5.i 2018 Spray Patching Pay Request No 2QBOLTON ENK
Real People. Real Solutions.
September 11, 2018
Honorable Mayor and City Council
14727 209th Street N
Scandia, MN 55073
RE: 2018 Spray Patching Project
City of Scandia
Dear Mayor and Council:
2035 County Road D East
Maplewood, MN 55109-5314
Ph: (6511704-9970
Fax: (651) 704-9971
Bolton-Menk.com
Enclosed please find Contractor's Pay Request No. 2nd and Final for the services Pavement Resources,
Inc. provided on the 2018 Spray Patching Project. We recommend the Council approves the pay request
in the amount of $1,500.00. All work has been completed in accordance with the plans and
specifications.
Please call me this week at 612.597.7140 if you have any questions or concerns regarding this
contractor's pay request.
Sincerely,
a
Ryan J. Goodman, P.E.
City Engineer
Enclosure: Contractor's Pay Request No. 2
\\Bolton-menk\drives\H\SCND\N13116203\1_Corres\C_To Others\Mayor and City Council_RJG^2018 Spray Patching Pay Request No 2.docx
Bolton & Menk is an equal opportunity employer.
CONTRACTOR'S PARTIAL PAY REQUEST
DISTRIBUTION:
2018 Spray Patching Project
CONTRACTOR (1)
OWNER (1)
City of Scandia, MN
ENGINEER (1)
BMI PROJECT NO. N13.116203
TOTAL AMOUNT BID PLUS APPROVED CHANGE ORDERS
$11,500.00
TOTAL, COMPLETED WORK TO DATE
$11,500.00
TOTAL, STORED MATERIALS TO DATE
$0.00
DEDUCTION FOR STORED MATERIALS USED IN WORK COMPLETED
$0.00
TOTAL, COMPLETED WORK & STORED MATERIALS
$11,500.00
RETAINED PERCENTAGE ( 0% )
$0.00
TOTAL AMOUNT OF OTHER PAYMENTS OR (DEDUCTIONS)
$0.00
NET AMOUNT DUE TO CONTRACTOR TO DATE
$11,500.00
TOTAL AMOUNT PAID ON PREVIOUS ESTIMATES
$10,000.00
PAY CONTRACTOR AS ESTIMATE NO. 2nd & Final
$1,500.00
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: Pavement Resources, Inc.
13535 Johnson Street NE
Ham Lake, MN 55304
By
Name
Title
Date
CHECKED AND APPROVED AS TO QUANTITIES AND AMOUNT:
ENGINEER: BOLTON & MENK, INC., 2035 COUNTY RD D EAST MAPLEWOOD, MN 55109.
By CITY ENGINEER
Ryan J. Goodman, PE
Date
APPROVED FOR PAYMENT:
OWNER: City of Scandia, MN
By
Name Title Date
Partial Pay Estimate No.:
2018 Spray Patching Project
City of Scandia, MN
BMI PROJECT NO. N13.116203
WORK COMPLETED THROHCH WPTFMRFR 11 201R
2nd & Final
8/8/2018 https://www.mndor.state.mn.us/tp/eservices/_/Retrieve/0/c-/sDPNVRnNmnYoIjMZLzEkxg_?FILE= Print2&PARAMS= 1400753320487874575
DEPARTMENT
OF REVENUE
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:
1-807-040-192
8 -Aug -2018 3:24:58 PM
PAVEMENT RESOURCES INC
41-1994447
PRI5182233
Contractor Affidavit
1644191744
5182233
CITY OF SCANDIA
N 13.116203
20 -Jun -2018
07 -Aug -2018
CITY OF SCANDIA
$11,500.00
No Subcontractors
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 651-282-9999, (toll-free) 800-657-3594, or (email)
withhold ing.tax@state.mn.us. Business hours are 8:00 a.m. - 4:30 p.m. Monday - Friday.
Please print this page for your records using the print or save functionality built into your browser.
https://www.mndor.state.mn.uS/tp/eservices/_/Retrieve/0/c-/sDPNVRnNmnYoIjMZLzEkxg_?FILE =Print2&PARAMS =1400753320487874575
1/1
MINNESOTA- REVENUE IC134
Contractor Affidavit
This Contractor Affidavit must be certified by the Minnesota Department of Revenue before the state of Minnesota or any of its
subdivisions can make final payment to contractors. For more detailed informat on, see the instructions on the back of this form.
Please type or print clearly, This information will be used for returning the completed form.
I company name — — — — — Daytime phone I Minnesota tax ID number
Pavement Resources, Inc. i 763 434-2828 5182233
Address Total contract amount Month/year work began
13535 Johnson Street NE I $ 11,500.00 July, 2018
City State ZIP code I Amount stili due Month/year work ended
�Ham Lake MN 55304
` _ _ _ _ _
— _) $ 11,500.00 August 7, 2018
Project number Project location
o N13.116203 City of Scandia
to Project owner Address City State ZIP cede
E City of Scandia 14727 209th Street North Scandia MN 55073
a
Did you have empioyees work on this project?
X Yes No. It n4 who did the work?
Check the box that describes your involvement in the project and fill in all information requested.
sole contractor
Subcontractor
Name of contractor who hired you
Address
m Prime contractor—If you subcontracted out any work on this project, all of your subcontractors must submit their own Contractor
Baa, Affidavits and have them certified by the Department of Revenue before you can submit your Contractor Affidavit. For each
subcontractor you had, fill in the information below and attach a copy of each subcontractor's certified Contractor Affidavit. If you
5 need more space, attach a separate sheet.
- Business name Address Owner/Officer
O
V
m 1 declare that all information I have filled in on this form is hue and complete to the best of my knowledge and belief. I authorize the Department of Revenue to
m disclose pertinent information relatirg to this protect, including sending copies of this form, to the prime contractor if 1 am a subcontractor, and to any subcon-
= tractors if I am a pri cortract to the contracting agency.
Contractor's signat re Title Date
President 8-8-2018
Mail to: Minnesota nue, Station 6610, St. Paul, MN 55146-6610
Phone: 651-282-99 9 1-80D- 7-3594 (TTY: Call 711 for Minnesota Relay).
Certificate of Compliance
Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this Contractor Affidavit
has fulfilled all the requirements of Minnesota Statutes 290.92 and 270C.66 concerning the withholding of Minnesota income
tax from wages paid to employees relating to contract services with the state of Minnesota and/or its subdivisions.
Department of Revenue approval
I Rev. 4/15)
Date