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CHANGE ORDER SUMMARY
<br />Change Orders approved in
<br />previous months by Owner
<br />TOTAL
<br />ADDITIONS
<br />22,877.00
<br />22,877.00
<br />1 DEDUCTIONS
<br />0.00
<br />Approved this Application
<br />.
<br />Number
<br />Date Approved
<br />TOTALS
<br />0.00
<br />0.00
<br />Net change by Change Orders
<br />22,877.00
<br />APPLICATION AND CERTIFICATE FOR PAYMENT
<br />TO: City of Ramsey
<br />(OWNER) 7550 Sunwood Drive NW
<br />Ramsey, MN 55303
<br />FROM (CONTRACTOR):
<br />CB &I Inc. - Steel Plate Structures
<br />9550 Hickman Road Clive, IA 50325 -5316
<br />CONTRACT FOR:
<br />2MMG HP 1152' TCL
<br />16600 St. Francis Blvd., Unit #2
<br />CONTRACTOR'S APPL CATION FOR PAYMENT
<br />CONTRACTOR: CB &I Inc. - Steel Plate Structures
<br />ENGINEER'S CERTIFICATE FOR PAYMENT
<br />In accordance with the Contract Documents, based on on -site nervations and the
<br />data comprising the above appplication, the Engineer certifies to the Owner that tope
<br />best of the Engineer's knowledge, information and belief the Work has progressed as
<br />indicated, the quality of the Work is in accordance with the Contract Documents, and
<br />the Contractor is entitled to payment of the AMOUNT CERTIFIED.
<br />AIA DOCUMENT G702 APPLICATION AND CERTIFICATE FOR PAYMENT AIRY 1983 EDmoN AIA Ifg 1992
<br />THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVENUE, NW., WASHINGTON, D.C. 20006
<br />CUSTOMER PROJECT:
<br />Water Tower No.3
<br />Project No.08-21
<br />�4 { � _� L ' "-Date: October 23, 2009
<br />A/R Administrato
<br />VIA (ENGINEER):
<br />Progressive Consulting Engineers,
<br />1118.
<br />6120 Earle Brown Drive, Suite 629
<br />Minneapolis, MN 55430
<br />The undersigned Contractor certifies that to the best of the Contractor's knowledge,
<br />information and belief that the Work covered by this Aplication for Payment has been
<br />completed in accordance with Contract Documents, that all amounts have been
<br />paid by the Contractor for for which previous Certificates for Payment were
<br />issued and payments received from the Owner, and that current payment shown
<br />herein is now due.
<br />AIA DOCUMENT G702
<br />APPLICATION NO:
<br />CB &I NO.
<br />PERIOD TO:
<br />ENGINEER'S
<br />PROJECT NO:
<br />a. 5% of Completed Work
<br />(Col D + E on G703)
<br />b. 0% of Stored Material
<br />Col F on 6703)
<br />Total Retainage (Line 5a + 5b or
<br />(Total in Coil of G703)
<br />6. TOTAL EARNED LESS RETAINAGE
<br />(Line 4 less Line 5 Total)
<br />7. LESS PREVIOUS CERTIFICATES FOR
<br />PAYMENT (Line 6 from prior Certificate)
<br />CURRENT PAYMENT DUE
<br />BALANCE TO FINISH, PLUS RETAINAGE
<br />(Line 3 less Line 6)
<br />8.
<br />9.
<br />Notary Public
<br />My Commission expires:
<br />By : . — E''r �r
<br />OWNER:
<br />By:
<br />4
<br />37147815
<br />10/24/09
<br />Project No. 08015
<br />CONTRACT DATE: 07/09/09
<br />Application is made for Payment, as shown below, in connection with the Contract.
<br />Continuation Sheet, AMA Document G703, is attached.
<br />1. ORIGINAL CONTRACT SUM
<br />2. Net change by Change Orders
<br />3. CONTRACT SUM TO DATE (Line 1 +1- 2)
<br />4. TOTAL COMPLETED & STORED TO DATE (Col G on G703)
<br />5. RETAINAGE:
<br />State of: IOWA County of: POLK
<br />Subscribed and swore to before me this 23rd day of October, 2009.
<br />AMOUNT CERTIFIED
<br />(Attach explanation if amount certified differs from the amount applied f or.
<br />ENGINEER Progressive Consulting En ineers, Inc.
<br />Date:
<br />pmsey
<br />Date:
<br />$72,915.72
<br />0.00
<br />This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
<br />Contractor named herein. Issuance, payment and acceptance of payment are without
<br />prejudice to any rights of the Owner or Contractor under this Contract.
<br />PAGE ONE OF TWO PAGES
<br />Distribution to:
<br />OWNER
<br />ENGINEER
<br />CONTRACTOR
<br />OTHER
<br />9
<br />/Ze 7
<br />$3,188,400.00
<br />$22,877.00
<br />$3,211,277.00
<br />$1,458,314.40
<br />$72,915.72
<br />$1,385,398.68
<br />$1,083,834.10
<br />$301,564.58
<br />$1,825,878.32
<br />GAYLA L. ZENZ
<br />- Commission Number 713888
<br />ly Commission Expires__
<br />•
<br />December, 3 20 /r
<br />•
<br />G702 -1992
<br />
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