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It <br />mla <br />TKD <br />APPLICATION AND CERTIFICATE FOR PAYMENT <br />TO OWNER: City of Arden Hills PROJECT: 2024 CIPP Lining APPLICATION NO.: 1 <br />1245 Hwy 96 PROJECT #: PW-23-0101, 20940.000 APPLICATION DATE: 7/3/2024 <br />Arden Hills, MN 55112 APPLICATION PERIOD TO: 713/2024 <br />FROM CONTRACTOR: Hydro-Klean ENGINEER: Larry Poppler CONTRACT DATE: 4/8/2024 <br />333 NW 49th Place TKDA <br />Des Maine, lA 50313 444 Cedar St <br />St Paul, MN 55101 <br />CONTRACT FOR: Cured -In -Place -Pipe Rehabilitation of Sanitary Sewer <br />Application is made for payment, as shown below, in connection with the contract. <br />1 ORIGINAL CONTRACT SUM <br />$ 505,280.00 <br />2 NET CHANGE BY CHANGE ORDERS <br />$ - <br />3 CONTRACT SUM TO DATE (Line 1 + 2) <br />$ 505,280.00 <br />4 TOTAL COMPLETED & STORED TO DATE <br />$ 62,136.00 <br />5 RETAINAGE: <br />a. Completed Work 5% $ 3,106.80 <br />b. Stored Materials 0% $ <br />Total Retainage <br />$ 3,106.80 <br />6 TOTAL EARNED LESS RETAINAGE (Line 4 - 5) <br />$ 59,029.20 <br />7 LESS PREVIOUS CERTIFICATES FOR PAYMENT <br />$ - <br />((Line 6 (paste # only) from prior Certificate)) <br />It <br />8 CURRENT PAYMENT DUE (Line 6 - 7) <br />$ 59,029.20 <br />9 BALANCE TO FINISH, INCLUDING RETAINAGE (Line 3 - 6) $ 446,250.80 <br />Addition Deduction <br />Total changes approved in previous months by Owner $ - $ - <br />Changes approved this month <br />Change Order 1 Sanitary casting replacement Included in quantities $ - <br />Change Order 2 $ - $ <br />Total additions and subtractions $ $ Net Changes by Change Order $ - <br />undersigned Contractor certifies that to the best of the Contractors knowledge, information and <br />of the Work covered by this Application for Payment has been completed in accordance with <br />Contract Documents, that all amounts have been paid by the Contractor for Work for which <br />rious Certificates for Payment were issued and payments received from the Owner, and that <br />ent payment shown herein is now due. <br />NTRACTOR: Hydro-Klean <br />333 NW 49th Place <br />Des Moine, IA 50313 <br />(320) 363-8500 <br />Title: Q o 4 r 11,�, <br />J r� day of -jk 0 �"i 2024 <br />ENGINEER'S CERTIFICATE FOR PAYMENT <br />In accordance with the Contract Documents, based on on -site observations and the data <br />comprising this application, the Engineer certifies to the Owner that to the best of the Engineers <br />knowledge, information and belief the Worst has progressed as indicated, the quality of the Work <br />is in accordance with the Contract Documents, and the Contractor is entitled to payment of the <br />AMOUNT CERTIFIED 59,029.20 <br />3rd day of July 2024 <br />