5.k) Bolton & Menk-Contractor's Request for Payment No. 2 and Final Payment, 2013 Seal Coat Project • = _ BOl_TON � M �N K , IN�
Consuiting Engineers & Surveyors
" 2035 Camty Road D East•Suite B•Maplewood,MN 55109-5314
Phone(651)704-9970• Fax(651)704-9971
www.bolton-menk.com
November 12`�',2013
Honorable Mayor and City Council
14727 209"'Street N
Scandia, MN 55073
RE: Contractor's Request for Payment No. 2 and FINAL
2013 Seal Coat Project
Project No.: N 15.107210
Dear Mayor and Council:
Enclosed please find Contractor's Request for Payment No.2 and FINAL for Fahrner Asphalt Sealer LLC
for the services they provided on the above referenced project. This request includes payment of their
retainage.All work has been completed as required by the Contract. IC-134s and the lien waivers for final
closeout are attached.
If the Council chooses to approve a payment for this project, it would be appropriate to approve
Contr�ctor's Request for Payment No.2 and FINAL and pay$9,792.14 to Fa6rner Asphatt Sealer
LLC for the work performed.
Please call me at 612-597-'�140 if you have any questions or concerns regarding this Contractor's
paymept request.
Sincerely,
BOLTON&MENK, INC.
,�"�"'�' �1-�`L..+."-.
Ryan J. Goodman, P.E.
City Engineer
�nclosures
DESIGNING FOR A BETTER TOMORROW
Bolton&Menk is an equal opportunity employer
CONTRACTOR'S PAY REQUEST DISTRIBUTION:
2013 SEAL COAT PROJECT CONTRACTOR(1)
CITY OF SCANDIA, MN OWNER(1)
BMI PROJECT NO. N15.107210 ENGINEER(1)
BONpING CO. (1)
TOTAL AMOUNT BID PLUS APPROVED CHANGE ORDERS $178,411.50
TOTAL, COMPLETEp WORK TO DATE $16�4,a92.69
_
TOTAL_, STORED MAT'ERIALS TO DATE $0.0
DEDUCTION FOR STORED MATERIALS USED IN WORK COMPLETED $0.0
TOTAL, COMPLETED WORK&STORED MATERIALS $164,492.69
RETAINED PERCENTAG� ( 0% ) $0.00
TOTAL AMOUNT OF OTHER PAYMENTS OR(DEDUCTIONS) $0.00
N�T AMOUNT DUE TO�ONTRAGTQR TO DATE $164 492.69
TOTAL AMOUNT P�ID ON PREVIOUS �STIMA�'�S � $154,700.55
PAY CONTRACTOR AS ESTIMMTE NQ 2& Final 9,792.14
Certificate for Final ayment
I hereby certify that, to the best of my knowledge and k�alief, all items quantities and prices
of work and material shown on ihi� �Stimate are corr�c#and that all work has been
performed in full accordance with th�terms and conditions of the Contrac# for this project
between the Qwner and the undersign�d Contractor, and as amended by any
authonzed changes, and that the foregoing is a true and evrrect statement of the amount
for the Final Estimate, th�t#he provisior�s of M. S. 290.92 f�ave bee�oompliec�with and that
aq clairr�s ag�inst me by�eason qf tFie�ontract have been paid or satisfactor�ly secured.
Contractof: �ahrner Asphalt Sea�er LLC
6615 U�S kdvay 1� W
E�u Claire, WI �4702
By
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EN�INE€R: BqL�CQ�U &IUIENK, iNC.,2Q3�CQUN�Y �OAD p �AS�f, 6UITE B, MAPLE�IVQDp, MN
gy , CITY`ENGiNJE�R
Date
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Page 1 of 1
MfNNESOTA• REVENU�
Contractor Affidavit Submitted
Thank you,your Contractor Affidavit has been approved.
