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Pay Estimate Summary Sheet <br />Estimate Number: 1 Partial <br />Project Number: 19-06 <br />Project Name: RTC 9th Addition Pond Lining Improvements <br />Period Ending December 31, 2019 <br />Contractor: JL Theis, Inc. <br />Address: 860 Quaker Avenue, Suite 102, Jordan, MN 55352 <br />1 Original Contract Amount $ 105,152.00 <br />2 Change Order(s) No. Thru No. <br />3 Total Funds Encumbered $ 105,152.00 <br />4 Value of Work Completed $ 102,055.00 <br />Value of Work Remaining $ 3,097.00 <br />Percent Complete 97% <br />5 Retainage 5 % $ 5,102.75 <br />6 Previous Payment(s) $ <br />7 Deductions or Charges <br />8 Total Retainage, Payments & Deductions (Lines 5+6+7) $ 5,102.75 <br />Payment Due (Lines 4-8) <br />$ 96,952.25 <br />Certification of Partial Payment <br />I hereby certify that, to the best of my knowledge and belief, all Items, quantities and prices of work and material shown on <br />this Estimate are correct and that all work has been performed In full accordance with the terms and conditions of the <br />Contract for this project between owner and the undersigned Contractor, and as amended by any authorized changes and <br />the foregoing Is a true and correct statement of the contract amount for the period covered by this estimate. <br />JL Theis, Inc. <br />Contractor Name <br />Ernie <br />Title <br />JwmiLih6s <br />Print Name <br />2 '2,3 2019 <br />Date <br />City of Ramsey Approval <br />RI Z-3/2011 <br />Si nature (Project Engineer) Date <br />Signature (City Engineer) 3 Date <br />l--23(lci <br />Pay Estimate Page 1 of 2 <br />