ,
ichard M. Hef � �� `� `i� y7 �( �' ���� �
City Bnqineerj0� ator of Public Worke
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APPLICATIOM FOR FAYMENT
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(LUMP SUM CONTRACT)
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Owner; ROSEMOUNT'� MINNESOTA Owner's Pro�ect No. 192 !
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Engineer's Pro�ect No. -$$9�$— �9as0
. LOCATIQN CITY OF ROSEMQUNT, MN
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Contractor � ORR CONSTRUCTION Contract Date 9/29/8$
13025 PIONEER TRAIL Contract Amount $89, 2Q0.00
I ' EDEN PRAIRIE, MN 55347
Contract for LIFT STATION NO. 5 - ROSEMOUNT, MINNESOTA T
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� Appiication: Date �u•�E. 3v - 8 9 �
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� For Period End'ii�'t� �- � � �
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APPLIGATION FOR PAYMENT
' +' PBRC.ENT AMC�UNT
DESCRiPTION SCHEDULE COMPLETE EARNED
; 1. PROJECT START $ 2,000.00 S 2,000.0�
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, 2. HOND, INSURANCE $ 3,000.00 S 3,000.00
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' 3. LIFT STATION
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� a. Material $ 5,000.00 -�.QG�� '!
� b. Labor $12,OOO.00 1a� 000, ••
i Page 1 of 2 SHORT-ELLIQTT-HENDRICKSON, TNG.
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� APPLICATION FOR PAYMENT
, (Continued)
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� � PERCENT AMOUNT
DESCRIFTION SCHEDULE COMPLETE EARNED
4. PIPING
a. Material S 7,000.00 �Ooo, �� �
b. Labor , $10,000.00 /O^000, °s
5. SEWAGE _PUMPS . � . . � .
' a. Material 535, 616.00 ,3� fes. "
b. Labor $ 2,010.00 � p/cv. ° '
6. TELEMETRY $ g,Q74,pp � O7�/, • •
. 7. BLACKTOPPING $ 500.Qp - O "
8. ELECTRICAL $ 3,000.0(3 ,�, 0 0 0 "'
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i PAGE 2 OF 3 SHORT-ELLIOTT-HENURICKSON, TNC.
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i � ,�TION FpR PAYMENT - Continu�
' Total Contract•Amount 5 89,200. 00 Total Amount Earned $ �'�, �OO, '°
Material Suitably Stored on Site, Not Incoporated into Work $
Contract Change Order �o. �! Percent.Complete ,�/o o ?a $ /D,�p 9 "°
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Contract Change Order !Io. percent Complete $
i Contract Change Order ��o. Percent Compiete g
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; GROSS AMOUNT DUE. . . . . . . . . . . . . . . � J' 9 .�a ���
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, LESS .r % RETAINAGE. . . . . . . . . $ �! 9 7 5f °° '
° AMOUNT DUE TO �ATE. . . . . . . . . . . . . $ �' ,S',� j� � e
-�53• 1 S
� LESS PRfVIOUS APPLICATIDNS. . . . . �
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AMQUNT QUE THIS APPLICATION. . . , $� ��a-a�;------
� CONTRACTOR'S AFFIDAYIT
� he undersigned Contractor hereby swears under penalty of per3ury that (1) all previous progress.
� payments received from the Owner on account of work p�rformed under the contract referred to
Iabove have been applfed •by th� undersigned to discharge in full all obTigatic�ns of the under-
� signed incurred in conn�ction with wark covered by prior Appllcatians for Payment under said
contract, and (2) all
I material and equipment incarporated in said Rraject or otherwise iisted in or covered by this
lApplication for Payment are free and clear of all liens, clatms, secur�ity interests and
encumbrances. '
; Dated ,3 d , ig S9 , Orr Construction �
� `���� Co ractor .
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' , Name and Title
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i �OUNTY OF , �� �aj� � SS
� �TA7E OF ' � -.
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' 3efpr me on this . � day of -'�'.-�.�.C� , 19 �`� personally appeared
' .��{� y �7 'known to me, wTio being duly sworn, dtd depose
3n say that he is the � of the� Contractor above mentioned;
Of ice
! 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 camplete..,
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My Commi s s i on Exp es �'�����I-��/;'��`�. �1;� , " �'� �
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My eomrns:,o,. ,sp�r•_, iA.,:�:: •, i.;1
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The undersigned has checked the Contr�etor's Application for Payment shown above. A part of
this Application is the Contractor's Affidavit statfng that all previous payments to him
� under this Contract have been applied by him to discharge in full atl of h1s obligations in
� connection wlth the work covered by all prior Appllcations for Payment. �
iIn accordance with the Contract, the undersigned approves payment to the Gontractor of the
' Amount Que.
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i �� ��9 B HORT E TT NEN CKSON IN
' Date /4 � �,
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