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r <br />. 4 <br />I. <br />> <br />PAYMENT APPLICATION Page 1 <br />TO: <br />FROM: <br />City of Orono <br />2750 Kelley Parkway <br />OroTK). MN 55336 <br />Attn: Accounts Payable <br />Dew Corporation <br />2125 Century Avenue <br />North St Paul. MN 55109 <br />PROJECT 03005 <br />NAME AND Navarro Fire Station <br />LOCATION: 37^^0.3790 shoreline Drive <br />APPLICATION » <br />PERIOD THRU: <br />PROJECT its: <br />Orono, MN 55336 <br />ARCHITECT: BKV Group. Inc <br />222 N. 2nd SI <br />Mrmcapoiis. MN 55401 <br />DATE OF CONTRACT: <br />8 JiniSl' DisUibuUon to: <br />04/28/2004 OWNER <br />(i3 ARCHITECT <br />07/01/2003 S] CONTRACTOR □□ <br />CONTRACTOR’S SUMMARY OF WORK <br />Applicatkxi Is made for payment as shown below. <br />Continuatkxi Pago is attached. <br />1. CONTRACT AMOUNT $1,138,000.00 <br />2. SUM OF/U.L CHANGE ORDERS $10,857-00 <br />3. CURRENT CONITMCT AMOUNT (Lino 1 ♦/-2)$1,148,857.00 <br />4. TOTAL COMPLETED AND STORED $1,148,857.00 <br />(Column G on Continuation Pago) <br />5. RETAINAGE: <br />a. 2-50% of Completed Work _______ <br />(Columns 0 ♦ E on Continuation Page) <br />b. 2 50% of Material Stored _ <br />(Column F on Continuation Page) <br />Total Retainage (Lino 5a ^ 5b a <br />Column I on Continuation Page) <br />6 TOTAL COMPLETED AND STORED LESS RETAINAGE <br />(Line 4 minus Line 5 Total) <br />7. LESS PREVIOUS PAYMENT APPUCATIONS <br />(Line 6 from prior Application) <br />8 PAYMENT DUE <br />9. BALANCE TO COMPLETION <br />(Line 3 mlrws Line 6) ________ <br />S28.72100 <br />$0 00 <br />$28,721 00 <br />$1,120.136 00 <br />$1.091.41400 <br />$28,722io' <br />$28,721.00 <br />SUMMARY OF CHANGE ORDERS ADDITIONS <br />Total Changes approved in $10,657.00previous months <br />Total appro^ this monlh $0.00 <br />TOTALS $10>57.6 o <br />NET CHANGES $10,857.00 <br />DEDUCTIONS <br />$0.00 <br />$6^ <br />$0.00 <br />Contractor's signature below is his assurance to Owner, concerning the payment herein applied for. <br />that: (1) the Work has been performed as required In the Contract Documents. (2) all sums <br />previously paid to Contractor under the Contract have been used to pay Contractor's costs for labor, <br />materials and other obligations under the Contract for Work previously paid for. and (3) Contractor is <br />legally entitled to this payment. <br />CONTRACTOR: <br />By: <br />Dew Corpor^ <br />Date:04/28^004 <br />Roberf^. Dew, President <br />State of: Minnesota <br />County ot Ramsey <br />Subscribed and sworn to before <br />me this 28th day of Aprfl 2004 a TAMMYJNELSON <br />notaiv ». euc - <br />llyF»OfttJin.3« <br />Notary Public »ammy no»on ^ \ A V 'iiiCN <br />My Commission Expires: January Jl. 20 <br />Tammy Nelson <br />ARCHITECT’S CERTIFICAT ON <br />Archiled's slgnalu'e below Is his assurance to Owner, concerning the payment herein applied (or. <br />Uiat: (1) Architect has inspected the Work represented by this Appticatton. (2) such Work has been <br />completed to the extent indicated in this Application, and the quaility of workmanship and materials <br />conforms with the Contract Documents. (3) this App'ication for Payment accurately states the amount <br />of Work completed and payment due therefor, and (4) Architect Ktk>ws of no reason why payment <br />should not be made. <br />CERTIFIED AMOUNT....................................................................... -- <br />(Hlhe ceitiTiod amount is attOrontfmm the paymoit due. you should ettech an explanation. <br />Initial all the tguros that are chanced to mate/i Vv ^lUTied amount.) <br />ARCHITECT: <br />By;Date;k/lfk'L <br />PAYyiEHT APPLICATION <br />Neither this Application nor paylwnl applied for herein is asslghabte or negotiable Paymem shall <br />be made only to C^ontractor, ay Is wthout prejudice to any rights of Owner or Contractor under <br />the Contract Docurpents or ^)nerwtse. <br />■ QSS. INC- DOCUMENT