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Home My WebLink About1998-06-24 PACKET 04.D.I.REQUEST OF CITY COUNCIL ACTION COUNCIL AGEfJDA MEETING ITEIVI # DATE 6/24/98 �' . � , PREPARED BY Public Works Les Burshten ORIGiNATING DEPARTMENT STAFF AUTHOR «.��.��..�««��«<.�,�.��»��.>..�,��.��.� COUNCIL ACTION REQUEST 7th and Final Request for Payment for the Eagle Ridge and Hidden Oaks Fourth Addition Utility and Street Improvements. BUDGET IMPLICATION $ $ BUDGETED AMOUNT ACTUAL AMOUNT FUNDING SOURCE ADVISORY COMMISSION ACTION DATE REVIEWED ❑ ❑ ❑ ❑ ❑ ❑ ❑ APPROVED ❑ ❑ ❑ ❑ ❑ ❑ ❑ DENIED ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ PLANNING ❑ PUBLIG SAFETY ❑ PUBLIC WORKS ❑ PARKS AND RECREATION ❑ HUMAN SERVICES/RIGHTS ❑ ECONOMIC DEV. AUTHORITY ❑ SUPPORTfNG DOCUMENTS � MEMO/LETTER: Eric Johnson, June 9, 1998 ❑ RESOLUTION: ❑ ORDINANCE: ❑ ENGINEERING RECOMPNENDATION: ❑ LEGAL RECOMMENDATION: � C7THER: Withholding Affidavit for Contractars, Request far Payment ADMlNISTRATORS COIUIMENTS � � J _ �-, .> City Administrator Date ��>��..��<��,��,��<��...�� cc�u�ci� �,c�ria� �raac��: ❑ ��P�ov�r� ❑ D�� ❑ ort-�� SUMMARY I Original Contract Amount 2 Change Order - Addition 3 Change Order - Deduction 4 Revised Contract Amounf 5 Value Completed to Date 6 Material on Hand 7 Amount Eamed 8 Less Re[ainage 0% 9 Subtotal $ S 7,156.29 $ 326,318.95 S 319.162.66 S 270.20836 S 0.00 S 210208.36 S 0.00 S 270.20836 $ 246,390.68 $ 23,817.68 10 Less Amount Paid Previously 1 1 AMOUNT DUE THIS REQUEST FOR PAYMENT NO. 7& Final Recommended for Approval by: BONESTROO, ROSENE, ANDERLIK & ASSOCIATES, INC. � Approve y Contractor: rown & i , Inc. � �� 1�. � Specified Contract Completion Date: Approved by Owner: City of Cottage Grove � .- ��.=-+�� Date: G�%g 1:\48\48378\REQUESi7. W 82 REQUEST FOR PAYMENT EAGLE RIDGE AND HIDDEN OAKS FOURTII ADDITION IMI'ROVEMF.NTS File No. 48378 Vo. 1 2 3 4 5 6 7 8 9 10 11 12 ]3 14 15 16 17 18 t9 20 ,� „ 23 24 25 26 Item Unit 12" RCP, 0'-8' deep, Class 5, in place LF 15" RCP, 0'-8' deep, ClassS, in place LF ( 8" RCP, 0'-8' deep, Class 5, in place I,F 24" RCP, 0'-8' deep, Class 4, in place LF 27" RCP, 0'-8' deep, Class 3, in place L,F 33" RCP, Class3, in place � 36".RCP, Class 4, in place � 12" RCP, t7ared end section with trash EA IS" RCP, f7ared end section with trash EA 18" RCP, flared end section with trash EA 27" RCP, flazed end sec6on with trash Ep 33" RCP, tlared end secdon with trash EA Standazd 4' diameter CBMH w/R3067V cstf EA Type II, 2' x 3' CB w/R3069V casting � EA Rip rap, Class 2 Cy Rip rap, Class3 hand placed Cy Seeding induding seed, mu)ch, fertilizer and disc. pC Bale check per detait GEN-13 EA 36" RCP, Class 3, equivalent arch, 0'-8' deep, in place LF 36" RCP equivalent arch FES with trash guard gp 30" RCP, Class3. 