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CONTRACTOR'S PAY REQUEST (DISTRIBUTION: <br />RIVERDALE DRIVE EXTENSION IMPROVEMENTS (CONTRACTOR (1) <br />S.A.P. 119-115-003 (OWNER (1) <br />CITY OF RAMSEY, MN (ENGINEER (1) <br />BMI PROJECT NO. R16.111092 (BONDING CO. (1) <br />TOTAL AMOUNT BID PLUS APPROVED CHANGE ORDERS $701,270.54 <br />TOTAL, COMPLETED WORK TO DATE $563,346.72 <br />TOTAL, STORED MATERIALS TO DATE $0.00 <br />DEDUCTION FOR STORED MATERIALS USED IN WORK COMPLETED $0.00 <br />TOTAL, COMPLETED WORK & STORED MATERIALS $563,346.72 <br />RETAINED PERCENTAGE ( 5%) $28,167.34 <br />TOTAL AMOUNT OF OTHER PAYMENTS OR (DEDUCTIONS) $0.00 <br />NET AMOUNT DUE TO CONTRACTOR TO DATE $535,179.39 <br />TOTAL AMOUNT PAID ON PREVIOUS ESTIMATES $414,016.13 <br />PAY CONTRACTOR AS ESTIMATE NO. 3 $121,163.26 <br />Certificate for Partial Payment <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 <br />contract amount for the period covered by this Estimate. <br />Contractor: <br />By <br />Date <br />Douglas -Kerr Underground, LLC <br />2142 330th Ave <br />Mora, MN 55051 <br />-/*7 <br />Title <br />CHECKED AND APPROVED AS TO QUANTITIES AND AMOUNT: <br />ENGINEER: BOL ON & MENK, INC., 7 33 SUNWOOD DRIVE, SUITE 206, RAMSEY, MN 55303 <br />By , PROJECT MANAGER <br />KEVIN P. KIELB, P.E. <br />(Date 12/11/2017 <br />APPROVED FOR PAYMENT: <br />OWNER: CITY OF RAMSEY <br />By j(,tA4 w v0 nn — � A J f vt e,— I Z 1 I(e ( 7 <br />Name J Title Date <br />Title Date <br />And <br />Name <br />