HomeMy WebLinkAbout20070917 - VI-06
VI-6
2335 Highway 36 W
SI. Paul. MN 55113
Tel 651-636.4600
Fax 651-636-1311
www.bonestroo.com
. Bonestroo
September 6, 2007
Mr. John Zgoda
Public Works Superintendent
City of Hastings
101 4th Street East
Hastings, Minnesota 55033
Re: Construction of Well Pumphouse No.8
Bonestroo File No. 000222-06107-1
Pay Request No. 12 (Final)
Dear Mr. Zgoda:
Attached are four copies of Pay Request No. 12 (Final). This pay request is for work completed on the
Pumphouse NO.8 construction. We recommend that the City pay the requested amount of $6,665.55.
Please sign all four copies and return one signed copy to our office, two copies to the contra<;tcr and retain
one copy for your file.
If you have any questions regarding this pay request please call me at (651) 967-4630.
Sincerely,
BONESTROO
Kevin A. Andersen, P.E.
Attachment
Engineers
Architects
Planners
st. Paul
S t. Cloud
Rochester
Milwaukee
Chicago
4-
Bonestroo
Owner: Ci
For Period:
Contractor:
Date:
5/8/2007 to 8/31/2007 Re uest No:
Ma ne Construction fne., 1401 Park Road, Chanhassen, MN 55317
CONTRAGOR'S REQUEST FOR PAYMENT
CONSTRUGtON OF WEll PUMPHOUSE NO.8
BONESTROO FILE NO. 000222-06107-1
SUMMARY
1 Original Contract Amount
2 Change Order - Addition
3 Change Order - Deduction
4 Revised Contract Amount
5 Value Completed to Date
6 Material on Hand
7 Amount Earned
8 less Retainage 0%
9 Subtotal
1 0 less Amount Paid Previously
11 liquidated damages -
12 AMOUNT DUE THIS REQUEST FOR PAYMENT NO.
$
$
12 AND FINAL
Recommended for Approval by:
BONESTROO
~~
Approved by Contractor:
MAGNEY CONSTRUGION INC
~~~
$
Au ust 31, 2007
12
657,400.00
9,155.13
0.00
$
$
$
$
$
$
$
$
$
Approved by Owner:
OTY OF HASTINGS
~,7r~
666,555.13
666,555.13
0.00
666,555.13
0.00
666,555.13
659,889.58
0.00
6,665.55
Specified Contract Completion Date:
April 30, 2008
Date:
000222-06107-1-RFP 12 Final Dellek-xls
9- (D-{)~
Application for Payment No. 12 - FINAL
To: City of Hastings (OWNER)
From: Magney Construction, Inc. 1401 Park Road, Chanhassen, MN 55317 (CONTRACTOR)
Contract: GeperaJ Construction
Project: Construction of Well Pumphouse # 8
Owners Contract No.
For work accomplished through the date ot:
Engineer's Project No.
6/412007
00022-06107-0
I) Original Contract Price:
2) Net Change by Change Order/Written Amendments (_/+)
3) Current Contract Price (1+2):
4) Total Completed and stored to date: .
5) Retainage (per Agreement):
0.00% of completed work
$0.00
5.00"~ of stored material:
$0.00
Total retainage:
6) Total Completed and stored to date less retainage (4-5)
7) Less Previous Application for Payments:
8) DUE TIDS APPLICATION
$0.00
$657,400.00
$9,155.13
$666,555.13
$666,555.13
$666,555.13
$659,889.58
$6,665.55
Accompanying Documentation:
CONTRACfOR'S Certification:
The undersigned CONTRACfOR certifies that (I) all previous progress payments received fiom OWNER on account of WOlfe.
done under the Cootrad referred to above bave been applied on accolBlt to discbarge CONTRACfOR'S legitimate obligations
incurred in COIIIIeCtion with Work covered by prior Applications for Payment oumben:d I through 9 inclusive; (2) tide of all
work, lJJlIterials and equipment incorporated in said Work otherwise listed in or covered by this Application for Payment will
pass to OWNER at time of payment free and clear of all Liens, security interest or encumblllllCe (expect such as are recovered
by a Bond acceptable to OWNER indemnifying OWNER against any such Lien, security interest or encumbrance); and (3)
all Work covered by this Application for Payment is in accordance by the Contract Documents and not defective.
Dated: 6/412007
Magney Construction, IDe.. (Contractor)
By: .p J:t- -------
Kevin Vrnnicar - Project Manager
State of MAl County of
Subscribed and sworn to before me this
~~
day of
,
~
,.
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(h~ ,2007.
-
Notary Public ~tL /It.
My Commission Expires:
J;ttttQt~
,7tl11. 3/, 201)7
.
RINA M. DILLARD I
NOTARY PU8UC-MINNfSOtA
My CoanIaIan &p/ru1aR. 31..
.
Payment of the above AMOUNT DUE THIS APPLICATION is recommended.
Owner:
Engineer:
By:
By:
Date:
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Consent of Surety
to Final Payment
OWNER 0
ARCHITECT 0
CONTRACTOR 0
SURETY 0
OTHER [J
AlA DOCUMENT G707
TO OWNER:
ARCHITECT'S PROJECT NO.:
(Name and address)
City of Hastings, 101 E. 4th Street,
Hastings, MN 55033
CONTRACT FOR:
PROJECT:
(Name and address)
Construction of Well Pumphouse No. 8
CONTRACT DATED:March 20, 2006
Magney Construction, Inc.
1401 Park Road Chanhassen, MN 55317
In accordance with the provisions of the Contract between the Owner and the Contractor as included above, the
Fidelity & Deposit Company of Maryland
210 No. Charles Street, Baltimore, MD 21201
(Insert name and address of Surety)
SURETY, on bond ofMaqney Construction, Inc.
(Insert name and address of Contractor)
1401 Park Road Chanhassen, MN 55317 ,CONTRACTOR,
hereby approves of the final payment to the Contractor, and agrees that final payment to the Contractor shall not relieve the
Surety of any of its obligations to
(Insert name and address of Owner)
City of Hastinqs, 101 E. 4th Street, Hastings, MN 55033
as set forth in the said Surety's bond.
, OWNER,
IN WITNESS WHEREOF, the Surety has hereunto set its hand on this date: June 14 r 2007
(Insert in writing the month followed by the numeric date and year.)
Attest
(Seal):
~iI~
Jack Cedarleaf II
(Printed name and title
Printed in cooperation with the American Institute of Architects (AlA) by the CNA Insurance Companies.
The language in this document conforms exactly to the language used in AlA Document G707 - Consent of Surety Company to Final Payment _
1994 Edition.
Consent of Surety
to Final Payment
OWNER 0
ARCHITECT 0
CONTRACTOR 0
SURETY 0
OTHER 0
AlA DOCUMENT G707
TO OWNER:
ARCHITECT'S PROJECT NO.:
(Name and address)
City of Hastings, 101 E. 4th Street,
Hastings, MN 55033
CONTRACT FOR:
PROJECT:
(Name and address)
Construction of Well Pumphouse No. 8
CONTRACT DATED:March 20, 2006
Magney Construction, Inc.
1401 Park Road Chanhassen. MN 55317
In accordance with the provisions of the Contract between the Owner and the Contractor as included above, the
Fidelity & Deposit Company of Maryland
210 No. Charles Street, Baltimore, MD 21201
(Insert name and address of Surety)
SURETY, on bond ofMaqnev Construction, Inc.
(Insert name and address of Contractor)
1401 Park Road Chanhassen. MN 55317 ,CONTRACTOR,
hereby approves of the final payment to the Contractor, and agrees that final payment to the Contractor shall not relieve the
Surety of any of its obligations to
(Insert name and address of Owner)
City of Hastings. 101 E. 4th Street. Hastings, MN 55033
as set forth in the said Surety's bond.
, OWNER,
IN WITNESS WHEREOF, the Surety has hereunto set its hand on this date: June 14, 2007
(Insert in writing the month followed by the numeric date and year.)
Attest:
(Seal):
~;j~
Jack Cedarleaf
(Printed name and title
Printed in cooperation with the American Institute of Architects (AlA) by the CNA Insurance Companies.
