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CONTRACTOR'S PAY REQUEST <br />DISTRIBUTION: <br />CONTRACTOR (1) <br />RAMSEY WELL HOUSE NO.3 NATURAL GAS GENERATOR <br />OWNER (1) <br />CITY OF RAMSEY, MN <br />ENGINEER (1) <br />BMI PROJECT NO. R16.113601 <br />BONDING CO. (1) <br />TOTAL AMOUNT BID PLUS APPROVED CHANGE ORDERS <br />$90,500.00 <br />TOTAL, COMPLETED WORK TO DATE <br />$10,170.00 <br />TOTAL, STORED MATERIALS TO DATE <br />$0.00 <br />DEDUCTION FOR STORED MATERIALS USED IN WORK COMPLETED <br />$0.00 <br />TOTAL, COMPLETED WORK & STORED MATERIALS <br />$10,170.00 <br />RETAINED PERCENTAGE ( 5%) <br />$508.50 <br />TOTAL AMOUNT OF OTHER PAYMENTS OR (DEDUCTIONS) <br />$0.00 <br />NET AMOUNT DUE TO CONTRACTOR TO DATE <br />$9,661.50 <br />TOTAL AMOUNT PAID ON PREVIOUS ESTIMATES <br />$0.00 <br />PAY CONTRACTOR AS ESTIMATE NO. 1 <br />$9,661.50 <br />I hereby certify that, to the best of my knowledge and belief, all items quantities and prices <br />of work and material shown on this Estimate are correct and that all work has been <br />performed in full accordance with the terms and conditions of the Contract for this project <br />between the Owner and the undersigned Contractor, and as amended by any <br />authorized changes, and that the foregoing is a true and correct statement of the amount <br />for the Final Estimate, that the provisions of M. S. 290.92 have been complied with and that <br />all claims against me by reason of the Contract have been paid or satisfactorily secured. <br />Contractor: KILLMER ELECTRIC CO., INC. <br />5141 Lakeland Ave N <br />Cry I, M Ne 9 <br />By Brian F. Bakk _CFO <br />Name Title <br />Date 2 % <br />CHECKED AND APPROVED AS TO QUANTITIES AND AMOUNT: <br />ENGINEER: BOLTON & MENK, INC., 7533 SUNWOOD DRIVE, SUITE 206, RAMSEY, MN 55303 <br />By SENIOR PROJECT MANAGE <br />Kevin Kielb, P.E. <br />Date <br />APPROVED FOR PAYMENT: <br />OWNER: CITY OF RAMSEY, MN <br />f <br />By bit 1cam <br />Name Title Date <br />And <br />Name Title Date <br />