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<br />. <br /> <br />. <br /> <br />. <br /> <br />APPLICATION FOR PAYMENT <br />PAYMENT NO, 3 <br /> <br />Project: <br /> <br />Lift Station #7 Rehabilitation / <br />Karth Lake Pumping Station <br />City of Arden Hills <br /> <br />Owner: <br />Owner No.: <br />Contractor: <br />BRW Job No.: <br /> <br />JAY BROS., INC. <br />37951-028-0101 <br /> <br />Application Date: 4/5/04 <br />For Period Ending: 413/04 <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 />$232,772.50 <br />$0.00 <br />$232,772.50 <br />$173,408.50 <br /> <br />$0.00 <br /> <br />$173,408.50 <br />$8,670.43 <br />$164,738.07 <br />$152,110.20 <br /> <br />$12,627.87 <br /> <br />VAS COpy <br />rCify Copy <br />Contractor Co" <br />Ins""",,_ '>-,Y <br />,,.......... Copy <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: ~~'f'q <br /> <br />Date: <br /> <br />S-"'l-O'-\ <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: {- Lj-f;? y <br /> <br />APPROVED FOR PAYMENT <br />Owner: City of Arden Hills <br /> <br />By: <br /> <br />Date: <br /> <br />Page 1 of 5 <br />