Confirmation Summary
Confirmation Number: 1-926-1$8-800
Submitted Date and Time: 8-Oct-2013 9:24:34 AIvI
Legal Name: FAHRNER ASPHALT SEALERS LLC
Federal Employer ID: 11-3804531
User Who Submitted: 8753f)03
Type of Request Submitted: Contractor Affidavit
Affidavit Summary
Affidavit Number: 1513750528
Account Number: 8753003
Project Owner: CITY OF SGANDIA
Project Number: 2013 SEAL COAT
Yroject f3egin Uate: 26-Aug-2013
Project End Date: 04-Sep-2013
Project Location: CITY OF SCANDIA
Project Amount: $164,492.69
Subcontractor Summary
Name ID Affidavit Number
CAREFREE SERVICES INCORP 2075051 1394737152
Important Messages
A copy of this page must be provided to the contractor or government agency that hired you.
Contact Us
If you need further assistance, contact our Withholding Tax Division at(Metro Area)651-282-9999,
(Greater Minnesota) 800-657-3594, (TTY Users)Ca11711 for Minnesota Relay,or(email)
Wit�holding.tax@state.mn.us. Business hours aze 8:00 a.m. -4:30 p.m. Monday-Friday.
How to View and �xint this Request
You cat�see copies of your requests by going to the History Tab.
Please print this confirmation na�e for your records using the print or save functionality built into your
browser.
https://www.mndor.state.mn.us/tp/retrieve?type=PrintFriend&key 1=152U335104&key2=1... 1 U/8/2013
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RECEIPT AND WAIVER OF LIEN RIGHTS
Project: City of Scandia - 2013 Seal Coat
Prime: Fahrner Asphalt Sealers, LLC
Location: City Streets Scandia, MN
The undersigned does hereby waive, release and surrender any
claim, lien or right of lien resultinq from labor, skill, and/or
materials, subcontract work, equipment or other work, rent,
services or supplies heretofore furnished in and for the
constructian, improvement, alteration or additions to the above
described project prior to the date hereof.
This release is given for and in consideration of the sum of
$164, 492. 69 and other good and valuable consideration received in
hand from the City of Scandia.
In further consideration of the payment made as above set
forth, and to induce the City of Scandia to make said payment,
the undersigned agrees to defend and hold harmless the City of
Scandia from any claims hereinafter made by the undersigned
and/or its material suppliers, subcontractors or employees,
servants, agents or assigns of such persons against the project.
It is hereby acknowledged that the designation of the above
project constitutes an adequate description of the property and
improvements for which the undersigned has received consideration
for this release.
This instrument shall constitute a full, final and complete
release of all rights and claims of the undersigned for the work
completed to date.
DATED this 28 day of Qctobe�, 2013.
FAHRNER ASPHALT SEALERS,
L.L.C. , a Wisconsin Limited
Liability Company
���
By: `
Name: Greg Kolodziej
Title: Project Manager
10f 30120i 3 10:03 7634796650 CAf�:FREE SERVICES IN PACa'E 01
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I
I R�C�TPT AND q,AIVER oF ,�TE3J RI�HTB
�
! nxo��ct: C�ty of aaandia - 2013
Pri�: Fahrner Asph�lt Sealers, T�,C
Location:Var�oa� Gity 5txeeta Scandi�, �1
?Me und�x�igned does haxaby waive, xelee►�� and auXr�nder any
elaim� lien or right o£ lien ,r!�sp�.t�.nq �ro�n labor, �1�ill, an,d/ex •
a�tar#.al$► �ubcor�tr��t wprl�. aqu��une»t s�z oth�x Work, �rnt,
�r�rv��s o� �ugpli�a hsx��pfor� �ur�imRed in a�id for kk�e
constru��io�i, i�r�reau�nt, alt��at�.on ar ec�ditianv to the abov�
dee�����d p�Q���� ��c�cr to th• dAte k►�rsn;�* �
This felQase �.s qivsn for an�. i,n cvn��.dsra�,io�, �af ��e s�m ��
417,6�2.00 �►�A oth,4� goosl and valut�bi� co»,�#.dAration xgce�.ved ia
li�nd �xc�m, Fahrnar l�sphalt 5ealexa, �.
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