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<br />. <br /> <br />. <br /> <br />. <br /> <br />APPLICATION FOR PAYMENT <br />PAYMENT NO, 4 <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 />X URS Copy <br />City Copy <br />Contractor Copil <br /> <br />FINAL PAYMENT <br /> <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: 1/6/04 <br /> <br />For Period Ending: 1/5/04 <br /> <br />Original Contract Amount: <br /> <br />Contract Amendments: <br />Contract Amount To Date: <br /> <br />Total Amount of Work Complete To Date: <br /> <br />Materiat Suitabty Stored On. Site but not <br />Incorporated into Work: <br /> <br />Gross Amount Due To.Date: <br /> <br />Less 0.00% Retainage: <br />Amount Due To-Date: <br /> <br />Less Previous Payments: <br /> <br />Total Due This Application: <br /> <br />$284,788.00 <br />$0.00 <br />$284,788.00 <br />$277,045.80 <br /> <br />$0.00 <br /> <br />$277,045.80 <br />$0.00 <br />$277 ,045.80 <br />$254,260.47 <br /> <br />$22,785.33 <br /> <br />I hereby certify that all items and amounts shown are correct for the work completed to- <br />date. <br /> <br />Contractor: JAY BROS., INC. <br /> <br />By: Date: <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 />By: <br /> <br />Date: <br /> <br />//7 klt <br />. <br /> <br />APPROVED FOR PAYMENT <br />Owner: City of Arden Hills <br /> <br />By: <br /> <br />Date: <br /> <br />Page 1 of5 <br />