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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 />BY <br />9/5/2024 <br />10/4/2024 <br />REVISED DAYS <br />REMAINING <br />29 <br />0 <br />4 <br />ORIGINAL DAYS <br />CONTRACT CHANGE ORDER SUMMARY PAY ESTIMATE SUMMARY <br />1 <br />9/30/20249/5/2024FROM <br />2024 SEAL COAT PROJECT <br />PROJECT NO. 2024.108 <br />CITY OF LAKE ELMO <br />3800 LAVERNE AVENUE NORTH <br />LAKE ELMO, MN 55042 <br />ATTN: JACK GRIFFIN, CITY ENGINEER <br />PEARSON BROS, INC. <br />11079 LAMONT AVE NE <br />HANOVER, MN 55341 <br />ATTN: TODD BARTELS <br />CONTRACT TIME <br />TOTALS $0.00 $0.00 $261,409.60 <br />NET CHANGE $0.00 <br />$13,758.405.0% <br />$0.00 <br />$0.00 <br />$275,168.00 <br />$278,107.40 <br />$275,168.00 <br />No.Approval <br />Date <br />Amount $278,107.40 <br />Additions Deductions $0.00 <br />FOCUS Engineering, inc.PROJECT PAYMENT FORM <br />09/20/2024