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REQUEST FOR PAYMENT <br />DATE:: September 30. 1985 <br />FOR PERIOD: <br />PLACE: Orono Minnesota From: Dec. 1, 1984 To Sept. 27, 1985 <br />PRU,:tCT. Trunk Highway 12 Sanitary Sewer Repair 6 Ditch Grading <br />PROJECT NO.: FILE NO.. 13925 SFECIFIED CONTRACT <br />CONTRACTOR: F. F. Jedlicki, Inc. i A .OMPLETION DATE: November 9, 1984 <br />ADDRESS: 14203 W. 62nd Street. <br />Eden Prairie, Minnesota 55344 <br />REQUEST FOR PAYKFNT NO.: Ind S Final <br />SUM ARY : <br />1. Original Contract Amounr <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 U X <br />9. Sub -Tot -,.I <br />10. Less Amount laid 1-reviously <br />11. AMOUNT DUE THIS REQUEST FOR PAYMe.NT NO.: 2-id b Final <br />`�WNr,R A P P R,)VA, (. <br />By <br />13,050.00 <br />$ 13,050.00 <br />$ 12,900.00 <br />$ <br />0.00 <br />3 12#900.00 <br />$ <br />0.00 <br />$ 12,900.00 <br />$ 11,685.0.0 <br />$ 1,215.00 <br />Approved By: 1 ;TR(,K), ROSENE, ANDERLIK S <br />ASbuCIATES, 14C. <br />B y :_;2 : - R <br />)ate Approved By' F F. Jedlicki, Inc. <br />Contractor <br />B y : <br />45l2c <br />