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CITY OF HUGO <br />14669 Fitzgerald Avenue North <br />Hugo, Wsb MN 55038 <br />Project 03288-190 -WaterWater <br />Tower No. 4 <br />Pay Voucher No. 1 <br />Contractor: CB&I, LLC City Project No. NA <br />PO Box 84627 For Period: 12/17/2018 - 02/15/2019 <br />Dallas, TX 75284-6217 <br />03288-190 <br />Contract Amounts <br />Original Contract <br />$ <br />3,510,500.00 <br />Contract Changes <br />$ <br />- <br />Revised Contract <br />$ <br />3,510,500.00 <br />Work Certified to Data <br />Base Bid Items <br />$ <br />113,710.63 <br />Backsheet <br />0 <br />Change Order <br />0 <br />Supplemental Agreement <br />0 <br />Work Order <br />0 <br />Material on Hand <br />0 <br />Total <br />$ <br />113,710.63 <br />Work Certified <br />This Pay Voucher <br />Work Certified <br />to Date <br />Less Amount <br />Retained <br />Less Previous <br />Payments <br />Amount Paid This <br />Pay Voucher <br />Total Amount <br />Paid to Date <br />$ 113,710.63 <br />$ 113,710.63 <br />$ 5,685.53 <br />0 <br />$ 108,025.09 <br />$ 108,025.09 <br />Percent retained 5% <br />Amount Paid This Pay Voucher <br />$ 108,025.09 <br />This is to certify that the items of work shown in this certificate of Pay Voucher have been actually furnished for the work comprising the above <br />mentioned projects in accordance with the plans and specifications heretofore approved. <br />Approved By: WSB <br />Project Engineer <br />Date <br />Approved By: City of Hugo <br />City of Hugo <br />Date <br />Approved By: CB&I, LLC <br />Contractor <br />Date <br />REMITTANCE 1 PAYMENT INFORMATION: <br />Regular Man: QYamiaht Mail- Hank of Amerka EFT Instructions: <br />CBM LLC (BPS Division) Bank of America Lockbox Services Account Nome: CB& LLC (SPS Division) <br />PO Box B46217 CB&I LLC (SPS Division)- Lockbox SM217 Account Number: 3756272668 <br />Dallas, TX 75284.6217 1950 N. Stammons Frwy, Suite 5010 ABA* 1110OW12 (ACH Only) <br />DORM, TX 75207 ABA a: D25009593 (Wins Only) <br />Questions about your invoice or payment? <br />Email us at USAinvoicing@mcdermott.com <br />KA03288-1901AdminlConstruction AdminlPay Vouchers) <br />Page 1 of 3 03288-190 PV1 021919VO 1 Cover <br />