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5.k) Contractors Request for Payment No 2 Final-Lilleskogen ParkBOLTONMF=NK, INC© Consulting Engineers & Surveyors 2035 County Road D East • Suite B • Maplewood, MN 55109-5314 Phone (651) 704-9970 • Fax (651) 704-9971 www.bolton-menk.com December 8, 2015 Honorable Mayor and City Council 14727 209th Street N Scandia, MN 55073 RE: Contractor's Request for Payment No. 2 & Final Lilleskogen Park Improvements Project No.: N15.106565 Dear Mayor and Council: Enclosed please find Contractor's Request for Payment No. 2 & Final for T.A. Schifsky & Sons, Inc. for the services they provided on the above referenced project. All work has been completed as required by the Contract. IC- 134's have been enclosed for final closeout. The Contractor's Request for Payment is for the amount of $3,194.90. At this time we recommend the Council make a payment in the amount of $3,194.90 to T.A. Schifsky & Sons, Inc. for the work performed. The request includes payment of their retainage. Please call me at 612-597-7140 if you have any questions or concerns regarding this Contractor's payment request. Sincerely, Ryan J. Goodman, P.E. City Engineer Enclosure: Contractor's Request for Payment No. 2 & Final and IC- 134's DESIGNING FOR A BETTER TOMORROW Bolton & Menk is an equal opportunity employer Date: 27-Oct-2015 CONTRACTOR'S PAY REQUEST Lilleskogen Park Improvements Pay Request No. 2 & Final City of Scandia, MN Consultant Project No. N15.106565 For Period Ending: 27-Oct-2015 Original Contract Amount $40,475.00 Approved Change Orders - Addition ($2,575.00) Approved Change Orders - Deduction $0.00 Revised Contract Amount $37,900.00 Completed Work to Date $33,555.00 Stored Materials on Hand $0.00 Sub -Total $33,555.00 Retained Percentage 0% $0.00 Liquidated Damages $0.00 Total $33,555.00 Total Amount Paid on Previous Estimates $30,360.10 Amount Due Contractor This Pay Request $3,194.90 Approved for Payment: T.A. Schifsky & Sons, Inc. Signature Date 2370 Hwy 36 E N. St. Paul, MN 55109 Printed Name and Title Checked and Approved as to Quantities and Amount: Signature Date Bolton & Menk, Inc. 2035 County Road D East, Suite B Maplewood, MN55109 Printed Name and Title Approved for Payment: City of Scanida City of Scandia Date Partial Pay Estimate No.: 2 & Final Lilleskogen Park Improvements City of Scandia, MN BMI Project No. N15.106565 WORK COMPLETED THROUGH OCTOBER 27. 2015 ITEM NO. ITEM UNIT PRICE AS BID PREVIOUS ESTIMATE COMPLETED TO DATE ESTIMATED QUANTITY ESTIMATED AMOUNT ESTIMATED QUANTITY ESTIMATED AMOUNT ESTIMATED QUANTITY ESTIMATED AMOUNT BASE BID: ALTERNATE NO. 1 - LILLESKOGEN PARK IMPROVEMENTS 1 Mobilization $5,000.00 1.00 LS $5,000.00 1.00 LS $5,000.00 1.00 LS $5,000.00 2 Traffic Control $1,200.00 1.00 LS $1,200.00 0.50 LS $600.00 1.00 LS $1,200.00 3 Subgrade Preparation $1.00 810.00 SY $810.00 810.00 SY $810.00 810.00 SY $810.00 4 Aggregate Base, Class 5 $15.00 230.00 TN $3,450.00 234.20 TN $3,513.00 234.20 TN $3,513.00 5 Concrete Curb & Gutter, B618 $20.00 280.00 LF $5,600.00 269.00 LF $5,380.00 269.00 LF $5,380.00 6 6" Concrete Sidewalk, Class A $53.00 75.00 SY $3,975.00 67.00 SY $3,551.00 67.00 SY $3,551.00 7 Pedestrian Curb Ramp $8.00 45.00 SF $360.00 45.00 SF $360.00 45.00 SF $360.00 8 Truncated Domes $50.001 8.00 SF $400.00 8.00 SF $400.00 8.00 SF $400.00 9 Bituminous Material for Tack Coat $1.00 40.00 GAL $40.00 0.00 GAL $0.00 0.00 GAL $0.00 10 Type Sp 9.5 Wearing Course Mixture 2,C $83.00 180.00 TN $14,940.00 148.00 TN $12,284.00 148.00 TN $12,284.00 11 Inlet Protection $125.00 1.00 EA $125.00 0.00 EA $0.00 1.00 EA $125.00 12 Hydraulic Matrix