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<br />^ <br /> <br />. <br /> <br />. <br /> <br />. <br /> <br />Project: <br />Owner: <br />Owner No.: <br />Contractor: <br /> <br />,tIRS Copy <br />If Clty Copy <br />Contractor Copv <br />Inspector Copy <br />2002 Pavement Management Program for Hunters Court and Waldon Place <br />City of Arden Hills <br /> <br />APPLICATION FOR PAYMENT <br />PAYMENT NO.3 <br /> <br />BRW Job No.: <br /> <br />T. A. SCHIFSKY AND SONS <br />INC. <br />37951-020-0101 <br /> <br />Application Date: <br />For Period Ending: <br /> <br />1/6/03 <br />1/13/03 <br /> <br />Original Contract Amount: <br /> <br />Contract Amendments: <br /> <br />Contract Amount To Date: <br />Total Amount of Work Complete To Date: <br /> <br />Material Suitably Stored On-Site but not <br />Incorporated into Work: <br /> <br />Gross Amount Due To-Date: <br /> <br />Less 5.00% Retainage: <br />Amount Due To-Date: <br /> <br />Less Previous Payments: <br /> <br />Total Due This Application: <br /> <br />$160,416.50 <br />$0.00 <br />$160,416.50 <br />$158,160.17 <br /> <br />$0.00 <br />$158,160.17 <br />$7,908.01 <br />$150,252.16 <br />$120,829.99 <br /> <br />$29,422.17 <br /> <br />I hereby certify that all items and amounts shown are correct for the work completed to- <br />date. <br /> <br />Contractor: T. A. SCHIFSKY AND SONS INC. <br /> <br />BY~ (; r...\~ S(,CreJ~ Date: (-~-D..3 <br /> <br />The work on this project and the application for payment have been reviewed and the <br />amount shown is recommended for payment. <br /> <br /> <br />Date: / / 5/0< <br /> <br />By: <br /> <br />APPROVED FOR PAYMENT <br />Owner: City of Arden Hills <br /> <br />By: <br /> <br />Date: <br /> <br />Page 1 of 5 <br />