4.3. SR 06-20-2016 - Laserfiche WebLink

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Contractor's Application For Payment No. 19 is approved by: Approved by: (Finance Director) Funding Agency (if applicable) EJCDC No. C-620 (2002 Edition) Prepared by the Engineers' Joint Contract Documents Committee and mclorxd by the Associated General Contractan of America and the Construction Specifications rnstifisO. (Date) (Date) Application Period To: 5/31/2016 Application Date: 5/31/2016 To (Owner): City of Elk River From (Contractor): Rice Lake Construction Group Via (Engineer): Balton & Menk, Inc. Project: Wastewater Treatment Facility Improvements 2014 Contract: All Construction Owner's Contract No.: Contractor's Project No.: 1422 Application for Payment Change Order Summary Approved Change Orders 1. ORIGINAL CONTRACT PRICE $16,525,200.00 Number Additions Deductions 2. Net change by Change Orders $259,991.59 1 $ 259,991.59 3. CURRENT CONTRACT PRICE (Line 1 t 2) $16,785,191.59 4. TOTAL COMPLETED AND STORED TO DATE (Column F on Progress Estimate) $13,899,995.83 5. RETAINAGE: a. 5% x $13,899,995.63 Work Completed $694,999.79 b. 5% x $0.00 Stored Materials $0.00 c. Total Retainage (Line 5a + Line 5b) $694,999.79 S. AMOUNT ELIGIBLE TO DATE (Line 4 - Line 5c) $13,204,996.04 7. LESS PREVIOUS PAYMENTS (Line 6 from prior Application) $12,980,466.05 TOTALS $259,991.59 $0.00 8• AMOUNT DUE THIS APPLICATION $224,529.99 8. BALANCE TO FINISH, PLUS RETAINAGE NET CHANGE BY (Column G on Progress Estimate+ Line 5 above) $3,580,195.55 CHANGE ORDERS $259,999.59 Contractor's Certification The undersigned Contractor certifies that (1) all previous progress Payment of: $224,529.99 payments received from Owner on account of Work done under the (Line 8 or other - attach explanation of other amount) Contract have been applied on account to discharge Contractor's legitimate obligations incurred in connection with Work covered by prior Applications for Payment; (2) title of ail Work, materials and equipment is recommended by: l tulle 7, 2016 incorporated in said Work or otherwise listed in or covered b this 7y Application for Payment will pass to Owner at time of payment free and (Eingineer) (Date) dear of all Liens, security interests and encumbrances (except such as are covered by a Bond acceptable to Owner indemnifying Owner against any $224, 529.99 such Liens, security interest or encumbrances); and (3) all Work Covered Payment of: by this Application for Payment is in accordance with the Contract (Line 8 or other - attach explanation of other amount) Documents and is not defective, is approved by: Approved by: (Finance Director) Funding Agency (if applicable) EJCDC No. C-620 (2002 Edition) Prepared by the Engineers' Joint Contract Documents Committee and mclorxd by the Associated General Contractan of America and the Construction Specifications rnstifisO. (Date) (Date)