0'-8' deep in place LF Remove and sah�aoe existing 36" RCP f7ared end section EA Ditch excavation Cy Clean fill for beraring Cy Seeding including seed, mulch, fetilizer and disc. pC Bale check per de[ai] GEN-13 EA Total Part 1- S[orm Sewer Part 2 - Sfreet Improvements 27 Sawcut bituminous surface [„p 28 Common excavation Cy 29 Aggregate backfill in place TTr 30 Subgrade pceparation gy Contract Unit Quantity Quantity Price to Date 126 25.10 304 270 26.45 144 85 28.15 56 33 3530 33 58 39.10 5g 60 4935 p 65 63.90 57 2 535.00 2 6 595.00 6 3 647.00 3 1 1,096.00 1 2 1,468.00 0 3 1,135.00 6 3 �93.00 2 60 50.00 50 155 50.00 102 2 950.00 15 55.00 4 200 77.'70 188 8 1,469.00 g l00 43.55 p I I57.00 2 100 15.00 53 2,700 2.50 360 1 8�5.00 10 55.00 p 240 2.00 90 400 6.50 p 815 4.76 ZZg 6,020 0.25 b,773 Amount to Date 7,630.40 3,808.80 1,576.40 I,164.90 2,267.80 3,642.30 1,070.00 3,570.00 1,94I.00 1,Q96.00 6,8 ] 0.00 1,586.00 2,500.00 5,100.00 220.00 14,60'7.60 I 1,7�'_.00 . 11 � �� k1 $72,358.20 180.00 1,085.25 1,693.25 1:148\48378\REQUEST7.W 82 31 32 33 34 35 36 37 38 39 40 41 42 43 44 4� 46 47 48 49 50 St 52 53 54 55 56 57 S8 59 Ciass 5 aggregate base in place 'i'N Type 31, bituminous bue '�.7 Type 41, bi[uminous wear course 'I'N Bituminous material for tack � GL B-618 concrete curb and gutter in place LF Adjust catch basin casting EA Boulevard grading per Special Provisions I-IR Power pick-up brrom with operator HR Skidster loader with operator � Remove and replace B-618 concrete curb and guttec � Fumish and install sign panels, Type C, high intensity SF Seeding, inlcuding seed, mulch, fertilizer and disc qC Prepazation of bituminous base as specified LS Total Part 2- Street Improvements To[al Paa I- Storm Sewer Total Part 2- Street Improvements Total Eagle Ridge Hidden Oaks 4th Addition Part 1 - Storm Sewer 12" RCP, Class 5, 0'-8' deep in ptace LF t 8" RCP, Class 5. 0'-8' deep in place LF 24" RCP, Class 3, 0'-8' deep in p(ace LF 2R" RCP, Class 3, 8'-10' deep in place LF 24" RCP, Class 3, 10'-12' deep in place L.F 24" RCP, Class 3, 12'-14' deep in place LF 36" RCP, Class 3, 0'-8' deep in place LF Std. 4' dia. MH w/t642B bolted casting in p EA Std. 6' dia. MH w/1642B bol[ed casung in p EA Std. 4' dia. CBMH wlR3067V casting in pta EA Type I CB w/R4342 casting in place EA 2'x3' precas[ CB w/R3067V cstg in pl. EA Const. 4' diameter MH over existing pipe EA 4' dia. MH depth greater than 8' dp. I.F 6' dia. MH depth greater than 8' dp. � 36" RCP, flared end with trash guazd Ep 2,500 455 455 310 2,690 6 12 6 6 6.50 27.78 3Q.05 1.Q1 6.87 51.00 61.00 61.00 66.00 260 19.00 30 25.00 30 3 I 30 180 1,308 85 180 165 35 9 I 1 1 i 1 I 2 I 888.00 1.5 1,332.00 1,000.00 1 I,000.00 $73,077.80 2,608 515 513 490 2,796 6 6 16,952.00 14,306J0 15,415.65 49a.40 19,208.52 306.00 366.00 737.50 $72,35810 573,077.80 $145,436.00 23.85 26.70 3035 30.90 31.55 32.25 52.75 962.00 2,111.00 982.00 651.OQ 758.00 928.00 60.00 134.00 1,501.00 28.00 180.00 I (51.00 275.00 100.00 200.00 32.00 9.00 2.00 1.00 1.00 I.00 1.00 1.40 2.00 I.00 667.30 4.506.00 34,932.8 i 8,497.50 3,155.00 6,450.00 1,688.00 8,658.00 4,222.00 982.00 651.00 758.00 928.00 84.00 268.00 1,501.00 I:\48\48378\REQUEST7.W B2 60 61 62 63 64 65 66 67 68 69 70 71 72 73 Remove existine flazed end EA Clearing and Gmbbing LS Salvage & reinstall fence I„p Salvage & �einstall