The language in this document conforms exactly to the language used in AlA Document G707 - Consent of Surety Company to Final Payment _
1994 Edition.
MINNESOTA' REVENUE
Withholding Affidavit for Contractors
This affidavit must be approved by the Minnesota Department of Revenue before the state of Minnesota or any of
its subdivisions can make final payment to contractors.
IC134
Please type or print clearly. This will be your mailing label for returning the completed lonn.
I(;ompanyname- - - - - - - - - - - - - - '\ Daytime phone
I Magney Construction, Inc. I (952) 474-1674
I Address I
I 1401 Park Rd. I $ & ~555, /
I City State Zip Code I Amount still due
,-Chanhasse~ _ _ _ _ MN _ _ ~531~ _ _ _./ $ '-I}' -tij, 03
Minnesota tax 10 number
1596928
Project number
13537.001
Project location
Hastings Well Pumphouse NO.8
Address
395 East 21 st Street Hastings, MN 55033
City State
Hastings MN
55033
Project owner
Zip Code
City of Hastings 101 4th Street East
Did you have employees work on this project? lZJyes DNo If no. who did the work?
Check the box that describes your involvement in the project and fill in all information requested.
o Sofe contractor
D Subcontractor
Name of contractor who hired you
Address
o Prime contractor-If you subcontracted out any work on this project, all of your subcontractors must file their own
ICl34 affidavits and have them certified by the Department of Revenue before you can file your affidavit. For each
subcontractor you had, fill in the information below and attach a copy of each subcontractor's certified IC134. If you
need more space, attach a separate sheet.
Business name
Address
~Yf. Paul, MtJ
~ (lM-v; MN
. flwJ. uAI
/I1dAJ:N
91 /UN
J J31POniU1'fittn, /t1f\/
I declare that all information I have filled in on this form is true and complete to the best of my knowledge and belief. I authorize the Department of
Revenue to disclose pertinent information relatIng to this project, Including sending copies of this form, to the prime contractor if I am a subcontractor,
and tD any subcontractors If I am a prime contractor, and to the contracting agency.
Owner/Officer
,k~~s
iil I
~ Vnt/L/au
fJ!:ts Mlt/I 1m! /i~
~:t:lt~.
Mm Jhee)~
1t/~ ~~e;ru
{J,,;US ( ~$
Contractor's signature
Title
Date
Mall to: Minnesota Revenue, Mail Station 6610, St. Paul, MN 55146-6610
Certificate 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 concerning the withholding of Minnesota income tax
from wages paid to employees relating to contract services with the state of Minnesota and/or its subdivisions.
.A:: ., '- '*=
Departmen'/Ofil'ftlJ?-tpapprovall, <. . /1 ~ ~:, . Date
f!:.'-.:~":"'I.I."r~ ./" ..I{..~- ..~;.,.. J' JUt
~..M;""'~;;;:'~.,_ V H-'<-'~-" ,,'(. I 2 4 2D07
Stock No. 5000134 (Rev. 2/03)
Hastings Well Pumphouse #8 IC134 List Con't
1. Heineman Painting, Cambridge, MN .. Lenny Heineman
2. Northern Plumbing Tech. - Elk River, MN - Phil Olson
3. Aslaksons Blacktopping - Red Wing, MN - Aaron Aslakson
4. Renowned Exteriors.. Brooklyn Park, MN - Chad Sigatoos
~ lI~nMiv Solis 8f9Itno lil_la",:" B~
Apr. 3. 2007 11:54AM
MINNESOTA. REVENUE
Contracto"-s Withholding Affidavit
Confirmation
KEYS WEll DRILLING CO
10 8105506
Please keep this information for your records.
Submit a copy of this page to the business that hired you to receive your final paymenL
COnfirmation number
Proje<:t owner
Project number
Project begin date
~rojec;t end date
Project location
Subcontractors
151414 Tue Apr 03 10:53;07 CDT 2007
CJTY OF HASTINGS
13537.001
August 2006
January 2007
HASTINGS WELL PUMPHOUSE NO.8
No subcontractors lisled.
https:l/www.mndor.state.mn.usIwc/actionlconfinnationPrint
No. 0927 P. 2 Page I of!
04/03/2007
04/03/2007 0~.: 3_0_. __ 7~~~?9i3.z~R...)' ....UlI;,,1.1 Ut,ilJ.un
I
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PAGE 02/02
T-436 P00Z(003 F-007
MINNESOTA. REVENUE IC:134
Withholding Affidavit for Contractors
This affidaVit must be 8PPR:lVed by the Minnesota Department of Revenue before the state of Minnesota or any of
Its Subdivisions can make fina' !)ayment to contr.lctors. _
Preaee lype or prim: c/oarly, ThIs will b$ your ~fIIng looef tor I1ltlJm/pg the compIBt$d fllffil.
~-~---------------
Companynftrtl! "\ 0lIyt1me~
. I ELECTRICAL fNSTAU"ATION , I 11 3-t.t'1 -~1"''-I
1A<ldl'll$8 1& MAJNTENANCE cu. -I lOttdconl/llllUmlllunt
I 1480 COUNlYROAD90 I $. 14 . DO
ICily !\I1AP.t.H PLA.It'<JMN bb~ I ^'-tltlltlUdue
\.-----------______/ $ \4stt\. ~
MInnesota tax ID IIUlIlIJet
toll -Z,b<o.~ I
MonIl>/Je work bl!gah
ca 2..D ol.p
Ml:lntJVi r-'l eOOed
~ z,007
ProJsct nIM1Irer Project IoCmlon
13597.001 HaSlfngs Well PumptJouse NO.8
"'Wtct IlWlIGr A<IdfOOR
...Q1!y ~ ti~ 101 41h SlreBt E.II6t
Dld)'OlI hlMl mnp/Qy~Ol' work OIl tlIIlI prqIoot? ~Y8ll OIVo Itn". ll/I1D did the WOtI(/
395 Ea9f 21st Stroot HllSlIngs, MN S5033
~ State ~COllIJ
Hastlnge MN 55033
,.
CheCk tilt;. bOK that descrtbBs your involltement in the pfDject ltnd fill In (J/11n~tlon requa$t.ecJ.
o Sole COll1t>>ctor
o ScJbcol1tt8ctar
"'lIll1o of ""nlnIclor' V/lllJ I1IftKt you
Add.....~
o Prime ll(lflttac1ior-lf you sUbcontmct"d out any wort< On this project., all of YOOf SfJI)contmctors must file tJJeir oWn
IC.134 affidavits and have thtml cettlflfJd by the Depal1lnent of Revenue bdore you can file your aflidlWit. For each
subcontnJctor you tJad. fill in tha iofom'latiorl below ~nd attaCh a copy of eooh subcontl3ctQl"S certlfled ICl34. If you
need more SPlIce. attach EI separate sheet.
BlltifiOllsll8me AddrO!lS ClwAer/Offlcer
J
J
I t1~ that afIlllfortmltfon I ham t/J/qd fh on tllk fcnn Illlnll/ W comp/8le flO tllflbesr of my ~ a'l't ~1If. , IHII1IDI1.II& the Dtlpattmf'llf of
RlMtnue ttJ d~ PMfnl!lrlt /rIoTll18t/rm tel4t/tlf1 ,., I#l1lJ Plf/foct. lrn;/udIng ff9l1dflllf RlPtes of thfa ftlrm, h) file primo ~nfmllfDr If r am B $ClCeoIltnlCfor,
SfId to !IIqr ~ If IlI/IllJ Pttne tlOlltTSCtm; #.lnct 10 ttm W/ltnJctfng /IJllmCY.
cOn~~~ Title ~
Mall to: Minnesota Revenue, Mal15tatlon 661.0, St. Paul, ~
47U~
Certlflcate of Compliance
Based Of! roCOl'ds Of the Minnesota Department of Revenue. I certify that the contractor Who has !Ilgnecf this certificate has
fulfilled aD the I9QUirements of Minnesota Statutes 290.92 and 290,97 concemiJlg tile withhaldfnl! of Minnesota i/'lCOms tex
from wa~..M!!f to emplo}/Bes relating to contract seNices with the stam Of Minnesota aM/or Its subdlvlslong"
Dfttmtm8f.,l~ "'PltlVIJ~~ 4~'1 0Irte
~!~f{:'~.,.31,r} :f .IIP Zf 1)fi.r>:! ..
{.~~~~8~~~t..__ .-. jk~.~~~"u~~. .
Sloclr 1lIl. 80001~4 (Rev. 2/OSt
-.........,-......
Apr 02 2007 9:25AM
Bostrom Sheet Metal Works 651-646-8081
p.2
MINNESOTA. REVENUE IC134
Withholding Affidavit for Contractors
This affidavit must be approved by the Minnesota Department of Revenue before the state of Minnesota or any of
Its subdivisions can make final payment to contractors.
I
Plealie type or print clearly. This will be )'Our mailing label for returnIng the completed foon.
'eompanyn;;;' - - - - - - - - - - - - - - "\ Da~mephone
I Bostrom Shoot Metal Works, Irn:_ I 165,) 646-7475
I Adc/re$S I Total contJMt aroounl
I 731 Hampden Ave I $ 16,680
I city State Zip Code I Amount sllR aue
\..StPau~_____MN__~5114 ___/ $ 834
MInnesota laX ID numller
8433073
Montl>/year'WOtkbegan
12/06
ManllVyearwork ended
3107
ProjectnumlJer
13537.001
Project Jocetlon
HASTINGS WELL PUMPHOUSE #8
Project owner
Address
City
HASTINGS
State Zip code
MN 55033
CITY OF HASTINGS 101 4TH ST EAST
DId you lime employees W01k on this project? IZJyes DNa If /10. who did the worl<?
Check the box: that describes your Invofvement in the project and till in a//lnformation requested.
o Sole contrac:tor
o Subcontractor
Name of conlmctDr II'l1o hired you
MagneyCon&tnJction. Ine
Mdren
1401 Park Road, Chanhassen. MN 55317
o Prflne con1ract_lf you subcontracted out any worll on this project. all of your subcontractors must file their own
IC134 affidavits and have them certified by the Department of Revenue before you can fila your affidavit. For each
subcontRlCtor you had. fill in the information below and attach 8 copy of each subcontractor's certified IC134. If you
need more space, attach a separate sheet.
8uslness name Address O1I'ner/otnoer
PalenlKimball Company
International Test & Balance
550 Vandalia St, Sl Paul, MN 55114
8401 73rd Ave. No., MInneapolis
I dechtnt that a11lnfonn8l1on I hava tII1ed In on this rorm Is t/ue and complete to tile besl of myHllOW/edge 8IId belief. I atllhorlze the /JepaIfIJJlIIJI of
~ 10 ~/ose pert/llent iPformefJon refatlng 10 thIs pro}eot. induding sent1lnl caples of thiS I\mn, to ttJe prime contnIctor If I am a subcon_r,
BIld 10 allY subconlI8cmlS if I am B plime contractor. and tD the COIlfIactillg agency.
Co at Title Date
~
tat/on 6610, st. Paul, MN 55146-6610
Certificate of Compliance
Based on records of the Minnesota Department of Revenue, I certify that the contractor who has sTgned thIs certificate has
fulfilled all the requIrements of Minnesota Statutes 290.92 and 290.97 concerning the withholding of Minnesota income tax
from wages paid to employees relating to contract services with the state of Minnesata end/or its subdivISions.
Df1partmen!n(p~ epprovat -'<=- ~ Date
p~,:;",. I\(o~" - -,.
;' ~'- --~'~\:1J. - i~' 1./; -:Nt' >:~ fJ.r:i.J<'/iJ -
;:. ~ .~ --,<,:<::; -~-~ _ V b1<". .-:..""~ __.,~
Slock flu. 5000134 \R8't. 2/03)
Bostrom Sheet Metal Works
02 2007 9:25AM
Apr n.r ~t ~D07 ~:3ZPM Bost~om Sheet Ne~a) Works
I
I
651-646-8081
6~I-S1G-B08J
p.3
p.;::
MINNESOTA' REVENUE 1CU4
WItIahoIcf..., Affldavft for Contractors
This -md1Ml rrKJ&f be fPPIOVecf by the MnnesDte Department of Revenue b~ the 6U1te of M/nnq* or 811y of
IB ~8Jonf C80 meb, tlnal PBmleI1t fIo contmctor.. . _
"'lell/Plt.. ""1ft doarIy. TlIIa otiA .. )1lUr..... Itll... rgr ..eum"'1I1' OOIlljlllrlecl tWmI.
r~,;;.---_________ - -"\ fJ'J'lJlw""'-
J In~O/lfJl Test A a.lance I (Je$) ~33-B 2 I
r~ I 1011'......'-"'\
I 8f01131d /We. /lID.. lea . f . 7:20
l~ a_ 2il>toN 'La. I 4b11f,nlltIHCllII
\.~nllGJlO/ll____~___~ny./ _, 720 .
1'lIUt<</ItlIIetr J ~Cf ""'-'t .
13SJ7.00t L Hl\snNGS WELL PUNPHouSE 38
"'-'1Ct_, AdlI'_
mv OF fWS1INGS 10141H ST eAST
DIcf,.......~""'*...1Nt~7 0v. DIIr> AIll>._dill/w Inl't7
CIb
tfASTlNGS
SIIlIlJ Z1p~,.
MN 55033
~ lit - tIlll t:Itlsct(JJes )'011' m~."t In rtIlt P'O/ef:t MrJ "" In ~tl frlfomtMJon ~
o .... CODb_lOw -
fZJ ........,
,....af~ llllolll,..._
D~ SIltc ..... """0. lito.
--
nTHI/IlPdeIIM..St~MN 55114
o ,.... cantrWDt-rr)'llU .ull<>>ntteote~ Clt.lt any lIIOI'II OJ! fh.. I"'O)ett, alf of)VUf eIIOcontr~ muS11fI~ tfIefr ClWI)
1C1.84 .",If."" 8nd #lava tI1.m .rllfted t.y tile ~of Ravenue ~ you c.,. fI'. your 8ftl4evlt. /"g( acn
eubaanbctor jo'Du 1I1d. fill irt tIte Informat!Gn below and &llUcb . copy or IIftt! suboontr.etar. celtffIH ICt34. If ~
IIIed mOm 'P"e, IttBcIt a SftIJ8rQt. .heat.
8~..... - ~.. (IIM."OIlbIr.
h,.....lItIl.UIlIl~__,'- MlItt if"" IIWltIMn r, I'WIIId ~... "11I01 IIll' ~ 1IId-.r.t I ~_0e~...
~ "'dlIclWe~Imlllmse,*"~,., rn.~~"~lIlIPIH ."1/1I ~ lD l/lt JIlN-lnIC111'll't_ .~.
..,,. ....ftlIIarIbCMItI./II.,..". -eo4lftIClIIW.......
CllMlNalr
... ~ MfnneS<<a Rewnue, Meli Station 8610. st. Pauf, M~
C<<t~ of Compliance
Baeed 0It RIcGtCfa of Ule Mhn~OliI Depertm.na of AlnIoe/hls. , C8IWt tllat II'Ia ~or wflo flaG IJe'llllt tNa ClIlftI"~ate lIu
,.."... all the "'ementa of Mnneeote ~uti. 2liIO.92 end 2$0.97 conoem,,,, th8 wfthllG''''' of AIJn,,~ lrK:o"'c_
fR1m waps peId to e41\pro,.. IeII1tInC tB ClOf\hct aeMces wftll h.taf.lJ at N'nn.~ 11M/or !fa etlbdM8fof'oS.
~ ~ /')'.A.=~ a,to
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'-'_~"'................y,::-...._. - ." ...."
Apr 02 2007 9:25AM Bostrom Sheet Metal Works
04/02/2007 ION 1:35 FAX 6516422564 Palen Kimball Co
651-646-8081
p.4
flloo2lo0Z
Mar 31 2007 4:30PM
~O$~rom Shee~ Me~al Works S51-S46-B061
f'_2
M.INNESOTA- REVENUE 1C134
WithholdIng Affidavit for Contractors
1111$ atrldlMl mtlit be approved ~ the> Mlrm8$(l(& D4Jpartnllmt of RIlYeDlllt befQre the stelle 01 MfnneS'ata or any of
Its SUbdMslan$ can make 1ine1 payment to oontmCtOF8. .
Pleece ~ or pr/IIt eIlIIe,ly. 1'IUa will ... JOUl rml",l4bel fOr Rt\Imll1ch uwnpl~ fonn.
~;-~.;;;.--------------'\ ~~
r P81ennGmbsll Company . t (&oil 6~.2546
I AddrNe I Ttr.h'unInIIlCM__
I 560 Vandalla at. f . 1875
I CIlr "'" . lip Colte --, ""Da".._1Iue
\.StPeuI______MN__-l!!~___..1 11875 .
~~~1H101lClIII\ltrf
fl36J.SlJ 2-
~r_"'1III
- 0/- 0"7-
17;?1Mf4
I
,...-.bo1 I ~_.....
13537.0(11 ,HAs'nNGS WELL PUMPHouse #8
'"JKt_ MdnIa
Cnv OF HAsTINGs t014TH ST. &\$1
w""''''''''''ot'"U _onf/tw pItljII..? Illv.. DNO .no._Clkf~..or!lt
CItf
fiASTlNGS
scn ;Il!l~
MN 56033
Chllell tI'te-~ UI4t ~)'OfIl' jn~t In the PAlJ8l1t ~ tiIIlD .,1 JttformatIon requesl!Xl.
(J 3q1e CObt~
lZJs~
"'tJlal~YllMohl,,*,_
BotCr1Il1l SIIMt Meal Werfw. IDe..
MlIreoa
~f HMIP4en A'fIl~ st.1"lwt. MN 851..
[J ...... 1I.....~)'OU Hbcontracttd out .nr ~ on th'- prqIJgt. all or)'OW alrlJtonttRto~ II1I18t file 1~1r OWl'!
1C134 IIIfIcfavft.s llI1lf heVo U1em OIrtm.d by 1I1e Depanment G# Aownue.oolMt Yatt oaa ,,. yWt .1'IICf1Mt. for aar:ll
'lIbcGnlractW' ~ lied, fill In tile InfOl1l1stlon Ilerow AInd a1taeh . copy or eeaII $UbOonflllctor'. oertfflcd 1C134. If .you
deed IlIO/'O space. Ilnach U MpIIl'lItIt -heet.
I~- tWd_ ~om-
I
I~ liar ell ~ Ih..... tIifeI In 1M are ltlmJ ,. we II"., ........ 11>.. b.r.t I1tY bIClII'~ .rtd Oc:.ht. ,.lIlIrotlm 1h4~1)f tIf
-- '" """"lItmntIlt~l~la -~ ~~llQII/M ala.- fMII, b. pdme ftIIhGIw/f'"" 'AfIco_b,
'I/If>>~ '~___N'J _ a"""., OOOlGOlOf. Met (q..... ~trftno'.
~~ll~'-~ ~
Mart to: Mfnnesota Reven . Mail Station 6610, St. Paul. NN 6514e-66~
....
t/ 0._
"''''Or
Certfllqte of CGmpIIuce
8IMCf 011 ftII:QIds of '#Ie Minneaote Depaltment 01 ~ I oeltlry tha1 till conuactor wIlCl has sICned lhIa certfflCllltcl fin
~d 811~ f~ of ftillnntMata _tute. 2QO.$2 end 290.97 conGemlng the wfthholdinf of Mi_ota JDCrlme teA
~ WI#* paid 10 8IllpIO)reea reIIItln8.to COIICPIet GeNcelP wllta fie SlBtct of MlnnesDta an.d/or'lts SubdMsrClll8.
~ of.......flJtfM>_ I JUl 2 4 2001 ~c
-...
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03-07-'07 15:20 FROM-Magney Construction
9524741679
T-212 P002/003 F-242
MINNESOTA, REVENUE IC134
Withholding Affidavit for Contractors
This affidavit must be approved by the Minnesota Department of Revenue before the state of Minnesota or any of
its subdivisions'can make final payment to contractors.
Please type or prlritclearty.This will be your mailing' label for returning the completed form.
fc;orp"'Y~--------------"'\ oaydmephone:
I tt.J L<-f y- S"~-f, J ~ <::..- I (If'p.... .
I Address ~ l'H= ~ I Tota~amount
I /08/ t(/ 0(.....0' J./ I $ ~ 6_~,C7Z?
I ~ ~ State M, ZlpCode I AmountstlU due
~____"?~ __-::::_s-s-~ $ ~FOO/
M3-"ur$2;:3
Montll/~/~b
ManiTr 2~b
I
Project number
13537.001
Project owner
Project location
Hastings Well Pumph,?use No. 8
395 East 21 st street Hastings, MN 55033
City State Zip code
Address
Cit. of Hastings 101 4th Street East
Old you have employees work OIIlhls project? Yes ONO If no. who did the WOIk?
Hastin
MN 55033
Check the box that describes your Involvement tn the project and till In afllnformatlon requested.
o Sole contractor
~ Subcontractor
N8meofCD~6r~C y ~~dr~
Address I ~CJ I fJA-/k ~ <6 / C:-fU ,t,.-f(465~/W~ S-.) ~ /7
o Prime contractor-If you subcontracted out any work on this project, all of your subcontmctors must tile their own
1C134 affidavits and have them certified by the Department of Revenue before you can file your affidavit. For each
subcontractor you had, fill in the information below and attach a copy of each subcontractor's certified ICl34. If you
need more space, attach a separate sheet.
Business name Address Owner/Officer
atlon I have filled In on thls form Is true and completa to the best of my Knowledge and IJelfet I 8urhorize file Department of
ettInent Information relating to this project. IrIcftJdlng sending copies of tills form, to the P"1OO contractor If I am 8 subcontractor,
ctOIS If I am a prime con etar, and to the contracting agency.
Title
I2C-s
MaD to. Minnesota Revenue, Mail Station 6610, St. Paul, MN 551.46-6610
Certificate of Compliance
Based on records of the Minnesota Department of Revenue, I certily that the contractor who has signed this certificate has
fulfilled all the reqUirements of Minnesota Statutes 290.92 and 290.97 concerning the withholding of Minnesota Income tax
from wages paid to employees relating to contract services with the state of Minnesota and/or its subdivisions.
Departm~~"",nue approWl.- Date
'"~ ~ ~
'"4 .
;,. o. . , oJ'
. .. ,......,.d.(;.. I
Stock No. 51166134 (Rev_ 2/03)
63/26/2007 14:20 7&36894526
\.'''':.\::.~~-- (I -i.....\. \':'-.-,. ..-:t.Jl:";:. __1.::...:....____.;.1
I
PAGE 61
MINNESOTA REVENUE
WIthhold' Affidavit for Contractors
IC134
e IlpprOYf.t(1 by ~ne MInnesOta ~rtm~nt 01 Revenue beklre tfle 1;:3t6 of Minne6lcta or any of.
rnal<e 1ina~ ;)ayment to contrectOfS.
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MonIIV__ b4i81"
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I
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_ _... . Hullngr. Well pumpn0Ull8 NO. ~ 3~ en' 21 lit Str~e1 Hut. MN !i6033
-- c.,.._
10t <4th St1eet eut Ioffill"98 M/Ii
...otl<OlIl1l/ejlf<lj~ oY.. O....lfnQ.whQ<I<lI"._?
J;2,~/&J.d....~ap. 1Yr.l-jVl'~~__~ /~
thllt ducrlbM your IflWllV\!ment In t!'te (J1'O}$Cf ana fill In Bit information nK;-4I<IiteG'.
11p_
Slilm
~~~;;c".;~1.;~'1i ~M =_
tof'.-If yo!: 5ubcOntr~ out IIfI)' R'OI'k on <his projl!Ct. 3il c,f )'0<.1' atJbccmltactors mu;tt Jile t!leor (0",,,
dll\lit!l ana navl': lI!em ~8":lllclO !>i t.'1e Oe part<n8n~ or ~t'''e''ue bl!~'!tl 'fOu (".all fll~ )OUr af'I\1\1Vll. for ea(:!l
$lI0C:0nt (:fcr fQU hao. N: in tl-.e -r-fOfI"l/ltion bIlloYo' ~r,O attB!:l1l e t;tlP1 O! 6t~::-' ~l)bOOtlIJ'llOtot'$ certl~d Ie:: 34. If you
n".(1 m 18 ~Pll~. attMtI tl $(Iperatll Sf\&et.
!!III,.,." ___. _~d"'__
Qw(\{r~,
..
1 c.c>1!rt1I fhet. In_' haWllfJvd In ...... thT1; f'orwr ,. ,,,.. M~. to III.- _ Of my lrnQ~ titd btIIIet ! .u<<ItorlN tM o.".rtm..nr d
lit_Ill\) " pl!fllmrn! nlorlJllllllla '8~ rn t~" t:fCll*Cr. 11rCi1Jd1tl1.."dlr-lt ""!~Jn 'If 1Ii~ (""'l. to It... pt1~ ~<UllillClG' '111m . ~('-01Icot.
."" fit ~ tillCfO!'ll If I .n: II "'~ /XIll~O;, ,~d ~J lII'tOOtfllCtfr!l.pIlCY
.~~ .---. ~ ~ ~ ,-'~;;;'~!~
esotEl H6vanue, Mail Station 6610, St. Paul. MN 55148-aa:1.O
CMtllhoate of Co.....ooe
J
U.
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'---'--------
----....--.--
MAR-11-2007 11:05 AM NPT
. - . - - - ........~ .._~._~ ~"J..:aI..J \.4\.ol..LVLJ
763 263 0830
~~~~t~~Ut~ J-~~L r~~~/~~S
MINNESOTA. REVENUE
Withholding AffIdavit for Contractors
This atridavlt must be approved bythc Minne$Otft Department of Revenue before the 9tate of Minnesota or any of
Ita lIubd/VIelona can ml!l1ul11r1s1 psym8nt to contl'80t0r$,
~"ee typlt or prlnt ~,"r\)'. Jhl. wit bit rour matins 18be1 for l'ItumInI tilt ODrnp~ flltm.
~----------~------
OOIl!panr....... '" Da)on8 p"e"...
f N.tMl..7HA4..;v Pj..'-MA!nNI7 -rE~"y. 1"1l.t.~ 24!~ Bt'jQS
I ~ I TOlaI-..-_
1/"~7k 2~O""H -'fV"r /\/'-'<./ I. 10 9l7DIt)D
I Cltr SIIiII ~ f;lld. ' I MIouru IIIIt
\.Eu<_fll\l~A.__HlN _~~5..2~b_/ $ '-2.0,00
Mlmn..tKlD~r
,?1~4~O
Mdlltb/,..-trOIk bclIIm
8/o~
~JRl"WIOlk lItllIod
Z. D"
I ~1lUIIbr ,..1oGIltl0ll
fMa"-OOl liaetrnllO Wflt PurriphouM No. 8
Pl$tIt_ Adi:lrNa
CIIv OJ tlllSt/nga 101 4th 9ftIat &It
llId "'" _em~ -o<l< ""Ihl. PIlIftICt? Jqv- [}c& It l'IO. 'Oho~I#ll\. WdIk?
I
SlM Etat 21M stteet Havtfngs. MN 55IJIl3
CIb> _.. llpOOl/o.
Haallr1l18 7 MN Noaa ~_
CllSOk the bQlC that desaibes yOUT InvoMilment In the tJ('Q}ect and ffllln .lIlnforrTllltlon ~8d.
o .... oo~
o hllooDtraotor
Nilme or CIIllt..w,r who IIlrad)lOU
Add,....
o Prime ~f )'011 auIIooPtractecl out any WDJk on thlc proJeot, 1111 01 your IllJbconJ:ractom mUBt nl& their own
fC194 atllda\libl tmei IN!lve them GonJfled by tlls Department of Revenue before you oan file your effklgyjt. For eaoh .
lIubconttactnr you IIeel, nit In tit., InfOfJllatlort below and attach a \;OJ)'( at eect\ 4lIbcontrlillltOr'lj l:eItifled 1C134. 1f)'Ol
need mote apace, ~~ " "'f'IIl'lIte ""eet,
1Iua~_ Md_ 0wn0r1Olft...
t
~
~
~-
- -
-'
I ~18/$ !IlItt lilT /nft)tm.Ilon I hlMl t/1JftIlrJ 011 thIa ^"'" Ia ft.,. IIItd ~ Ia llle belli d"" ~ 11'Id!18/lM. , autlIlll1at !he ~ or ,
~- fa ~ .oM/Iltllt Mrm#Olt M1atI1I.f t& tIIIa P1q/tlf:r. IIIeIIIIJln, __ t.tJR/H IIIlftll1l1lrn1. 10 ffl" JJrl/mIIIOIIImdrJt It I am _
lIflCl /II My "If~ntraoIoIJ If 1m_ /HfrIJf OOIlImlIofs Ifld 111 "'II CIOIlWGfIlW .,.".
eon_tDr'. ....'"" .
~~a-- "P~F:J"lt?~;,r-.3
Mall to: Minnesota ReIIIlnUA. Mall Station 6610, St. Paol. MN &5146-6610
CGI'tIIkIaIe of CompIIanH
IJGee(f on ruoorde of thll MlmHoUr Department of ~VIInIMI, . oertl1y tl1St tINt oontl8GtDJ v.tJo 118 81gned tIlI& cartltlcate hU
fulflllea ell tho roqulrori1ents of Mlnneeotll Statute., 290.~ tvld 290.97 conaH'IIIng 1M- wtthholclfng of MInneGOta Income tllx
from wages peld to employees relating to contract &eMcee with the BIUte of MiMll80ts 8I'Id,lOf Ita aubclMsions.
Of :p~~....~~ IJUL 2 4 2007 o.r.
-".,. MOOs,.. CIleo. MIll
Fax 6513B50730
MINNESOTA- REVENUE
Contractor.s Withholding Affidavit
Confirmation
ASLAKSONS BLACKToppmG SERVICE !NC iD 6032526
Please keep this information for your records.
Submit s copy of ti-Jis page to the business that hired you to rccehls your finai payment.
COilfinnation numb~r
Project owner
Project number
Project Mgin data
Project end da~
Project location
Subci)ntr..ctofs
149419 Thu Mar Q8 08:13:48 CST 20G7
CITY OF HASTINGS
pur,;,p HOUSE 8
Nover..ber 2DGB
- Novembe~ 2\)OB
395 EAST 21 ST STREET HASTINGS, MN. 55033
No subcontractors listed.
https:/fwww.mndor.state.mn.uslwc/actionlconfirma.tionPrint
Mar 8 2007 09:26am P002/002
3/8/2007
05-07-' 01 14: 44 FHOM-Magney Const ructlon
- .Fl139 -P110ZTlIllilJ l'-~.fOr
IC134
MINNESOTA- REVENUE
Withholding Affidavit for Contractors
This affidavit must be approved by the Minnesota Department of Revenue before the state of Minnesota or any of
its subdivisions can make final payment to con1ractOrs. -
I
Please type or print clearly. ThIs wilt be your mailing label for returning the completed fORll_
~-----------------,
IComr:z~Ownu{ Ex-ftVfors I f:e7~& 4300
Illddre8ll rvi . I I Total contJ8damount
I ~rPt - qfJ Y\vt N _ I $, ;)-?7-, W,
IJJfrCOltl Vl PtIL~ Il* flI\.J~~ 3 I (fgstil' 8 . QQ)
\.!----1-------~--./,'-------.-- -
Pnljectnumller Project IocatlOn
13537_001 Hastings Well pumphouse No. 8 395 East 21 st Street Hastings, MN 55033
Project owner Address CiIV State
City Of Hastings 101 4th Street East Hasmgs MN
Oidyou_emp/ClyeesworkontlriSproject? Dyes UJk,lfno.whOdiclmework?
Hvva.uto So 1 i 5
Check the box that describes your Involvement In the project and flflln alllnformat/on requested.
o Sole contractor
[sysubcoIltrac:tor
NameofcontractDrwhohiredyou Matlrt0 f JJ/r1Str'W f1 0 n
Address 140 I flGK ~d. I ChV1 ha<;,~
ZIp code
55033
I f\Jl;1\J 55 ~ /7
I3Y' Pdme contractor-If you subcontracted out any work on this project, aU of your subcontractors must tile their own
fC134 affidavits and have them certified by the Department of Revenue before you can file your affidavit. for each
subcontractor you had, fill In the information below and attach a copy of each subcontractor"S certifIed 1C134. If you
need more space, attach a separate sheet.
Business Address
tIW end comp/efe to tile beSt 01 my knowledlIe and befJe(. , alJthollZe tile Department of
projeCt. ItIt:ludIng sending copies of this am, fa file ~ confrBcIDr If f em a subeonfIltCtor;
fa the c:ontnrctIng agency.
Title
Dw~
Certificate of Compliance
Based on records of the Minnesota Department of Revenue. I certify that the contractor who has sigt1ed this certificate has
fulfilled all the requirements of Minnesota Statutes 290.92 and 290.91 conceming the withholding of Minnesota income tax
from wages paid to employees relating to contract services with the state of Minnesota and/or its sublflVisions.
OepaltmeRt .~. IIPProvat1' ~o - ~-.. Dare
. - . _ ~7J
, -.,.. -,~ . .. -,...-.:...---'
Sta<_ No. 5OO()l3oO (Rlw. 2/03)
RECEIPT AND WAIVER OF MECHANIC'S LIEN RIGHTS
Date: 6-6-07
The undersigned hereby acknowledges receipt of the sum of ($ 4.975.15 ,)
Four Thousand Nine Hundred Seventy Five and 15/100 DOLLARS.
FROM:
Marotey Construction. Inc
CHECK ONLY ONE
1) _ as partial payment for labor, skill and material furnished
2) l as payment for all Jabor, skill and material furnished or to be furnished
(except the sum of $ 261.85 retainage or holdback)
3) _ as full and final payment for all labor, skill and material furnished or to be
furnished
To the following described real property: (legal description, street address or name)
395 21st Street E, Hastings, MN
Well Pump House #8
and for value received hereby waives all rights acquired by the undersigned to file or
record mechanic's lien against said real property for labor, skill or material furnished to
said real property (only for the amount paid if Box I is checked, and except for retainage
shown in Box 2 is checked). The undersigned affirms that all material furnished by the
undersigned has been paid for, and all subcontractors employed by the undersigned have
been paid in full, EXCEPT:
TIllS LIEN WAIVER IS NOT PERFECTED UNTIL THE REMITTANCE HAS
CLEARED THE BANK.
RENOWNEDE~RJOOs~
BY: ~
...-
Kale Wallner - OWNER
5909 92nd Ave North
Brooklyn Park. MN 55443
67/13/2607 13:16 7634793745 ElM
- "" -'-'" OJ, -'-V.J.I:. rmJl.T'l:ll1!:1IIW....lHlSl:ruGrlon
PAGE 02/02
T-061 pe02/002 F-445
FINAL WAlViRAND RELEASE
- 00
- . Thc.~ped hlllJ ~ paid..-nd hilI ~wd fhe sum~Of $ -SJ' "~'t' final ~_for an Iebor.
~. ~CIlt 8DdIor-matetial tbmisbed-to . _. ("1be
Ccmcmctort') Ol' to jW subcontmclor f,Jt SUpplier (lQ : . - ~:~:~ ~ C'fhe
PrQ,ject") and doc:a hereby.m. reIeaso &Qd fOmror diSOb. 0 Conttac:tur. tho Owner oftltc Project. their ~~
fIUl'efics. if any. QRd I1IlImuf9. frnprovemeDtB, daaaerll ancl Olhet- rea! and penIODBI propmty ~ with or a part of
the Project finm any RIld ell cl&inJs, debmds. liens md daPIages wJJatI/IIIWer ari8Dtg out of or related to the Project
which is now hBB or .&e.reaibr might or COlJld haw, itlc1uding witbout Umitation mcc:htmic'!i l~ stop ftOtice ad bond
dllims.and tiddB.
Thfs P"JIllIl Waivllr lUld RcIe8!re Ilh6Jl inure 10 the beD_ ofthC ConCmctor. the Owner oflhe Project. and their
~ SlU'l'ltie5, SUCCCIllIOf/l and assigus. and lIban bet biDding upcm lhe III1detslgned. and if/I hcim. SUCCl!lltOl'lJ and .
lWdgns. . -
Subscribc:d1lnd SWOt1l-m before me E lee:. +(\ CG. \ ~ iA.\kbo ^ .... W\<M<'I ~"a..l1C-~
tI1is-lidayof -ru-l'j .~. CompmyNamc /JIll.'
cib~ 1M K\8~Md&r ~ - Of ~_,
Title:--LhCt> J,'e..(~ d.eio t
LOUISE M. KlsqADEN
NOTARY PUSUC 'MINNESOfA
My COlllmlS8loD ~.tan. 3f..2OtO
Exhibit B-4
IIrn
8
ltl~ A tlJ l'urdlM6 AgfalIIIttIt
03-07-'07 15:30 FROM1'~gney Construction
T-222 P002/002 F-250
Form No. 120-M (1031)
Receipt and Waiver of Mechnic's Lien Rights
REC'{ir7"~T~
<.4-i, ~f4' h
U '.~'''''-''.
,"IA--~'
.if 1 6 ~ulII .
Date:
J1 AIU I--f
I ~ ;7,t>o7
The undersigned hereby acknowledges reciept of the sum of $
(pU??' 11
Check only one
1)
as partial payment for labor, skill and material furnished.
2)
as Payment for all labor, skill and material furnished or 10 be furnished
(except the sum at $ ... retainage or holdback)
3) 't
as full and final payment for all labor, skill and material furnished or to be
furnished to the following described real property:
(legal description. street address, or project name)
Hastings Well Pumphouse No.8
395 East 21st Street
Hastings, MN 55033
fA/i/D/LIZ /:l:-.I0'71071'"
and for value received hereby waives all rights acquired by the undersigned to file or recor mechanic's
liens against said real property for labor, skill or material furnished to said real property (only for the
amount paid if Box 1 is checked, and except for retain age shown if Box 2 is checked). The undersigned
affirms that all material furnished by the undersigned has been paid for, and all subcontractors
employed by the undersigned have been paid in full, EXCEPT:
Hawkins, Inc.
3~OO East Hennepin Avenue
M,nneapolis, Minnesota 55413
Company:
By:
Title:
Address:
3/11f 107
NOTE: If this instrument is executed by a
corporation, it must be signed by an officer,
and if executed by a partnership. it must
be signed by a partner.
04-03-' 01 10: 01 FHQM-t1agney Construction 9524741679
----- -.
T -438 P002/002 F-009
Form No. t20-M (tOOt)
Receipt and Waiver of Mechnlc's Lien Rights
1\\ - 10 - 0 -1
Date: \
The underaigned hereby acknowledges reelept of the 8um of $ -.,(1 Cl S, '5-0
Check only one
1) as partial payment for laborF sldll and material furnished.
2) as Payment for aD labor, sid" and material furnished or to be fumlshed
(except 1he sum of $ - - ratalnage or holdback)
3)
:/
, .
~
as fuR and final payment for aD labor, skill and material furnished or to be
haniahed to the following described reel property:
.(legal description, street addressF or profecl name)
Hastings Well Pumphouse No.8
395 East 21st Street
Hastings, MN 55033
and for value received hereby waives all rights acquired by the undersigned to file or recor mechanic's
liens against said real property for labor. skill or matmiaI furnished to said real property (only for the
amount paid if Box 1 is che<:ked, and except for relainage shown if Box 2 is checked). The undersigned
affirms that all material furnished by the undersigned has been paid for. and all subcontractors
employed by the undersigned have been paid in full. EXCEPT:
Company:
By:
Title:
Address:
1t'1"t.l~ L -l:2<_5~Cj ~!l <)
A ~ -.=> /l
'-- II Y\ I (~.feA..- ~( l-; 1\.<:-' ''y-....
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L ia'? ti .ua: vlC (iJi^ v-1;-W
7< Li I''L' Ct /vt {lJ "'5)0; {
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be
03-07-'07 15: 22 FHOM-Magney Construction
9524741679
T-212 P002/002 F-248
Date:
Form No. 120-M (1031)
Receipt and Waiver of Mechnic's Lien Rights
~ I;t/07
The undersigned hereby acknowledges reclept of the sum of $ 5 ~ ~ ,~
Check only one
1) as partial payment for labor, skill and material furnished.
0J.,~ ;J&t!l, ~ayment for all labor, skill and material furnished or to be furnished
~ (except the sum of $ '2 (fa; , Cfl? retalnage or holdback)
3)
as full and final payment for all labor, skill and material furnished or to be
furnished to the following described real property:
(legal description, street address, or project name)
Hastings Well Pumphouse No.8
395 East 21 st Street
Hastings, MN 55033
and for value received hereby waives all rights acquired by the undersigned to file or recor mechanic's
liens against said real property for labor, skill or material furnished to said real property (only for the
amount paid if Box 1 is checked, and except for retainage shown if Box 2 is checked). The undersigned
affirms that aU material furnished by the undersigned has been paid for, and all subcontractors
employed by the undersigned have been paid in full, EXCEPT:
Company:
By:
Title:
Address:
f~~
~
<:::!-~~.
