HomeMy WebLinkAbout4.e. Approve Final Payment of Erickson Park LightingDATE: JULY 15, 1988
TO: MAYOR & COUNCILMEMBERS
C/O ADMINISTRATOR JILK
r
FROM: CITY ENGINEER/PUBLIC WORKS DIRECTOR HEFTI�
RE: ITEMS FOR JULY 19, 1988 COUNCIL MEETING
CONSENT AGENDA
Approve Final Payment for Erickson Park Softball Field Lighting
The Contractor for this project, Berg Electric Company, has completed all the
facets of this project in accordance with the Contract Documents. Therefore,
Staff is recommending approval and acceptance along with final payment for the
Erickson Park Softball Field Lighting project.
Recommended action for Council to consider would be to approve the Final Payment
#2 for Erickson Park Softball Field Lighting in the amount of $4,163.
MONTHLY STATEMENT OF CONTRACT ACCOUNT
REQUEST FOR DATE
PROJECT
PAYMENT NO... --- --
!I`Af1T IAl. OR FINAL)
PROJECT r ilf ti. ►-1� !LIQ �T �%+ l( ' lc.Q .( i</L�L:YL
OWNER
CONTRACTOR
STATEMENT OF THE CONTRACT ACCOUNT
')RI>INAL. CONTRACT AMOUNT
AMOUNT ADDED BY CHANGE ORDERS
IOTAL
AMOUNT DEDUCTED BY CHANGE ORDERS
TOTAL CONTRAC r THIS DATE y
—
VALUE OF WORK COMPLETED TO DATE
LESS.` PERCENT RETAINABLE
NET TOTAL
LESS AMOUNT PREVIOUSLY PAID6)
AMOUNT DUE THIS REQUEST
CERTIFICATE OF THE CONTRACTOR
1 hereby certify that the work performed :u1J ill(. uraletials 111%( llcd a1141 (Wit the jolr ."Itc t(..Ir(Le, as sh(mn o1i
tl is Bequest for Pavruent, represent the ac u.tl value of.accomplrslunent under the Terms of the Contract date
rtom{- au(i..-z.�,�_ r
C1,�i� i ��+�t Imo+
-----a�ILTCl7`t r,LiISY''�!!ss thereto.
2705 W. Ilio hl(II, l)r.ve
l� 1 Bimisville: MIA 55137� -�
t
L`JL1
If ONT RACTORI `- (TITLE)
CERTIFICATE OF THE ARCHITECT OR ENGINEER
-Chis is to certify that in accordance with the Terms of the Contract the Contractor is entitled to a
payment in the amount requested.
,7
,!!,proved its to gmijrtitics :uT(I estimate diue
', SAltl'fl If(t (�7 IN.1N✓IN� � y
Hy y,
Ic t 34'
(Rev. 785)
Iv1rii { " 6 1983 i Minnesota I- t
contractor
epar men l of fievenue
Affidavit for Obtaining Final Settlement of Contract with the State of
Minnesota and any of its Political or Governmental Subdivisions
Minnesota identification number -- -
-_ lit none„ read insir runst
Business dein; — -- - --- — --
�:3
' y post
lzE L�... Area code and telephone number
City,Y �Ln or post oflice , � '" State �------
/ Zip code
Check the box which describes your involvement In this project (read definitions on other side)
❑ Prime contractor .V Contractor ❑ Subcontractor i
Project location )-- --.- —___ —_ _
Project or c ntract nu r bet Peri°d of contract 1M Ah/Year)
r� / _ From 7/ n
Name of Minnesota g ernmental unit for which work was performed nt �5 To
p T I amount of contrac�� --'�
° Ue
% ) Am un%t still d
�c• c�
Address of Minnesola ver l d entaunit "- yi; ) 6+ c , town or post office _
S' j` a J �/� / //1 Irn Code
--_ L .�� _ 1//cL 1 Y l l�'' ct�
Did you pay or supervise the payment of persons en played on this contract? (. Yes
No
If yes, did you withhold Minnesota income tax from the wages
of each employee as required by Minnesota Statute 290.92? DO Yes L_J No
Have you filed all required withholding returns and deposited Minnesota tax withheld with
the Department of Revenue as required by Minnesota Statutes 290.92 and 290.97? �(� Yes ❑ No
Do you authorize the Department to inform the prime contractor
Upon it's request whether your form IC -134 has been certified? I Yes J) No
If you are a subcontractor, list your prime contractor's business name and address.
Name:
if you are a contractor or subcontractor, skip the next section of this form and sign below.
If you are a prime contractor, fill in the names and addresses of all your subcontractors. If you need more space to list your
subcontractors, attach a separate sheet. Also you must attach certified affidavits of your subcontractors and sign below.
Name and address - -- --- ------------ —
Nanre and address
Name and address -- --- - -- —
Name and address -._— -
-----
Nrone and address-
_.
Name and address
I declare undgr'ihd, penalties of criminal liabylitq} for willfully making a false statement, that the above statements are true and correct to the best of my
knowledge a id belie
Sin >
9 , `, , '
_ � ��-/+.� '� � ''� c� f
fYUlli lgnalure
Here
I- - - - ---
Date
Certificate of Compliance with Minnesota Statutes 290.92 and 290.97
I':►sed on the facts stated in the above affidavit and the facts in (he fil4and records of the Department of Revenue, the above
)ntractor,subcontractor has properly complied with all of the provisions of Minnesota Statute 290.92 relating to the withholding
,-f income tax on wages paid to employees and Minnesota Statute 290.97 relating to contract services with the State of
+ irnnesota pr.xiny of its governmental or political subdivisiot is.
tn.dwr c+�aulhuntt.d Dcrpartuu.nt of fie vvi !Jif representative
4„ Date