sign gp, Pond excavation Cy Rock excavation Cy Check dam g,q Granulaz bedding � Class 3 rip rap, hand placed Cy Remove & replace silt fence per Plate SP-85 LF Erosion convol system in pl. per Plate SP-b LF Seeding, inci. seed, mulch, fert. & disc anch AC Wood fiber blanket, high velocity SY Sodding w/4" topsoil gy Total Part 1- Storm Sewer Part 2 - Stree[ Improvement 74 Subgrade prepazation gy 75 Common excavation Cy 76 Aggregate bac�ll in place 'I'DI 77 Class 5 aggregate base in place 'jN 7S Type 3]-B, bituminous bue course mixmre T'N 79 Type 41-B, bituminous wzar course mixwre TV 80 Bituminous material for tack coat in place C�L 81 Surmountablz concrete curb and gutter in piace LF 82 Adjust ca�ch basin casting EA 83 Adjust manhole casting EA 84 Boulevazd grading per Speciat Provisions HR 85 Remove and replace surmountable concrete curb and gutter LF 86 Fumish and install sign panel, Type C high in[ensity SF 87 Seeding, inc. seed, mulch, fertilizer, disc AC 88 Sawcut ex. bit. or concrete � 89 Double wood bamcade in place EA 90 Power pickup broom w/operato� � 91 Skidsteer loader wloperator HR 92 Preparation of tii[uminous base as specified LS Total Pari 2- Street Improvement 1 1 50 1 1,200 200 2 I,100 25 50 50 2 430 100 2,070 700 1,500 940 ]90 190 t05 157.00 6,100.00 10.00 300.00 4.00 49.70 900.00 2.18 50.00 2.02 ] 0.00 884.00 2.02 1.93 0.25 6.00 4J6 7.40 27.27 29.29 r.oi ],410 6.21 2 51.00 2 253.00 8 65.00 40 19.00 6.25 1 60 1 4 4 1 26.00 884.60 3.50 378.00 70.00 60.00 1,OOQ.00 I.00 1.00 0.00 0.00 800.00 89.00 2.00 61.00 39.00 0.00 0.00 1.00 0.00 0.00 2092.00 565.00 806.00 236.00 229.00 iao.00 157.00 6,100.00 3.200.00 4,42330 1,800.06 132.98 1,950.00 SSa.00 596,896.43 523.00 2,689.40 5,964.40 6,435.72 6,707.41 IAL40 1509.00 9,370.89 2.00 102.00 2.00 506.00 3.00 195.00 I5.00 285.00 6.25 0.50 37.00 1.00 162.50 442.00 129.50 378.00 I.00 1,000.00 $35,032.22 I:\48\48378\REQ UE S77. W 82 Total Part i- S[orm Sewer Total Part 2- Stree[ Improvement Total Hidden Oaks 4th Addition Change Order No. 1 1 Eagle Ridge Compleuo� Date Extension 2 Hidden Oaks 4th Addidon Comp. Date Ext. Totai Change Order No. l Change Order No. 2 1 Type 31B Bimminous Base Course Mixture TN 2 Type 41B Bituminous Weaz Course Mixture TN 3 Bituminous Material for Tack Coaz in Place GL 4 Surmountabie Conc. Curb & Gutter in Place I.F Total Change Order No. 2 Total - Eagle Ridge To[al - Hidden Oaks 4th Addition Total Change Order No. 1 Total Change Order No. ? Total Work Completed [o Date (73) (73) (�) (481) $96,896.43 $35,032.22 $131,928.65 $0.00 $0.00 $0.00 27.27 (73) (1,990.71) 29.29 (73) (2.138.17) 1.01 (40) (40.40) 6.21 (481) (2,987.01) ($7,156.29) 5145,436.00 5131.928b5 $0.00 (S7, ] 56.29) $2�0,208.36 I:\48\48378\REQUEST7. W 82 PROJECT PAYMENT STATUS Owner Ciry of Cottage Grove Project No. 48378 File No. 48378 Contractor Brown & Cris, Inc. CHANGE ORDERS Material on Aand I:\48\48378\REQU EST7. W82 PAYMENTSUMMARY � Bonestroo Rosene � � Andertik & Associates Engineers & Architects June 9, 1998 Mr. Les Burshten City of Cottage Grove 7516 - 80th St. S. Cottage Grove, MN 55016 Bonettroo, Aosene, AntlerUk an0 Assodaees Inc e an AfJVmaelve AcUon/Equal OpporzunlFy Employer Princlpals' Oao G- Bones[roo P,E. • Joseph C Antletlik, PE • ��fiarvin L Sorvata. r".E. • 2ichar4 E Turner, P.E • Glenn 2 Cook. PE. • Robert G. SchunlcbL P.E. • Jerry A. Bourdon, PE. • Robert W Rosene. P.E. znd Susan M. Ebetlin CPA.. Senior Consultznts Arsociate Frincipals: Howzrd A. San`:ord, PE. � Keitb A. Gortlon, P.E � RoCer[ R. Pfef(erle, PE. • Richard W Poster, PE • Dzvid O. Loskotz, RE � Robert G Russek, A.I.A. • Mark A. Hanson, PE � Michael T Rautmann, flE • Tetl K Flelp. HE. � Kenneeh R Antlerson. IiE � Mark R. Rolfs, P.E. • Sitlney P Williamson. PE, LS. � Robert F Ko[smlth � Agnes M. Ring � Michael fl Rzu, f'.E. • A�lan Rick ScbmitlL PE. Of/icesSt Paul. RocM1es[er, Wilimar antl St Ooutl, MN � Mliwaokec, WI Website: wwwbonetvonmrzi Re: Eagle Ridge and Hidden Oaks Fourth Addition Utility and Street Improvements Our File No. 48378 Deaz Mr. Burshten: Enclosed please find three (3) copies of the 7th and Final Request for Payment documents for the Eagle Ridge and Hidden Oaks Fourth Addition Utility and Street Improvements This work has been satisfactorily completed by the Contractor, Brown and Cris, Inc., in accordance with the contract plans and specifications. Therefore, it is recommended tbat final payment be made and the project be accepted by the City of Cottage Grove. Below is a construction cost comparison chart from the preliminary report estimate through the final construction amount Preliminary Original Final °Io Final Const. RepoR Contract Construction Amt. is ± Orig. Cateeorv Estimate lAmount Cost �ontract Amt. Eagle Ricige Stormsewer $108,434 $94,595.05 $72,358.20 -23.5% Streets 80 141 80 974.45 73 077.80 -9.8% Sub-Total: $188,575 $175,569.50 $145,436.00 -17.2% Hidden Oaks 4"' Addition Storm sewer $106,943 $107,284.90 $96,896.43 -9.7% Streets 51 562 43 464.55 35 032.22 -19.4% Sub-Total: $158,505 $150,749.45 $131,928.65 -12.5% Total $347,080 $326,318.95 $270,208.36 -17.2% Change Order No. 1 Completion date extension- No Additional cost. Change Order No. 2 Hidden Oaks 4`" Addidon Delete the construetion cost for the 74�' Street construction from the original conuact amount. Total deleted amount is $7156.29. 2335 West Highway 36 ■ St. Paul, MN 55173 ■ G12-G3G-4G00 • Fax: 612-G3G-1311 Cateeorv Original Final % Final Const. Contract Constnzction Amt. is t Orig. Amount Cost Contract Amt. Hidden Oaks 4`�' Addition Storm sewer $107,284.90 $96,896.43 Streets 43,464.55 35,032.22 Change Order (7,156.29) Sub-Total: $143,593.16 $131,928.65 -8.1% Total $319,162.66 $2'70,208.36 -153% The final construction amount is 15.3% below the original contract arnount. Overrun ancT Underrun Cost Summarv This project underran largely due to existing site vaziations from the flown topography. These differences resulted in field modifications to the storm sewer system, which ultimately reduced the amount of infrastrocture along with some of the erosion control measures. Other items underan and ovenan due to normal quantity deviations. Sincerely, BONESTROO, ROSENE, ANDERLIK & ASSOCIATES, INC. 1..1 �t GA Eric A ohnson Enclosures -_- MINNESOTA Department of Revenue Withholding Affidavit for Contractors MA� �' '� 1� This aNidavit must be approved by �he Minnesota Department of Reve�ue before the state of Minnesota or any of its subdivisions can make final payment to controctors. C a ';::'::�.... � .r:.. C�.;. a .