CCP 07-09-2013 - Laserfiche WebLink

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Shank Constructors, Inc. APPLICATION FOR PAYMENT 3501 85th Avenue North Project: New Brighton WTP#1 -Chemical Upgrades Brooklyn Park, MN 55443 Engineer: Barr Engineering Shank Project No: 1256 TO: Barr Engineering Application Number: 03 4700 West 77th St. Date: 06/25/13 Minneapolis, MN 55435 Period From: 04/26/13 To: 06/25/13 CHANGE ORDER Application is made for Payment in connection SUMMARY with the Contract. Continuation Sheet is attached. Additions Deductions The present status of this Contract is as follows: Change Orders approved previous by Owner TOTAL ORIGINAL CONTRACT SUM 138,600 Subsequent C.O. Net Change by Change Orders 1,500 CONTRACT SUM TO DATE 140,100 TOTAL COMPLETED&STORED TO DATE 140,100 RETAINAGE: 0% 0 TOTALS TOTAL EARNED LESS RETAINAGE 140,100 Net Change by C.O. 1,500 LESS PREVIOUS PAYMENT 128,250 The Contractor certifies that the work covered by this application for payment has been completed in CURRENT PAYMENT DUE 11,850 accordance with the Contract Documents, that all State of: Minnesota County of: Anoka amounts have been paid by him for Work for which Subscribed and sworn to before me Date:(42/21/1 j previous Certificates for Payment were issued and payments recieved from the Owner, and that the current Notary Publi6. payment shown is now due. My Commissi•• xpires:' v M.sEYIOLA CONTRACTOR. PubicNotary itycalwribtilAinmic Date: 12-4/13 -( . ENGINEER'S CERTIFICAT FOR PAYMENT In accordance with the Contract and this Application for payment the contractor is entitled Owner to payment in the amount shown above. _ Engineer ENGINEER: _ Contractor By: Date: OWNER'S CERTIFICATE FOR PAYMENT In accordance with the Contract and this Application for payment the contractor is entitled to payment in the amount shown above. OWNER: By: Date: This certificate is not negotiable. It is payable only to the named herein and its issuance, payment and acceptance are without prejudice to any rights of the Owner or Contractor under their Contract.