9.f Request for payment for 2017 patching contractBolton & Menk is an equal opportunity employer.
CONTRACTOR'S FINAL PAY REQUEST
DISTRIBUTION:
CONTRACTOR (1)
2017 Bituminous Patching Project
OWNER (1)
City of Scandia, MN
ENGINEER (1)
TOTAL AMOUNT BID PLUS APPROVED CHANGE ORDERS
$56,833.50
TOTAL, COMPLETED WORK TO DATE
$40,707.90
TOTAL, STORED MATERIALS TO DATE
.$0.00
DEDUCTION FOR STORED MATERIALS USED IN WORK COMPLETED
$0.00
TOTAL, COMPLETED WORK & STORED MATERIALS
$40,707.90
RETAINED PERCENTAGE ( 0%)
$0.00
TOTAL AMOUNT OF OTHER PAYMENTS OR (DEDUCTIONS)
$0.00
NET AMOUNT DUE TO CONTRACTOR TO DATE
$40,707.90
TOTAL AMOUNT PAID ON PREVIOUS ESTIMATES
$0.00
PAY CONTRACTOR AS ESTIMATE NO. 1 & Final
$40,707.90
Certificate for Final Payment
I hereby certify that, to the best of my knowledge and belief, all items quantities and prices
of work and material shown on this Estimate are correct and that all work has been
performed in full accordance with the terms and conditions of the Contract for this project
between the Owner and the undersigned Contractor, and as amended by any
authorized changes, and that the foregoing is a true and correct statement of the amount
for the Final Estimate, that the provisions of M. S. 290.92 have been complied with and that
all claims against me by reason of the Contract have been paid or satisfactorily secured.
Contractor: Northwest Asphalt, Inc.
1451 Stagecoach Road
Shakopee, MN 55379
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Name Title
Date
CHECKED AND APPROVED AS TO QUANTITIES AND AMOUNT:
ENGINEER: BOLTON & MENK, INC., ENGINEERS, 2035 COUNTY RD D EAST MAPLEWOOD, MN 55109
By , CITY ENGINEER
Date
APPROVED FOR PAYMENT:
OWNER: City of Scandia, MN
By
Name Title Date
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6/13/2017 https://www.mndor.state.mn.us/tp(eservices/ /Retrieve/0/c-/u0 keWXn3NLPxARjHM7Byg ?FILE=Print2
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Contractor Affidavit Submitted
Thank you, your Contractor Affidavit has been approved.
Confirmation Summary
Confirmation Number:
Submitted Date and Time:
Legal Name:
Federal Employer ID:
User Who Submitted:
Type of Request Submitted:
Affidavit Summary
Affidavit Number:
Minnesota ID:
Project Owner:
Project Number:
Project Begin Date:
Project End Date:
Project Location:
Project Amount:
Subcontractors:
1-589-385-024
13 -Jun -2017 3:29:15 PM
NORTHWEST ASPHALT INC
41-1321372
northwest
Contractor Affidavit
161849344
5333310
CITY OF SCAN DIA
2017 BIT PATCH
05 -Jun -2017
06 -Jun -2017
SCANDIA
$40,707.90
No Subcontractors
Important Messages
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Contact Us
If you need further assistance, contact our Withholding Tax Division at 651-282-9999, (toll-free) 800-657-3594, or (email)
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https://www.mndor.state.mn.us/tpleservicesl lRetrievelOIc-iu0 keWXn3NLPxARjHM7Byg_?FILE=Print2 111