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i/llBonestroo <br />£sRosene <br />nAnderlik& <br />|\|| Associates <br />EngnttniArdattcts <br />Owner City of Orono. P. O. Box 66. Orono. MN 55323-0066 Date: November 4.2003 <br />For Perfod:11/3/2003 to 11/4/2003 Request No; l <br />Contractor E. J. Mayers. 21360 Larkin Rd.. Corcoran. MN 55340 <br />CONTRACTOR'S REQUEST FOR PAYMENT <br />OLD LONG LAKE ROAD SEWER EXTENSION <br />BRA FILE NO. 139-03-127 <br />SUMMARY <br />1 Original Contract Amount <br />2 Change Order - Addition <br />3 Change Order - Deduction <br />4 Revised Contract Amount <br />5 Value Completed to Date <br />6 Material on Hand <br />7 Amount Earned <br />8 Less Retainage S% <br />9 Subtotal <br />10 Less Amount Paid Previously <br />11 Liquidated damages • <br />12 AMOUNT DUE THIS REQUEST FOR PAYMENT NO. <br />S <br />S <br />0.00 <br />0.00 <br />$ <br />$ <br />s <br />s <br />s <br />S, <br />s, <br />s <br />s <br />39.950 00 <br />39,950 00 <br />22.900 00 <br />000 <br />22.900.00 <br />1.145.00 <br />21.755 00 <br />0.00 <br />000 <br />21.755 00 <br />Recommended for Approval by: <br />BONESTROO, ROSENE. ANDERUK A ASSOCIATES, INC. <br />Approved by Contractor <br />EJ MAYERS <br />Approved by Owner <br />CITYOFORONO <br />Specified Contract Completion Date: <br />November 14.2003 <br />Date: