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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 />1,250.00
<br />Number
<br />Date Approved
<br />#4
<br />12/07/10
<br />TOTALS
<br />1,250.00
<br />0.00
<br />Net change by Change Orders
<br />38,403.00
<br />APPLICATION AND CERTIFICATE FOR
<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 / 152' 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 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 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 />AIR Administr• or
<br />PAYMENT
<br />CUSTOMER PROJECT:
<br />Water Tower No.3
<br />Project No.08 -21
<br />Date: January 31, 2011
<br />AIA DOCUMENT G702 APPLICATION AND CERTIFICATE FOR PAYMENT MAY 1983 EDIT ION AIA 1992
<br />THE AMERICAN INSTITUTE OF ARCHITECTS. 1735 NEW YORK AVENUE, N.W., WASHINGTON, D.C. 20006
<br />VIA (ENGINEER): ENGINEER'S
<br />Progressive Consulting Engineers, PROJECT NO:
<br />Inc.
<br />6120 Earle Brown Drive, Suite 629
<br />Minneapolis, MN 55430
<br />AIA DOCUMENT G702
<br />APPLICATION NO: 18
<br />CB &I NO. 37147815
<br />PERIOD TO: 01/22/11
<br />a. Set Amount
<br />(C0113 + E on G703)
<br />b. 0% of Stored Material
<br />Col F on G703)
<br />Total Retainage (Line 5a + 5b or
<br />(Total in Col I 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 />8. CURRENT PAYMENT DUE
<br />9. BALANCE TO FINISH, PLUS RETAINAGE
<br />(Line 3 less Line 6)
<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, 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 />State of: IOWA County of: POLK
<br />Subscribed and sworn to before me this 31st day of January, 2011.
<br />Notary Public
<br />My Commission expires:
<br />Dec. 03, 2013
<br />$7,500.00
<br />0.00
<br />ENGINEER'S CERTIFICATE FOR PAYMENT AMOUNT CERTIFIED 7 - .7x 7
<br />In accordance with the Contract Documents, based on on -site observations and the (Attach explanation if amount certified differs from the amount applied for.)
<br />data comprising the above appplication, the Engineer certifies to the Owner that to the ENGINEER: Progressive Consulting sneers, Inc.
<br />best of the Engineer's knowledge, information and belief the Work has progressed as By: LLB - ,<�'r/'�! Date: /l f
<br />indicated, the quality of the Work is in accordance with the Contract Documents, and OWNER:. City o ' amsey
<br />the Contractor is entitled to payment of the AMOUNT CERTIFIED. By: Date:
<br />;,...1/46///
<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 />$3,188,400.00
<br />$38,403.00
<br />$3,226,803.00
<br />$3,226,803.00
<br />$7,500.00
<br />$3,219,303.00
<br />$3,180,553.00
<br />$38,750.00
<br />$7,500.00
<br />0702.1092
<br />
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