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HomeMy WebLinkAbout4.h. Request for Payment #1, Central Supervisory Control SystemF 1987 0 1 COPIED TO COUNCIL JAN 0 2 198' APPLICATION FOR PAYMENT (LUMP SUM CONTRACT) NO. / Owner: CITY OF ROSEMOUNT, MN Owner's Project No. Engineer's Project No. 86097 LOCATION ROSEMOUNT, MINNESOTA Contractor Autocon Industries, Inc. Contract Date 995 University Avenue Contract Amount $35,595 St. Paul, _MN 55014 Contract for CENTRAL SUPERVISORY CONTROL SYSTEM - ROSEMOUNT MN Application Date bac / �_/ � For Period Ending LSE c /'S, APPLICATION FOR PAYMENT PERCENT AMOUNT SCHEDULE COMPLETE EARNED -upervisory C `- '-em ( Computer coo s) $7,996 07 9� Auto=— MI.. 9800 tanda_ ckaga a_.CA = 3,324 \ of SHORT-ELLIOTT-HENDRICKSON, INC. CL IS 9 � 1987 APPLICATION FOR PAYMENT (CONTINUED) PERCENT AMOUNT DESCRIPTION SCHEDULE COMPLETE EARNED C. Autocon Unit #1 Remote Terminal Well #7 $1,030 O�n0,5 00 D. Autocon Unit #2 Remote Terminal Well #3 1,030 E. Autocon Unit #3 Remote Terminal Well #4 1,030, / ©L o F. Autocon Remote Terminal Unit #4 #1 Lift Station 1,030 G. Autocon Remote Terminal Unit #5 #2 Lift Station 1,030 010 / 630".-- H. Autocon Remote Terminal Unit #6 #3 Lift Station 1, 030 iC� ©° oIf 00 %f I. Buyout Hardware ( Flow meters etc) 5,553, 00`x© Qp 1q J. Engineering Services, Admin. oJ of Installation, 12,542lo Page 2 of 3 - APPLICATION FOR PAYMENT - Continued corsFILE 1 9 Total Contract Amount $ 35,595.00 Total Amount Earned $ Material Suitably Stored on Site, Not Incoporated into Work $ Contract Change Order No. Percent -Complete $ Contract Change Order No. Percent Complete Contract Change Order No. Percent Complete $ GROSS AMOUNT DUE.... ....... $ �� 1 LESS d % RETAINAGE......... AMOUNT DUE TO DATE .......... . .. LESS PREVIOUS APPLICATIONS..... $ AMOUNT DUE THIS APPLICATION.... $�-i,, CONTRACTOR'S AFFIDAVIT he 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 under- signed incurred in connection with work covered by prior Applications for Payment under said contract, and (2) all material and equipment incorporated in said Project or otherwise listed in or covered by this Application for Payment are free and clear of all liens, claims, security interests and encumbrances. Dated L� EC /�j 19 is'b Autocon Industries, Inc. Contractor COUNTY OFSS STATE OF )II, Before�me on his, /.. day of �1cC�}) ti , 19 Z�_ personally appeared i • . , . own to me, who bei ng sworn, did depose and say that hr is the of the Contractor above mentioned; (Office) that he executed the above Application for Payment and Affidavit on behalf of said Contractor; and that all of ths-s-talawate-castaina ein are true, correct and complete. DONNA M. WINTER / My Commission Expi F NOTARY PUBLIC - M'NN=SOTA f)(k� �� iL-k l 1 /O - RAMSEY COUNTY --� (Nota Public) t at t % .( _�� ! 7 �a� - ., ,i�* My commission expires 5.23-92 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 obbligations in connection with the work covered by all prior Applications for Payment. In accordance with the Contract, the undersigned approves payment to the Contractor of the Amount Due. r Date �Ur- 9� 1 {? Page 3 of 3