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<br />. <br /> <br />. <br /> <br />. <br /> <br />APPLICATION FOR PAYMENT <br />PAYMENT NO.3 <br /> <br />Project: <br /> <br />2003 Sanitary Sewer Rehabilitation <br />Lift Station #5 Reconstruction <br />Lift Station #2 Reconstruction <br />City of Arden Hills <br /> <br />URSOcpf <br />cay ecw <br />'t< COllbaclOlCtlpf <br />Inspector Copy <br /> <br />I hereby certify that all items and amounts shown are correct for the work completed to- <br />date, <br /> <br />Contra JAY BROS" INC. <br /> <br />Owner: <br />Owner No,: <br />Contractor: <br />BRW Job No.: <br /> <br />JAY BROS., INC. <br />37951-024-0101 <br /> <br />Application Date: <br />For Period Ending: <br /> <br />10/27/03 <br />10/20/03 <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 /> <br />Total Due This Application: <br /> <br />$284,788.00 <br />$0.00 <br />$284,788.00 <br />$267,642.60 <br /> <br />$0,00 <br /> <br />$267,642,60 <br />$13,382,13 <br />$254,260.47 <br />$233,524.96 <br /> <br />$20,735.51 <br /> <br />By: <br /> <br /> <br />Date: /0 r- Z F CJ '5 <br /> <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 />By: <br /> <br />Date: /0';< /.&')3 <br /> <br />APPROVED FOR PAYMENT <br />Owner: City of Arden Hills <br /> <br />By: <br /> <br />Date: <br /> <br />Page 1 of 5 <br />