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CHANGE ORDER SUMMARY <br />Change Orders approved in <br />previous months by Owner <br />TOTAL <br />ADDITIONS <br />37.153.00 <br />37,153.00 <br />DEDUCTIONS <br />0.00 <br />Approved this Application <br />Number <br />Date Approved <br />TOTALS <br />0.00 <br />0.00 <br />Net change by Change Orders <br />37,153.00 <br />A. 1 41V,11 ■V1■ Al \1J VLI• 111 1 Vf\ VI\ 1 7 1 Ivi1.1• 1 <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 />The undersigned Contractor certifies that to the best of the Contractors 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 Work 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 />CONTRACTOR: CB &I Inc. - Steel Plate Structures <br />AIRAdmin'- I .to <br />ENGINEER'S CERTIFICATE FOR PAYMENT <br />In accordance with the Contract Documents, based on on -site observations and the <br />data comprising the above appplication, the Engineer certifies to the Owner that to the <br />best of the Engineer's knowledge, information and belief the Work has progressed as <br />indicated, the quay 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 MAY 1983 EDITION AMA M 1992 <br />THE AMERICAN INSTITUTE OF ARCHITECTS. 1735 NEW YORK AVENUE N.W.. WASHINGTON, D 20006 <br />CUSTOMER PROJECT: <br />Water Tower No.3 <br />Project No.08 -21 <br />VIA (ENGINEER): <br />Progressive Consulting Engineers, <br />Inc. <br />6120 Earle Brown Drive, Suite 629 <br />Minneapolis, MN 55430 <br />ate: LL December 9, 2010 Notary Public <br />My Commission expires: <br />AIR 1/V4VAIIGIV 1 l7I VG <br />APPLICATION NO: 17 <br />CB &I NO. 37147815 <br />PERIOD TO: 11/27/10 <br />ENGINEER'S <br />PROJECT NO: <br />CONTRACT DATE: 07/09/09 <br />Application is made for Payment, as shown below, in connection with the Contract. <br />Continuation Sheet, AIA 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 />a. Set Amount <br />(Col D +Eon G703) <br />b. 0% of Stored Material <br />Col F on G703) <br />Total Retainage (Line 5a + sb or <br />(Total in Col 1 of G703) <br />6. TOTAL EARNED LESS RETAINAGE <br />(Line 4 Iess Line 5 Total) <br />7. LESS PREVIOUS CERTIFICATES FOR <br />PAYMENT (Line 6 from prior Certificate) <br />8. CURRENT PAYMENT DUE <br />9. BALANCE TO FINISH, PLUS RETAINAGE <br />(Line 3 Tess Line 6) <br />State of IOWA County of: POLK <br />Subscribed and sworn to before me 0hls 9th day of December, 2010. <br />AMOUNT CERTIFIED <br />ENGINEER: <br />By: <br />OWNER <br />By <br />Project No. 08015 <br />Dec. 03,20 <br />r <br />Date. <br />rnwc VAIL Vr n W V rn1wca <br />$45,000.00 <br />0.00 <br />(Attach explanation if amount certified differs from the amount applied for) <br />Distribution to: <br />OWNER <br />ENGINEER <br />CONTRACTOR <br />OTHER <br />Progressive Consulting Engine , Inc. <br />Date: <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 />$3.188,400.00 <br />537,153,00 <br />$3,225,553.00 <br />83,225,553.00 <br />$45,000.00 <br />$3,180,553.00 <br />$3,128,786.41 <br />$51.766.59 <br />$45,000.00 <br />0702-1952 <br />