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<br />r <br /> <br />. <br /> <br />. <br /> <br />. <br /> <br />APPLICATION FOR PAYMENT <br />PAYMENT NO.3 <br /> <br />fURS Copy <br />J C~y Copy <br />Contractor Copy <br />Inspector Copy <br /> <br />Project: <br />Owner: <br />Owner No.: <br />Contractor: <br /> <br />2002 Sanitary Sewer and Water Main Rehabilitation Project <br /> <br />City of Arden Hills <br /> <br />BRW Job No.: <br /> <br />VISU-SEWER CLEAN & <br />SEAL, INC. <br />37951-022-0101 <br /> <br />Application Date: <br />For Period Ending: <br /> <br />1/3/02 <br />12/30/02 <br /> <br />Original Contract Amount: <br />Contract Amendments: <br />Contract Amount To Date: <br />Total Amount of Work Complete To Date: <br />Material Suitably Stored On-Site but not <br />Incorporated into Work: <br />Gross Amount Due To-Date: <br />Less 5.00% Retainage: <br />Amount Due To-Date: <br />Less Previous Payments: <br />Total Due This Application: <br /> <br />$246,435.50 <br />$0.00 <br />$246,435.50 <br />$173,875.25 <br /> <br />$0.00 <br />$173,875.25 <br />$8,693.76 <br />$165,181.49 <br />$115,490.07 <br />$49,691 .42 <br /> <br />I hereby certify that all items and amounts shown are correct for the work completed to- <br />date. <br />Contractor: VISU-SEWER CLEAN & SEAL, INC. <br /> <br />By: yd~ 6- ~___ <br /> <br />Date: <br /> <br />/- ~ -OJ <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: <br /> <br />!/S/b '] <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 />