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REQUEST FOR PAYMENT <br />1/fft A b 1 <br />PLACE: <br />•JSIIViaLj €m J % <br />Orono, Minnesota <br />PROJECT:Lift Station No. 8 Renovation <br />PROJECT NO.:FILE NO.:13945 <br />rOMTRACTOR;Northwest Mechanical. Inc. <br />ADDRESS:432 Mill Street. PO Box 40 <br />Lona Lake. MN 55356 <br />FOR PERIOD: <br />From: Dec. 22, 1990 To; Jan. 22. 1991 <br />SPECIFIED CONTRACT <br />COMPLtTION DATE: <br />October 01, 1990 <br />REQUEST FOR PAYMENT NO.t i FINAL <br />SUMMARY: <br />1. Original Contract Amount <br />Change Order • ADDITION <br />Change Order - DEDUCTION <br />Reviled Contract Amount <br />Value Completed to Date <br />Material on Hand <br />Amount Earned <br />Leia Retainage 0 Z <br />Sub-Total <br />2. <br />3. <br />4. <br />5. <br />6. <br />7. <br />a. <br />a. <br />10. <br />11. <br />Leas Amount Paid Previously <br />AMOUNT DUE THIS REQUEST FOR PAYMENT NO.; 4 & F <br />S <br />$ <br />$ <br />$ <br />S <br />$ <br />$ <br />$ <br />Recommended fot Approval by: <br />BONESTROO, ROSENE, ANDERLIK 4 <br />ASSOCIATES. INC. <br />By A // <br />QVNER APPROVAL: <br />■f_ _ _ _ _ _ <br />»y_ _ _ _ _ _ <br />48.000.00 <br />48.000.00 <br />48.000.00 <br />0.00 <br />48.000.00 <br />0.00 <br />48.000.00 <br />45.600.00 <br />2.400.00 <br />Date:Approved By; NORTHWEST MECHANICAL. INC. <br />Contractor <br />Bv:Apnroval stated on attached AIA form <br />13945PR