� � .� a�. _ Please lype or print cleady. This will be your moiling label for re�urning the completed form. _ _ _ _ _ — �Gompany name 1 Dayfime phone � Srown & Cris, Inc. � 16121 469-2121 � Address � Total mntm<f amounr � __14Z4Il�enrick Avemie-- - -- �-$-31Q- 7��7 _ F,ji- I Ci1y $bte Lp Code I Amount stili due � — _ Z.d�RV-.�l�-fl,�- — 1�`'�1 — — — —J�� _ _ � $_._�- Month/year work began Pmjeanumber ', Projectbcation _ G.$3Z$ _.Cott�e Grove, Minnesota Projectowner Address City State Zipcode _C�t�.._p� Cot a e Gxov�___ 7516 SOth St. S.________Cottage Grove _MN__55_016 Did yoo have employees work on thls pmject? � Yes ❑ No If no, who did tne work? Check the box that desc�ibes your involvement in ihe project and fi�l in a�l informaiion requested. ❑ Sole conTractor ❑ Subcontractor Name o? confmclor who hired you '_'__ "'--_"_' '_....._......_____ Address `` � Prime contractor—If you subcontracted out any work on this project, aI) of your subcontractors must file their own ,, IC-134 affidavits and have them certified by the Department of Revenue before you can file your affidavit. For each subcontractor yov had, fill in the information below and aBach a copy of each subcontracror's certified IG134. If you � need more space, attach a separate sheer. Are Rlackt�p 72$2Dic.kmaz�..Trail Inver Grove Aeh�s, MN Alex Schield .�.n. •. - . 1 ..♦ . .n u � I dedare fhaf all informalion I have filled in on fhis form is true and mmplete b lhe best o/ my knowledge and belief. 1 aufhorize the Deportmenf of Revenue fo disdos rtinent information relotirtg to this project, induding sending mpies of this form, ro the prime mNrocfor if I am o submnhoctor, and to any subm , rac rs if I am a n e conVactor, ond to the contrading agen<y. ._..______ a . � � t r i tura i! �� itle �� --�--� �� ;� Aat --- con }p�� .� � �t � �' � � ° ! � U-' �1 - �t�!. � _ � _ -- to: Mail Station 6610, 51. Paul, MN 55146-6610 Certifecate of Compliance Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this certificate has fulfilled all the requirements of Minnesota Statutes 290.92 and 290.97 conceming the withholding of Minnesota income tax from wages paid to employees relating to contract services with the state of Minnesota and/or its subdivisions. Department of Revenue approval Date , d „�� , X�' "� /� ' �, i 6< e�.f`��;C�A�AY :L . . . . .. ��, . ._.