I IO;? ~ g=~ '" $T
~~~~J 4/--~~)L'~_
. . ,~
NOTE: If this instrument Is executed by a
corporation, it must be signed by an officer,
and if executed by a partnership, it must
be signed by a partner.
03-07-'07 15:31 FHOM-Magney Construction
T-224 P002/002 F-254
flEOEIVED
Form No. 120-M (1031) M.
Receipt and Waiver of Mechnic's Lien Rights ~R 09 lUOl
:3 ---7-01
Date:
The undersigned hereby acknowledges reclept of the sum of $ Q ez> a, (jJ 7
Check only one
1) as partial payment for labor, skill and material furnished.
2) as Payment for alllabor, skill and material furnished or to be furnished
(except the sum of $ . . retalnage or holdback)
3) -K. as full and final payment for all labor, skill and material furnished or to be
furnished to the following described real property:
(legal description, street address, or proJect name)
Hastings Well Pumphouse No.8
395 East 21 at Street
Hastings, MN 55033
and for value received hereby waives all rights acquired by the undersigned to file or recor mechanic's
liens against said real property for labor, skill or material furnished to said real property (only for the
amount paid if Box 1 is checked. and except for retainage shown if Box 2 is checked). The undersigned
affirms that all material furnished by the undersigned has been paid for, and all subcontractors
employed by the undersigned have been paid in full, EXCEPT:
Company: ~
By:
Title:
Address:
NOTE: If this Instrument is executed by a
corporation, it must be signed by an officer,
and if executed by a partnership, it must
be signed by a partner.
MAR~11-2007 11:05 AM NPT
- -...._4~ "'-~.._:I _L..n:.~"J"..l'..It...LUJ.'
:JOJw"S I"iUJI;'
763 263 0830
T-Z:1::l
P.02
t'ld61Z1~Ol l212
Form No. 120.M (1031)
Receipt and Waiver of Mechnlc'. Uen Rights
Oate: ?J //1 I ()7
,
Tit. unde'.lgn~ hereby aoknowl.dg.. reo/apt of the aum of .
4f ~80. lJ6
Check only one
1) ~ .. partial payment for labor, .letll and mlterlal tumlahed.
2) .. Payment for .lllmor, Ildll Ind materl.1 fumf~ ~ to be furnllhed
(~the !um of $. .. Ml8lnaga or hDfdback,)
3) .. full and fInal PtlVmlll1t for alf "bar. sIdIl and matarlal furn"hed or to be
fumlehed to ... following dc.orlbM ...1 property:
(leOlll d-.erlptlon, __ adcIraa, or ptOject name)
Hastings Wen Pumphoua8 No.8
386 Ea. 21.t St.....
Haatlnge, MN 55033
and for value received hereby waives all rights acquired by the I.lnderaigned to file or reoor mechanic'.
llana agalnl'lt aeJd real prop<<ty for IClbor, sldh or matorict' fUrnlshed to sald teal proporty (only for lfle
8mount pald If Box 1 Is checked, and 8Xoept tor retainage 15hown If 60x 2 Is Med<ed). Tho t1nders/SJled
afllrms tlUlt 8/1 materlallumlshed by th.lJJ'Ideraigned hIlS been paid for, and all subcontractors
employed by the undersIgned ha~ /)$en paid In fuB, EXCEPT:
Company;
By:
Tltle:
Add.....:
Npr /IVL-
~ ..'"
.~FS/ v~;V r-"
1/t'''''7~ ;J..""!;1c>rH AVs
eLk:.-. ~""VE~ "'N SS3~'Z>
NOll!: If 1hlalnatrument Is lIDCU~ by a
corporation, It mutt be etgned by.n offk:er,
net . ~ bV. partner.hlp. It mU81
bo. "eel b .
_._-._--..-----~-...-... _._--~--_.. --.. -~_._--- -- .-.---.--.. .
r
I
I
j
03-07-'07 15:27 FRQM-Magney Construction
9524741679
T-219 P003/003 F-249
R7J:ivn--.
fl..~~jy~J. 1r...
-$ , V'Ph
MAR . . - ~..~,u
Form No. 120-M (1031) . 09 LtlU{
Receipt and Waiver of Mechnic.s Lien Rights
Date:
3-~-()7
The undersigned hereby acknowledges reciept of the sum of $---.lJ 0 d!!5d-
Check only one
1)
as partial payment for labor, skill and material furnished.
2)
as Payment for all labor, skill and material furnished or to be furnished
(except the sum of $ . retainage or holdback)
3) /'
as full and final payment for all labor. skill and material furnished or to be
furnished to the following described real property:
(legal description, street address, or project name)
Hastings Well Pumphouse No.8
395 East 21 st Street
Hastings, MN 55033
and for value received hereby waives all rights acquired by the undersigned to file or recer mechanic's
liens against said real property for labor, skill or material furnished to said real property (only for the
amount paid if Box 1 is checked, and except for retainage shown if Box 2 is checked). The undersigned
affirms that all material furnished by the undersigned has been paid for, and all subcontractors
employed by the undersigned have been paid in fun, EXCEPT:
NOTE: If this instrument is executed by a
corporation, it must be signed by an officer,
and if executed by a partnership, it must
be signed by a partner.
~3-07-/~7 15:26 FHOM-Magney Construction
T-218 P~02/002 F-247
Form No. 120-M (1031)
Receipt and Waiver of Mechnlc's Lien Rights
Date:
3/7 /07
The undersigned hereby acknowledges reciept of the sum of $ 40,1/7. SO
Check only one
1)
as partial payment for labor, skill and material furnished.
2)
x
as Payment for all labor, skill and material furnished or to be furnished
(except the sum of $ -2,122.50 retainage or holdback)
3)
as full and final payment for all labor, skill and material furnished or to be
furnished to the following described real property:
(legal description, street address, or project name)
Hastings Well Pumphouse No.8
395 East 21 st Street
Hastings, MN 55033
and for value received hereby waives all rights acquired by the undersigned to file or recor mechanic's
liens against said real property for labor, skill or material furnished to said real property (only for the
amount paid if Box 1 is checked, and except for retainage shown if Box 2 is checked). The undersigned
affirms that all material furnished by the undersigned has been paid for, and all subcontractors
employed by the undersigned have been paid in full, EXCEPT:
Company:
By:
Title:
Address:
-'
Keys Well Drilling Canpany
~:~
1156 Homer street
~r Prill' MN ~~116-1?3?
.
NOTE: If this instrument is executed by a
corporation, it must be signed by an officer,
and If executed by a partnership, it must
be signed by a partner.
Fax:9529442689 Mar 7 2007 16:03 P.Ol
1.:l.:s-k:!f--lDf .1::): 61 l'llUl"l-rJagney t;Ol1struCtlon ~!:)t.:4741fl'lS T-223 P~l:12/0l!l2 F-253
L
~
Form No. 120-M (1031) ,
Receipt and Waiver of Mechnlo1e Lien Ri~hto
DaM; 2/7/ D1
(
The undersigned hereby acknowledgH reciept of the sum of $
!oOB~.'5"~
1
ChGCk only one
1) as partial paYfJ18nt for labor, skill and material furn~d.
2) as Payment for all labor, .ldll and material furrri$hed or tc? be furnished
(exeept the sum of $ . retalnage or hoIdba~)
3)
)(
8S full and firulf payment for an labor, skill and materltll fUrnished or to be
furnished to the following described real property:
.(legal ~lptlon) strwt address, or project name)
Hastings Well Pumphouse No. 8
395 East 21st Street
Hastings, MN 55033
and for value received hereby waive$ all rights acquired by the undersigned to fire or recor mechanic's
liens aaaln~t said real property tor labor. skUf or material furnished to said real gropeJ1y (only for the
aM~ pclld If Bell: 1 is ehaoket!l, a"d e~cept fer ",UlMae shewn If Bo~ 2 "ch~eked). The umfersl;"ed
affirms that all material furnished by the undersigned haG been paid for. an~ aft subconb'actors
employed by the undersigned have been paid In full, EXCEPT:
J
Company: e.on~t~4 MQ:hL\~t \t\<:'
Br-~
Add:: ..., . .::... . A~... ~
0'\f\ ~ t H.Nj S ~,
NOTE: If thlslnsf!ument 18 exeouted by a
c=orporati~~.lt.mult be signed by an offiCer',
and if executed by a partnership, it must
. be 81gned by a parinQ(.
