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CONTRACTORS REQUEST FOR PAYMENT <br /> Project: Downtown Storm Water Phase 1 Contract A Job No. 2109 <br /> For Period: 7/14/11 through 9/14/11 Date: 9/14/2011 <br /> Pay Estimate No: 3 (Final) <br /> Owner Contractor <br /> City of Centerville Ellingson Drainage, Inc <br /> 1880 Main St. 56113 State Hwy 56 - Box 68 <br /> Centerville, MN. 55038 West Concord, MN. 55985 <br /> CONTRACTOR PAYMENT REQUEST SUMMARY: <br /> Original Contract Amount $124,721.65 <br /> Change Order • Addition $ - <br /> Change Order - Deduction $ - <br /> Revised Contract Amount $124,721.65 <br /> Value Completed To date $120,623.99 <br /> Materials On Hand $0.00 <br /> -- Amount Eamed - <br /> - - - $120,629:99 - -- - <br /> Less Retainage 0 %, <br /> $0.00 <br /> Subtotal <br /> $120,623.99 <br /> Less Previous Payment Requests $113,490.79 <br /> Total Amount Due $7,133.20 <br /> SUMMARY OF PREVIOUS PAYMENTS REQUEST: <br /> NO. DATE TOTAL <br /> 1 03/17/2011 $83,071.80 <br /> 2 07/14/2011 $30,418.99 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> TOTAL PRIOR PAYMENTS $113,490.79 <br /> i 1 <br /> Contractor Engineer <br /> Ellingson Drainage, Inc. <br /> 29 <br />