__ IC-134 Minnesofa withho(ding tax ID number 6279608 Smck No.5000134 (Rev. I 7/96! priNed on reryded paper wrtn 70% post<onsumer wasle using say�based ink. FROM : LANDMRRK PHONE N0. : 6124340315 Mar. 23 1998 1�:�3aM F2 �.s.r MiNNESOTA �epartment of Reve Withhoiding Affidavit for Contractors � ic-� 34 �� f} ��is oNidavi� musl be epproved by the Minnesofa Deponmenl ol Revenue be(ore Ihe s�ole of � nnesoto or any o/ i1s subdi�isions can moke final payment 10 coNroc�ors. Pleose ype oi prin� clanrly- Thit wi0 be you� moilin label hr rntvmin r __ g g�e mmple�od lorm, °,j.+, w�ly �Com,paoy noinv � � � _. � _ _ _ _. � � L7;�� Landmazk CbllC�e'CE� IL7C OoN�mepho�� 61� 434-0330 ,'�"��i'"'�ai' i Addmis ��"—� ' � � Tolal coMracl omount � � 18 .U1 ssES St N'E 'm� 1 Y � $Z6.388.43 tt=�^ �� East V3ethel MN 55011 I A "'1 �3�36.80 :�+;�:. `--------- $ -� �or xro�k andcd � � 7 . �w�� :. Pio�ean mber � Projectiocmio.� �`= 48378 Cottage Grove, MN > re� ._—..—_ --._._—�._.—� .__..__.----__— ----- --_...._ _ "��'E� p City�of Cottage Gxove 7516 80th St S Cottage Grove MN 5 ��5p�� n y�� D�e yoo ho�e �m�ioyeer ..o�k on �h's p�o�na2 �Ves � No H no�who d�d �hc vor4i � ,.� —_ ��— -- � Udf M'PYS, . __.__._ .....____.. eck Ihe box Iho! describes your involvemenl in the projeU ond fili in oll infoima�ion req�es�ed. ❑ Sole contraeror � Subcontroc Nomp � In c Add �� ;s 1 , 9740 Kenrick Ave LakevilJ.e, �MN 55044 �ai'�� Q Prime contractor—If you subcontroclad outany work on ihis project, all of your subconGCCtors�musl File ihei� own � .�.'�','�� IG i 34 aHidovits oncl hQVe fhem certiFied by Yhe Depnrtmenl of Revenue before you can fi{e your aE(idaviL 'ror eoch '�7i;;� su6conircuor you hacJ, fill in the infarmolion belaw ond al�ocn o copy of each 5ubconlrptfor's certified IC• 1 3d. I( you . �';' nepd mo�e spoce, onoch o separote sheet. � Q�.� Bw��¢s� nome . Add eas ., —.•'-- --'—'_'.'. ' Ownct(Gfr<ar �. O{'�� ...'_--" _...'_'....._... ` "_.. .___ ..—"___ . V r _.._..___.._ __._.._... y i .. .._—_.._._...__.. __ _"_—._„___ � m' m��. � dedorc ihai afl Inlormobon I have lillod in on Ihis lorm is Irue ond complete la fhe F.�es� ol my knowledgc ond behe/ l ou�hor'te Ihe Geportmenr o1 Reveno ro d•tdo>a panlnmr inlormatro relvlin o rhis projen, including sendjrtg mpici o/ th�s form, !o �h� pr�m, com� r( 1 om ,=�,J; o�d �o y 3ex nr �crors d l am a p�' conf or, on o �hc mnbocGng ogenty. a aubmnnocro., �' Co o< r s no�w � � ��, `�' "_ " ',.� ._.. Ti e�114�...��-f�... — "' --_' Dare - �� __ _ �, Mail to: MN Depi, o( Revenue, Wi�hholding Divlsion, Moil Stalion 661 D, Sr. Poul, MN 55 146�66I 0 �� _� � Certificate of Compliance Based on records o! ihe Minnesoio Deportment of Revenue, I certify �hof �hE confrodor who has s�gned this certiflcaie hos Iul!illed oll ihe reGuiremenfs of Mlnnesoro Stotores 290,92 ond 290.97 <onceming Ihe wilhholding of Minnew�o income tox from wogea poid to employees reloting lo conlrotl services with Ihe stole oi Minnesoto ond/or i1s wbdivisipns. �z o ,�N,9��, Rn c n e ;��` �, '}"y"t .ii�J(/'✓.f� V 'v�va- , ��L� ..ts✓ Polo � 1 R n � — �r,l � �; ;�, �.<`�� < <v y �.��s�� Minneso�o .+hhhald'mg io. ID nombe� 2833839 �- yeor .