1''''.,.,.......''-'''
03-07-'07 15:33 FBOM-Magney Construction
Fax 65.1J.850131L. _. ___ Mar 8 2007 09:26am POO1l002
T-226 P002/002 F-256
Date:
Fonn No. 120-M (1031)
Receipt and Waiver of Mechnic's Lien Rights
3/~/D7
. i
The undersigned hereby acknowledges reciept of the sum of $ h ;) 8/. 3 0
Check only one
1) as partial payment for labor, skill.and material furnished.
2) v:
as Payment for aU labor~ skill and mtlterial furnisOOd or to be furnished
(except the sum of $ . 3"3 0 I>:l.. retalnage or holdback)
3) as full and final payment for all labor, skill and material furnished or t.o be
furnished to the following described real property:
.(tegal description, street addre&S, or project name)
Hastings Well Pumphouse No.8
395 East 21st Street
Hastings, MN 55033
and for value received hereby waives all rights acquired by the under'signed to fila or rceor mOOhanic's
liens against said real property for labor, skill or material tumished to said real property (only for the
amount paid if Box 1 is cneck.ed, and except for re1ainage shown if Box 2 is GhecI<ed). The undersigned
affirms that aU material furnished by1he undersigned has bBen paid for. and all subcontractors
employed by the undersigned have been paid in full. EXCEPT:
company:~t..,1.i::. 50:X---; jJ~rWl//aV~
By: ~A~{P<~
Title: C&V
Address: ~;: i;;::::; f;:: ~CG
. (
NOTE: If this instrument Is executed by a
corporation, It must be signed by an officert
and If executed by a partnership. It must
be atgned by a partner.
MAR-7-2007 03:50P FROM:DAVID HARDWARE PHONE 651-429-9767
-. --.-- ..........,.. .f-.::J".-::I __..._""...__...___
TO: 9524741679 P.l
.. --- - ---, --- - ---
Form No. 120-M (1(31)
Receipt and Waiver of Mechnic's lien Rights
Date:
The undersIgned heteby acknowledges reclttpt of the .urn of $
Check only one
1) as partial pQyment for labor, .kllI and material furnished.
2) as Paymenl tor an labor. .kHland material furnished or to be fumlahed
(except the sum of $ retalnags or holdback)
3} --L... full and final payment for an labor. aldn and malerlal furnished or to be
furnished to the following described real property:
('egal dqcrlptlon. atreet address, or project name)
Hastings Well Pumphouse No.8
395 East 21st Street
Hastings. MN 55033
and for value. received hereby waives all rights acquired by the undersigned to file or recor mechanfc's
liens against said real property for labor. skill or material furnished to saId real property (only for the
amo.unt paid if Box 1 Is checked, and except for mtainage shown if Box 2 is checked). The undersfgned
affirms that all material furnished by the undersigned has been paid for, and all subcontractors
employed by the undersigned have been paId In full, EXCEPT:
01z&~/~C
. .
NOTE: If thta lnatrument la ~~ed by a
corporation, U muat be slgn"- by .n offIcer,
and If exacuted by . pat1nenlhlp, It muat
beal b B r.
.;
03-07-'07 15:29 FROM-Magney Construction
9524741679
T-221 P002/002 F-252
Form No. 120-M {1031}
Receipt and Waiver of Mechnic.s Lien Rights
Date: ~c~ It; 2M?
The undersigned hereby acknowledges reciept of the sum of $
j{) /q~. & Cf
)
Check only one
1)
as partial payment for labor, skill and material furnished.
2)
as Payment for all labor, skill and material furnished or to be furnished
(except the sum of $ . - retainage or holdback)
3)
/
as full and final payment for all labor, skill and material furnished or to be
furnished to the following described real property:
.(Iegal description, street address, or project name)
Hastings Well Pumphouse No.8
395 East 21 st Street
Hastings, MN 55033
and for value received hereby waives all rights acquired by the undersigned to file or recor mechanic's
liens against said real property for labor. skill or material furnished to said real property (only for the
amount paid if Box 1 is checked, and except for retainage shown it Box 2 is checked). The undersigned
affirms that all material furnished by the undersigned has been paid for, and all subcontractors
employed by the undersigned have been paid in full, EXCEPT:
Company:
By:
Title:
Address:
~~v;ds fed~
~ V _Y/-2 v
/17anar '
~l~ 3J% 4",flU~
w. - JJ / S ~tJZ::.3
NOTE: If this instrument is executed by a
corporation, It must be signed by an officer,
and if executed by a partnership, it must
be signed by a partner.
03-27-'07 10:28 FROM-Magney Construction
9524741679
1-402 P002/002 F-847
Form No. 12D-M(1031)
Receipt and Waiver of Mechnic's lien Rights
Date: ---2J 3 \ \ t>"\
bJ
--
The undersigned hereby aCknowledges reciept of the sum of $ 3D ( t.t l> 0 .
Check only one
1) ^
I
as partial payment for 'abor, skill and materiar furnished.
2) as Payment for alflabor, skill and material furnished or to be furnished
(except the sum of $ . retainage or holdback)
3) as full and final payment for all labor, skill and material furnished or to be
furnished to the following described real property;
(legal description, street address, or project name)
Hastings Well Pumphouse No.8
395 East 21 st Street .
Hastings, MN 55033
and for value received hereby waives all rights acquired by the Ulldersigned to file or recor mechanic's
liens against said real property for labor, skill or material furnished to said real property (only for the
amount paid if Box 1 is checked, and except for relainage shown if Box 2 is checked). The undersigned
affirms that all material furnished by the Ulldersigned has been paid for, and all subcontractors
employed by the underSigned have been paid in full, EXCEPT:
Compan~~-=-C'r~~~
By: ~I;"'" k _
~ I
Title: y~ .
Address: ,3{ \cl..A~~ F\u1.
5~. y^,^, M tJ ss-~\ 't
NOTE; If this instrument is executed by a
corporation, It must be signed by an officer,
land if execUted by a partnership, it must
be signed by a partner.
07-12-'07 10: i0 FJl(tJ'-Magr.ey C':lnstruction
9524'141679
T-060 f002/002 F-~5
70 -iP3'!, L/52/p
I
I
~.-...
..........-,
FINAL WAIVIK AND ULlWiJ:
;JI?
ne ~ Jiu bHa pid ud baa ~YI:d Ill...... of S lJl.7&ll ill 8uaJ ~
III"VicN. ~t ed/(Jr..... Atmillled to .
~ or II) ice ~traOb' t1I tuppUIr _ .
~, tad........,"Miw.!8t0Q81Dd &rewr ~ . Coo~. the <macr orG:lo PJrqj-.
1InIi-. if -.y. lad 111 bIuIt. ~tI. dldel. IIId odMr real .- pcnonaI JlI'OpIItty **'~
the Prqect 80m ~ lIlld all ~ ~ JHm ucl.... ~ .mo.. CRlI of or
wIIicb . DR ... ex berattu' miaht or amatd bJw. 11Ialll6t& wilbouC 1Uai1ati0ll m~buaic'. SillD,. .....
daima M4riJh"
nit PIDIIl WIMr.-d RcIoate Ihdl.... to tile bcUfu QtthO C~ dt~ OWllor vl1bo
. rapmiw mmb.1IIlClCClISOrI md"au..slball be 1lkKIiD1 wpm" ~ - itlWrt.
.....
-.w~-.-
~~d&y~. ~.
Gw... jtA - ti1
Hoary Public
fbr all labor,
("tIe
(...
e1r~
lit' . put of
eCJ tbo frojoI;t
aoci bood
RINA M. DILLARD I
NOTARY PUSllC-MlNNESOTA
My Commission &pIres Jan. 31, 2009
.
.
s.blbit B-4
1b)
.
IllWA.
~
10 39l;1d
9~Sv689E9L
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