HomeMy WebLinkAboutApplication for Payment
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APPLICATION FOR PAYMENT
STATE OF Kentucky
COUNTY OF Meade
r-. COMES the undersigned affiant, Michael T. Nutt
~. ?E~ERAL CONTRACTOR for the construction of the
, and states that he is President of MTN Construction. Inc.
City of Jeffersonville. Magnolia Ave Lift Station
By his personal knowledge, he further states that the WORK covered by APPLICATION FOR PAYMENT NO. 1 dated 1/31/07
has been completed in accordance with the CONTRACT DOCUMENTS and executed amendments thereto; that for this APPLICATION FOR
PAYMENT, except as noted hereinafter as exceptions, the CONTRACTOR has paid in full or has otherwise satisfied all obligations (1) for
equipment and materials (whether incorporated into the WORK or acceptably stored on-site), (2) for all work, labor, and services performed,
and (3) for all known indebtedness and claims against the CONTRACTOR for damages arising in any manner in connection with the
performance of this CONTRACT for which the OWNER, the OWNER's property, or the CONTRACT funds might in any way be held responsible,
including the applicable State Statute, and that the current payment on this APPLICATION FOR PAYMENT Is now due and payable.
EXCEPTIONS: (If none, write "NONE", Attach additional sheets, if necessary. If required by the OWNER, the CONTRACTOR shall furnish
a bond satisfactory to the OWNER for each exception).
This affidavit is directed to
Citv of Jeffersonville, IN
by and through its
Enaineer. Jacobi. toombs and Lanz. Inc.
C
CONTRACTOR
~~
--_L/'3 I'D'7
DATE
SUBSCRIBED and sworn to before me by Michael T. Nutt
Commission Expires: IYlCUl 2&. ~o ( 0
~fh.l~h-
/ ~~~~;; PUBLIC . SEAL
on this
BI~-r day of
'"Jd.VI. , 2007.
STATEMENT BY ENGINEER
BASED upon oh-site observation, and to the best of my knowledge, understanding, and belief. the WORK has progressed to the point
indicated herein; and the quality of the WORK complies with the requirements of the CONTRACT DOCUMENTS.
ENGINEER
DATE
$55,324.00
TOTAL CON'tRACT PRICE
ORIGINAL CONTRACT PRICE
+CHANGE ORDER
+CHANGE ORDER
+CHANGE ORDER
+CHANGE ORDER
+CHANGE ORDER
+CHANGE ORDER
+CHANGE ORDER
TOTAL CONTRACT PRICE TO DATE
$264,616.00
APPUCATION FOR PAYMENT SUMMARY
ORiGINAL CONTRACT WORK COMPLETED TO DATE
+CHANGE ORDER WORK COMPLETED TO DATE
TOTAL WORK COMPLETED TO DATE
+BALANCE OF STORED MATERIALS
TOTAL ENTITLEMENT TO DATE
-AMOUNT RETAINED AT 10%
-CLAIMS AGAINST THE CONTRACT FUNDS
TOTAL DUE CONTRACTOR TO DATE
-TOTAL AMOUNT OF PREVIOUS PAYMENTS
$55,324.00
$55,324.00
5,532.40
AMOUNT DUE CONTRACTOR THIS PAYMENT
$49.791.60
e
$264,616.00
Percent Complete (Excluding Stored Materials)
18.8%
AUTHORIZATION BY OWNER:
~~~JJ rfv .
~~ 141,7"l1,60
OWNER
DATE
ATTACHMENTS:
r IX] Application for Payment No.1
\. [] Change Order No.(s)
[ ] Bonds
[ ] Progress Schedules
] Record/Projection of Cash Disbursement
] Inventory of Stored Materials
] Invoices
] Other
The Review and Acceptance of Application for
Payments does not Attest to the correctness of
the quantities or that the work has been perfonned
in accordance with the Plans and Specifications.
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