+ork ocgon —96 . o s��,. . i I/cel F�.n��tl o� wrdoa n=cu ..,d� i a �� oR Po.iconmm.i .. ..i mg �cybo�oa m4. �J'%4, ��:�� P� � BROWN & CRIS p3/20/88 FRI 10:44 FAX 612 489 24Ba � YC; C�UO2 iVIINNESOT'A Tae partme n t of Revenue _ . � + ithhofding Affidavit �or Contrctictors MAR � 1 1� is pffldavif must be opproved by the MinnesWa Depar'tment oF Revenue beFore the state ��f Minnesoto or any of its svbdivisions con moke �nol pqyment to contractors. �c�rl p �� i � '^i >. � d w' �i �!' �� i9� �'� ry �� 'd ,�;d� a:,p,..,�� :;, i � �,�; 3!'' �' 1, �� i �, �a i Ip '� . �� a. ��I�w-w�l:l't� ik it•�sa pleata ype or prfM elaorly. This wiA he yu+r malliny te6e1 for reluminq the completsd Form. �^"— —"—� i � � , Dayfime phone I htinnetota wlfhholding bx ID numhe� I Company �wmu I � 66708 _ Ace Blacktop t6121 45D-1237 ' I �MonM/ earwarkbegar � A dross Tarol wnlraet amoum I Y � 7 �$!J ttickmaa. s ii Code i� 85fi��J.S.-. . Nion�h/� 0 w -�9�i-_ d ad C' Y P AmoVn� �till due i � �` ti. _._ Znua•- r,,-�.:o�3Bhts �-- S1N— SSQZ6_ —1 �1.�648-2.9 -— 1 .�'�`" - Peojxt numbe. I Pro+e I�ption _�Y83-Z8 �1._-C�Ctage-('r'a".'o^—*ti„n cn�� ry Swre Z�pcode Proiect owner Addrus ____Gi,tiy „f r °�ov� �-Z5.7.6�.flOs3�-St�S.-.. _._-�o�-.Gt.os�e_. _�IDi_-- — Did you 6ave �mploye�e. wodc on this projoct9 V Yrz �� No iF no, who did the wvrk2 � �� Chack the box that describcs your invofvemenf rn Ihe projecl and fill in all information requestmd. -.+-� ACT BLACKTGP ❑ Sole eontracfer �] Subcontraetar _ __ _ — Nama od qontmWr whc himd you . —�LQ.WI1_St--CiYj-3..r_�31.4.+-... . _... . _ .. _. ._. Addreas 1 Ken Av L MN 55 � Prittita tontrtlet4r•-If you subtontracted out any Work on this project, all oF your subconrractors must file the�r own IC-134 afFidavihs Cnd have f6am certiFiet! by the Department of Revenue before you can file your affidavit. For sach svbconYractor you had, fill in thQ ink�mation below and attoch a copy oi each subcontrocror's cortiFied !C•13a, If you need more apace, atlach a separate aheet. Bus'nesaname_. . ._ , Addresc„ _ .. _ _ Owner Off� e ,.. _ � � m � 0 � 1 detlore thaf all in(olmoNon I Fpve filled in on �his hrm is Irve and mmple�e ro the best of my knowledge and belieF, 1 ovihorise �hc Deparrment of Reven�e lo diatlose pCtlinent informotion relofing ro this praject, irrcl�ding cending cop'�es cf this (orm, ro Ihe prime mnfrocror "rf 1 em a submntroeror, end Iq ony subco��roCk7R if I om a ptima contncbf, onC� b fhe COflMOCHng agMCy. ___ _ pctor's eignalVre �1�� p � Tille Dota ��:�^.� .�.5'�� .�2�S2_L�!+ __ _�-?-�Q� - Mnll tw. MN Dapt. 04 Revenue, Wifhha{di�g Di�ision, Mai151otion 6614, S�. Pav . 55146bbt 0 Certifitaive af Compliance Bosed on records of the Minnesatd Department o( Revenue, I certffy that Fhe conhpcfor who Mas signed th�s cerfif�cpre hos fulfilled al) �ha reqoiremenfs oF Minnesotp Statutes 290.92 and 290�97 concerning �he withholding of MinneSOra incomo rox from wagea paid ro employaes reloting ro contract services with the srete of Minnesota and/or i1s subdivisions. Oeparfinent of Revenua etpp�ro�v�1,� Dole �., ,' � . r ` I �J."�.�LfLttz 6f � � __ ` Grock No, 500013a � �� IRw. 11/96� MInIBd on mcyded pOpBr Wilh �lOYa po+bcn^sumr� wdde usin9 soy�DOxad inA. V • � na-vft-98 :.,:OG AM P62