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APPLICATION AND CERTIFICATION FOR PAYMENT <br />CUSTOMER: City of Hugo PROJECT: Hugo Public Works Facility APPLICATION NO: 1 Distribution Via Email: <br /> 14669 Fitzgerald Ave. N. <br />Hugo, MN 55038 <br /> 8220 140th St N <br />Hugo, MN 55038-9447 <br />INVOICE NO: 49220 □ OWNER <br /> □ ARCHITECT <br /> PERIOD TO: 7/31/2022 □ CONTRACTOR <br />CONTRACTOR: Peterson Companies, Inc. VIA ARCHITECT: □ <br /> 8326 Wyoming Trail <br />Chisago City, MN 55013 <br /> PROJECT NO: 22075 □ <br />CONTRACT FOR: CONTRACT DATE: 5/25/2022 <br />CONTRACTOR’S APPLICATION FOR PAYMENT <br />Application is made for payment, as shown below, in connection with the Contract. The undersigned Contractor certifies that to the best of the Contractor’s Knowledge, <br />Continuation Sheet Page 2, is attached. information and belief the Work covered by this Application for payment has been <br />completed in accordance with the Contract Documents, that all amounts have been paid by <br />the Contractor for Work for which previous Certificates for Payment were issued and <br />payments received from the Owner, and that current payment shown herein is now due. <br />1. ORIGINAL CONTACT SUM <br /> <br />$ 122,991.00 <br /> <br />2. Net change by Change Orders <br /> <br />-12,933.00 CONTRACTOR: Peterson Companies, Inc. <br />3. CONTRACT SUM TO DATE (Line 1±2) <br /> <br />110,058.00 <br /> <br />4. TOTAL COMPLETED & STORED TO <br /> <br /> By: ________________________________________ Date: ___________________ <br /> DATE (Column G on G703) 107,280.70 <br />5. RETAINAGE: <br /> <br /> State of: MN County of: Chisago <br />a. On Completed Work $ 0.00 Subscribed and sworn to before me this ________ day of __________________ <br /> (Column D + E on G703) Notary Public: <br />b. On Stored Material 0.00 <br /> <br /> My Commission Expires: <br /> (Column F on G703) <br /> <br /> <br /> <br /> Total Retainage (Line 5a + 5b or <br /> <br /> <br /> Total in Column I of G703) <br /> <br />0.00 <br />6. TOTAL EARNED LESS RETAINAGE <br /> <br />107,280.70 <br /> (Line 4 less Line 5 Total) <br />7. LESS PREVIOUS CERTIFICATES FOR <br /> <br />0.00 <br /> PAYMENT (Line 6 from prior Certificate) <br />8. CURRENT PAYMENT DUE <br /> <br />107,280.70 <br />9. BALANCE TO FINISH, INCLUDING RETAINAGE 2,777.30 <br /> (Line 3 less Line 6) <br /> <br />Change Order Summary Additions Deductions <br />Total Changes approved <br />in previous months by Owner: 0.00 0.00 <br />Total approved this Month 18,764.00 31,697.00 <br />NET CHANGES by Change Order $ -12,933.00 <br /> <br /> <br /> <br />CRITL <br /> <br />7/21/22 <br />21 July 2022 <br />1/31/24