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5.j Bliss Addition Drainage Improvements Pay Request No 1 and FinalQBOLTON ENK Real People. Real Solutions. September 13, 2018 Honorable Mayor and City Council 14727 209th Street N Scandia, MN 55073 RE: Bliss Addition Drainage Improvements Contractor's Request for Payment No. 1 and Final Dear Mayor and Council: 2035 County Road D East Maplewood, MN 55109-5314 Ph: (651) 704-9970 Fax: (651) 704-9971 Bolton-Menk.com Enclosed please find Contractor's Pay Request No. 1 and Final for the services Peterson Excavating, Inc. provided on the Bliss Addition Drainage Improvements. We recommend the Council approves the pay request in the amount of $15,442.50. All work has been completed in accordance with the plans and specifications. The contractor's IC -134 is attached for closeout. Please call me this week at 612.597.7140 if you have any questions or concerns regarding this contractor's pay request. Sincerely, Ryan J. Goodman, P.E. City Engineer Enclosure: Contractor's Pay Request No. 1 & Final, IC -134 H:\SCND\N15106565\Bliss Addition -Ditching Improvements\Pay Request\Mayor and City Council_RJGABliss Addition Drainage Improvements Pay Request No 1 and Final.docx Bolton & Menk is an equal opportunity employer. Date: 13-Sep-18 CONTRACTOR'S PAY REQUEST Bliss Addition Drainage Improvements Pay Request No. 1St and Final City of Scandia, MN BMI Project No. N15.106565 For Period Ending: 9/13/2018 Original Contract Amount $15,442.50 Approved Change Orders $0.00 Revised Contract Amount $15,442.50 Completed Work to Date $15,442.50 Stored Materials on Hand $0.00 Sub-Total $15,442.50 Retained Percentage 0% $0.00 Deduction $0.00 Liquidated Damages $0.00 Total $15,442.50 Total Amount Paid on Previous Estimates $0.00 Amount Due Contractor This Pay Request $15,442.50 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. Peterson Excavating Inc. Signature Date P.O. Box 69 Scandia, MN Printed Name and Title Checked and Approved as to Quantities and Amount: Signature Date Bolton & Menk, Inc. 2035 County Road D East Maplewood, MN 55109 Printed Name and Title Approved for Payment: City of Scandia, MN Name Title Date Partial Pay Estimate No.: BLISS ADDITION CITY OF SCANDIA, MINNESOTA BMI PROJECT NO. N15.106565 BASE BID 1st and Final 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 information, see the instructions on the back of this form. Please type or print clearly. This information will be used for returning the completed form. / Company name 1 Daytime phone Peterson Excavating Inc I 651-433-2977 Address Total contract amount PO Box 69 $ 15,442.50 city State ZIP code I Amount still due Scandia MN 55073 $ 15,442.50 Minnesota tax ID number 6148448 Month/year work began 07/2018 9/2018 Project number Project location c N13.116203 City Of Scandia R Project owner Address city State ZIP code a 0 City of Scandia 14727 209th St N Scandia MN 55073 Did you have employees work on this project? Y Yes ❑ No. If no, 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 o ❑ Prime contractor—If you subcontracted out any work on this project, all of your subcontractors must submit their own Contractor FAffidavits and have them certified by the Department of Revenue before you can submit your Contractor Affidavit. For each c subcontractor you had, fill in the information below and attach a copy of each subcontractor's certified Contractor Affidavit. If you Q need more space, attach a separate sheet. 0 Business name Address Owner/Officer 0 V y 1 declare that all information 1 have filled in on this form is true and complete to the best of my knowledge and belief. I authorize the Department of Revenue to y disclose pertinent information relating to this project, including sending copies of this form, to the prime contractor if I am a subcontractor, and to any subcon- tractors if I am a prime contractor, and to the contractency. = Verified by PDFfiller I Contractor's signature 09/12/2018 Title Date N ----------- owner 09/12/2018 Mail to: Minnesota Revenue, Mail Station 6610, St. Paul, MN 55146-6610 Phone: 651-282-9999 or 1-800-657-3594 (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 Date (Rev. 4/15) MINNESOTA• REVENUE Form IC134 Instructions Contractor Affidavit No state agency or local unit of government can make final payment to a contractor un- til the Department of Revenue has certified that the contractor and any subcontractor have fulfilled the requirements of Minne- sota withholding tax laws. If you are a prime contractor, a contrac- tor or a subcontractor who did work on a project for the state of Minnesota or any of its local government subdivisions — such as a county, city or school district — you must submit a Contractor Affidavit to the Depart- ment of Revenue to receive a certificate of compliance. Use of Information The Department of Revenue needs all the requested information to determine if you have met the state income tax withholding requirements. If all required information is not provided, Form IC134 will be returned to you for completion. All information on this Contractor Affidavit is private by state law. It cannot be given to others without your permission, except to the Internal Revenue Service, other states that guarantee the same privacy and certain government agencies as provided by law. Minnesota Tax ID Number You must have a Minnesota tax ID number if you have employees who work in Min- nesota. You must enter your Minnesota tax ID number on Form IC134. If you don't have a Minnesota tax ID number, apply online at www.revenue.state. mn.us or by calling our Business Registra- tion Office at 651-282-5225 or 1-800-657- 3605. If you have no employees and did all the work yourself, you do not need a Minnesota tax ID number. Instead, enter your Social Security number in the space for Minnesota tax ID number and explain who did the work. Submit Contractor Affidavit Form IC134 cannot be processed by the Department of Revenue until you finish the work. If you submit the form before the project is completed, it will be returned to you unprocessed. If any withholding payments are due to the state, Minnesota law requires certified pay- ments before we approve your Form IC134. If you are a subcontractor or sole contractor, submit the form when you have completed your part of the project. If you are a prime contractor, submit the form when the entire project is completed and you have received certified Contractor Affidavits from all of your subcontractors. If you're a prime contractor and a subcontractor on the same project If you were hired as a subcontractor to do work on a project, and you subcontracted all or a part of your portion of the project to another contractor, you are a prime contrac- tor as well. Complete both the subcontrac- tor and prime contractor areas on a single Form IC134. You may submit your Contractor Affidavit either electronically or by mail. This af- fidavit must be certified and returned before the state or any of its subdivisions can make final payment for your work. For an immediate response: Complete and submit your Contractor Affidavit elec- tronically. Go to wwwrevenue.state.mn.us and choose Withholding Tax. Under the File and Pay tab, click on Contractor Affida- vit Information for Government Projects. You may complete and mail Form IC134 to: Minnesota Revenue, Mail Station 6610, St. Paul, MN, 55146-6610. If you have ful- filled the requirements of Minnesota with- holding tax laws, the department will sign your Form IC134 and return it to you. To receive your final payment, submit the certified Contractor Affidavit to the govern- ment unit for which the work was done. If you are a subcontractor, submit the certified Contractor Affidavit to your prime contrac- tor to receive your final payment. Information and Assistance Additional forms and information, includ- ing fact sheets and frequently asked ques- tions, are available on our website. Website: www.revenue.state.mn.us Email: withholding.tax@state.mn.us Phone: 651-282 9999 or 1-800-657-3594. We'll provide information in other formats upon request to persons with disabilities.