Type Hydraulic Mulch $2.50 150.00 SY $375.00 0.00 SY $0.00 0.00 SY $0.00 13 Seed Mixture 25-131 $10.00 10.00 LB $100.00 0.00 LB $0.00 0.00 LB $0.00 14 Common Topsoil Borrow LV $30.00 50.00 CY $1,500.00 0.00 CY $0.00 0.00 CY $0.00 15 4" Solid Line White - Epoxy $4.00 210.00 LF $840.00 0.00 LF $0.00 218.00 LF $872.00 16 Pavement Message(Handicap Symbol) - Epoxy $280.00 1.00 EA $280.00 0.00 EA $0.00 0.00 EA $0.00 17 Silt Fence $3.00 260.00 LF $780.00 0.00 LF $0.00 0.00 LF $0.00 18 Remove Timber Retaining Wall $600.00 1.00 LS $600.00 0.00 LS $0.00 0.00 LS $0.00 19 Sediment Control Log $5.00 20.00 LF $100.00 12.00 LF $60.00 12.00 LF $60.00 TOTAL BASE BID: $40,475.00 $31,958.00 $33,555.00 CHANGE ORDER NO. 1: PART 1-DEDUCT Hydraulic Matrix Type Hydraulic Mulch $2.50 -150.00 SY $375.00 0.00 SY $0.00 0.00 SY $0.00 Seed Mixture 25-131 $10.00 -10.00 LB $100.00 0.00 LB $0.00 0.00 LB $0.00 Common Topsoil Borrow LV $30.00 -50.00 CY $1,500.00 0.00 CY $0.00 0.00 CY $0.00 Remove Timber Retaining Wall 1 $600.00 -1.00 LS $600.00 0.00 LS $0.001 0.00 LS $0.00 TOTAL CHANGE ORDER: ($2,575.00) $0.00 $0.00 TOTAL BASE BID PLUS CHANGE ORDER NO. 1: $37,900.00 $31,958.00 $33,555.00 12/8/2015 https:/Iwww.mndor.state.mn.usitp/eservicesl /Retrieve/0/b-/7dUXDWnTusndZcbS VCing ?FILE_=Print2 MINNESOTA- 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: Subcontractor Summary Name M. MILLER EXCAVATING LLC 0-629-493-824 8-Dec-2015 3:06:27 PM TA SCHIFSKY & SONS INC 41-0808498 taschifsky Contractor Affidavit 1448820736 8648671 CITY OF SCAN DIA N 15.106565 03-Aug-2015 30-Oct-2015 LILLESKOGEN PARK, SCANDIA, MN $33,555.00 ID Affidavit Number *** "*-0653 522895360 RON KASSA CONSTRUCTION INC 2991400 2000797696 SAUVES OUTDOOR SERVICE INC 4311356 1511407616 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) withholding.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/ IRetrievelO/b-[7dUXDWnTusndZobS VCing ?FILE= Print2 1/1 11/9/2015 https://www.mndor,state.mn.usftp/contractorafidaviUl /Retrieve/O/b-/Byl_eweglWES3[FbLJrvgcL?FILE—=Print2 Contractor Affidavit Submitted Thank you, your Contractor Affidavit has been approved. Confirmation Summary Confirmation Number: Submitted Date and Time: Legal Name: Social Security Number: Type of Request Submitted: Affidavit Summary Affidavit Number: Project Owner: Project Number: Project Begin Date: Project End Date: Project Location: Project Amount: Subcontractors: 1-209-811-008 9-Nov-2015 1:16:37 PM M. MILLER EXCAVATING LLC ***--**-0653 Contractor Affidavit 522895360 T.A. SCHIFSKY & SONS INC. 15-104 01-Jun-2015 21-Oct-2015 LILLESKOGEN PARK IMP., SCANDIA. MN $3,650.00 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) withholding.tax@state.mn,us. Business hours are 8:00 a.m. - 4:30 p.m. Monday - Friday, Please pritit this page for your records using the print or save functionality built into your browser. https://www.mndor.state.mn,usltplcontractoraffidavitl lRetrievel0lb-16yl_eweglWES3lFbLJrvgg__?FILE= Print2 ill 11/18/2015 https:/lwww.mndor.state.mn.us/tp/eservices/ 1Retrieve/Oib-/cpNPv22ND[Rl6LwjvEkLjw_?FILE =Print2 MINNES A ` REVENUE Contractor Affidavit Submitted Thank you, your ContractorAffidavit 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: 0-712-384-576 18-Nov-2015 9:36:52 AM RON KASSA C ON STR U CTION INC 41-1861276 RonKassa Contractor Affidavit 2000797696 2991400 CITY OF SCANDIA 15-104 01-Aug-2015 31-Aug-2015 PARKING LOT IN SCANDIA $8,800.00 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) withholding.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:lwww.mndor.state.mn.usltpleservicesl IRetrievet0lb-lcpNPv22NDIR16LwjvEkq%A ?FILE= Print2 1/1