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PROJECT PAY FORM <br />PARTIAL PAY ESTIMATE NO. <br />PERIOD OF ESTIMATE <br />TO <br />PROJECT OWNER:CONTRACTOR: <br />1. Original Contract Amount <br />2. Net Change Order Sum <br />3. Revised Contract (1+2) <br />4. *Work Completed <br />5. *Stored Materials <br />6. Subtotal (4+5) <br />7. Retainage* <br />8. Previous Payments <br />9. Amount Due (6-7-8) <br />*Detailed Breakdown Attached <br />START DATE:ON SCHEDULE <br />SUBSTANTIAL COMPLETION:X <br />FINAL COMPLETION: <br />ENGINEER'S CERTIFICATION:FOCUS Engineering, inc. <br />DATE <br />CONTRACTOR'S CERTIFICATION:CONTRACTOR <br />DATE <br />APPROVED BY OWNER:CITY OF LAKE ELMO, MINNESOTA <br />DATE DATE <br />BY <br />BY <br />YES <br />NO <br />The undersigned Contractor certifies that to the best of their <br />knowledge, information and belief the work covered by this payment <br />estimate has been completed in accordance with the contract <br />documents, that all amounts have been paid by the contractor for <br />work for which previous payment estimates was issued and payments <br />received from the owner, and that current payment shown herein is <br />now due. <br />The undersigned certifies that the work has been reviewed and to the <br />best of their knowledge and belief, the quantities shown in this <br />estimate are correct and the work has been performed in accordance <br />with the contract documents. <br />ENGINEER <br />11/21/2023 <br />BY <br />7/5/2022 <br />11/24/2022 <br />REVISED DAYS <br />REMAINING <br />142 <br />0 <br />0 <br />10/14/2022 <br />ORIGINAL DAYS <br />CONTRACT CHANGE ORDER SUMMARY PAY ESTIMATE SUMMARY <br />12(F) <br />12/1/202311/15/2023FROM <br />PARKVIEW-CARDINAL NBRHD STREET & UTILITY IMPROVEMENTS <br />PROJECT NO. 2020.121 <br />CITY OF LAKE ELMO <br />3800 LAVERNE AVENUE NORTH <br />LAKE ELMO, MN 55042 <br />ATTN: JACK GRIFFIN, CITY ENGINEER <br />T.A. SCHIFSKY & SONS, INC. <br />2370 HIGHWAY 36 EAST <br />NORTH ST. PAUL, MN 55109 <br />ATTN: JONATHON HAGER <br />CONTRACT TIME <br />TOTALS $532,687.70 $0.00 $38,422.11 <br />NET CHANGE $532,687.70 <br />5 6/28/2023 $18,600.80 $0.000.0% <br />6 11/21/2023 $25,269.50 $3,803,788.79 <br />3 2/21/2023 $443,817.79 $0.00 <br />4 6/8/2023 $2,917.00 $3,842,210.90 <br />1 8/12/2022 $29,630.61 $3,842,210.90 <br />2 9/20/2022 $12,452.00 $3,842,210.90 <br />No.Approval <br />Date <br />Amount $3,309,523.20 <br />Additions Deductions $532,687.70 <br />FOCUS Engineering, inc.PROJECT PAYMENT FORM <br />3/18/2024