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0 <br />Project: Wastewater <br />Application for Payment <br />Change Order Summary <br />Application venoo i o: <br />From (Contractor): Rice Lake <br />Contract: All Construction <br />Contractor's Project No.: 1422 <br />Contractor's Certification <br />The undersigned Contractor certifies that: (1) all previous progress <br />payments received from Owner on account of Work done under the <br />Contract have been applied on account to discharge Contractor's <br />legitimate obligations incurred in connection with Work covered by prior <br />Applications for Payment; (2) title of all Work, materials and equipment <br />incorporated in said Work or otherwise listed in or covered by this <br />Application for Payment will pass to Owner at time of payment free and <br />Gear of all Liens, security interests and encumbrances (except such as are <br />covered by a Bond acceptable to Owner indemnifying Owner against any <br />such Liens, security interest or encumbrances); and (3) all Work covered <br />by this Application for Payment is in accordance with the Contract <br />Documents and is not defective. <br />Contractor's Application For Payment No. <br />5 lAvolication Date: 7/31/2015 <br />Bolton & Menk, Inc. <br />ORIGINAL CONTRACT PRICE <br />Net change by Change Orders <br />CURRENT CONTRACT PRICE (Line 1 t 2) <br />TOTAL COMPLETED AND STORED TO DATE <br />(Column F on Progress Estimate) <br />RETAINAGE: <br />1. 5% x $6,947,790.49 Work Completed <br />J. 5% x $0.00 Stored Materials <br />:. Total Retainage (Line 5a + Line 5b) <br />AMOUNT ELIGIBLE TO DATE (Line 4 - Line 5c) <br />LESS PREVIOUS PAYMENTS (Line 6 from prior Application) <br />AMOUNT DUE THIS APPLICATION <br />BALANCE TO FINISH, PLUS RETAINAGE <br />(Column G on Progress Estimate + Line 5 above) <br />Payment of: $916,141.53 <br />(Line 8 or other - attach explanation of other amount) <br />$16,525,200.00 <br />$259,991.59 <br />$16,785,191.59 <br />$6,947,790.49 <br />$347,389.52 <br />$0.00 <br />$347,389.52 <br />$6,600,400.97 <br />$5,684,259.44 <br />$916,141.53 <br />$10,184,790.62 <br />is recommended by: C July 31, 2015 <br />(Engineer) (Date) <br />Payment of: $916,141.53 <br />(Line 8 or other - attach explanation of other amount) <br />is approved by: <br />Approved by: <br />(Finance Director) <br />Funding Agency (if applicable) <br />FICDC No. C-620 (2002 Edition) <br />Prepared by the Engineers' Joint Contract Documents Committee and endorsed by the Associated General Contractors of America and the Construction Specifications Institute. <br />(Date) <br />(Date) <br />