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<br />ENGINEER)S COpy I <br /> <br />4- <br /> <br />Bonestroo <br /> <br />Owner: City of Centerville, 1880 Main St., Centerville, MN 55038 Date: Julv 15, 2009 <br />For Period: 6/18/2009 to 7/15/2009 ,. Reauest No: 3 <br />Contractor: Forest Lake Contractina, 14777 Lake Dr, Forest Lake, MN 55025 <br /> <br />CONTRACTOR'S REQUEST FOR PAYMENT <br />PELTIER LAKE DRIVE STREET AND UTILITY IMPROVEMENTS <br />BONESTROO FILE NO. 000616-09169-0 <br />CITY PROJECT NO 200901 <br /> <br />SUMMARY <br />1 Original Contract Amount <br />2 Change Order - Addition <br />3 Change Order - Deduction <br />4 Revised Contract Amount <br />5 Value Completed to Date <br />6 Material on Hand <br />7 Amount Earned <br />8 Less Retainage 5% <br />9 Subtotal <br />10 Less Amount Paid Previously <br />11 Liquidated damages - <br />12 AMOUNT DUE THIS REQUEST FOR PAYMENT NO. <br /> <br />$ 249,11625 <br />$ 000 <br /> <br />3 <br /> <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br /> <br />Recommended for Approval by: <br />BONESTROO <br /> <br />Ity <br /> <br />Approved bY. '"""~ r:. . <br />F~KE CON G J ft <br /> <br />c' ;...{"t.{ <br />- <br />t _.// <br /> <br />Approved by Owner: <br />CITY OF CENTERVILLE <br /> <br />$ <br /> <br />1,534,085.11 <br /> <br />1,783,20136 <br />510,089.86 <br />0.00 <br />510,089,86 <br />25,50449 <br />484,585.37 <br />296,716.07 <br />0,00 <br />187,869.30 <br /> <br />Specified Contract Completion Date: <br /> <br />Date: <br /> <br />61609169REQ3x1s <br />