K-3 - Pay Application 1 - McComas Lacina - Sidewalk to Soccer Fields

APPLICATION FOR PARTIAL PAYMENT OF CONTRACT Project Title: Tiffin Sidewalk Connection to Soccer Fields Contractor: McComas-Lacina Construction LC Address: 1310 Highland Court, Iowa City, IA 52240 Finance Budget Code: Finance Project # ________ Vendor Project or Invoice #: 34431-01 PO # ________ Original Contract Date: December 7, 2023 Engineer PN # 13603015 Date of Council Meeting: January 9, 2024 PAYMENT REQUEST # 1 PAYMENT PERIOD: From: December 7, 2023 Through: January 5, 2023 Contract Summary Original Contract Amount: $ 64,935.54 Net change by Change Orders: $ - Contract Amount to Date: (line 1 ± 2) $ 64,935.54 Total completed and stored to date: $ 49,046.99 Retainage: 5% of Completed Work: $ 2,452.35 Total Earned less Retainage: $ 46,594.64 Less previous applications for payment: $ - SUBTOTAL $ 46,594.64 OTHER CHARGES (Attach an itemized list) $ - CURRENT PAYMENT DUE $ 46,594.64 Balance to finish, including retainage: $ 18,340.90 Notice to Proceed: December 14, 2023 Substantial Completion Date: May 24, 2024 The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and belief the work covered by this Application for Payment has been completed in accordance with the Contract Documents, that all the amounts have been paid by the Contractor for work for which previous Certificate(s) for Payment were issued and payments received from the Owner, and that current payment shown herein is now due. Construction Contractor Approval: McComas-Lacina Construction LC Signature ____________________________ Date 1/2/24 Firm Name ____________________________ Engineer / Consultant Approval: MSA Professional Services, Inc. Signature ____________________________ Date 01/02/2024 Firm Name ____________________________ Owner Approval: City of Tiffin Signature ____________________________ Date __________ Owner Name _________________________ Submit to: ____________________________ E-mail: _____________________________ Phone: ______________ Fax: ______________