APPLICATION AND CERTIFICATE FOR PAYMENT
TO: PROJECT: APPLICATION NO: 5
INVOICE NO: 5.0
FROM: INVOICE DATE: 01/11/2024
PERIOD TO: 01/1/24-01/11/24
CONTRACT NO: CONTRACT DATE: 12/02/2021
CONTRACTOR'S APPLICATION FOR PAYMENT Application is made for Payment, as shown below, in connection with the Contract.
Continuation Sheet,Schedule Values by item, is attached.
CHANGE ORDER SUMMARY
Change Orders approved in 1. ORIGINAL CONTRACT SUM $61,200.00 previous months by Contractor 2. Net change by Change Orders $20,371.68 TOTAL $20,371.68 $0.00 3. CONTRACT SUM TO DATE (Line 1+/- 2) $81,571.68 Approved this Month 4. TOTAL COMPLETED AND STORED TO DATE $81,571.68 Number (Column G on G703)
1 5. RETAINAGE:
2 a. 10% of Completed Work $4,078.58
3 4 b. 0% of Stored Material $0.00
5 6 Total Retainage
TOTALS $0.00 $4,078.58
Net Change by Change Orders $20,371.68 $0.00 6. TOTAL EARNED LESS RETAINAGE $77,493.10 (Line 4 less Line 5 Total)
The undersigned Contractor certifies that to the best of the Contractor's knowledge, 7. LESS PREVIOUS CERTIFICATES FOR information and belief the Work covered by this Application for Payment has been PAYMENT (Line 6 from prior Certificate) $69,768.00 completed in accordance with the Contract Documents, that all amounts have been 8. CURRENT PAYMENT DUE $7,725.10 paid by the Contractor for Work for which previous Certificates for Payment were 9. BALANCE TO FINISH, PLUS RETAINAGE $4,078.58 issued and payments received from GSWC, and that current payment shown (Line 3 less Line 6) herein is now due.
CONTRACTOR:
By: Date:
Date Approved
06/15/2020
Delta Electric LLC
Delta Electric LLC
Santa Clarita Ca 91387
$12,240.00
$8,131.68
2021-5
01/11/2024
ADDITIONS
17007 Strawberry Pine Ct
DISTRIBUTION TO:
PM: Domingo Gonzalez
INSPECTOR
City of Barstow
220 East Mountain View St.
Barstow CA 92311
2021-05 Generator Replacement
at Fire District Station 363
DEDUCTIONS
CONDITIONAL WAIVER AND RELEASE
UPON PROGRESS PAYMENT
CALIFORNIA CIVIL CODE SECTION 8132
Name of Claimant: _____________________________________________ Name of Customer: _____________________________________________ Job Location:__________________________________________________ Owner:_______________________________________________________ Through Date:__________________________________________________ This document waives and releases lien, stop payment notice and payment bond rights the claimant has for labor and service provided, and equipment and material delivered, to the customer on this job through the Through Date of this document. Rights based upon labor or service provided, or equipment or materials delivered, pursuant to a written change order that has been fully executed by the parties prior to the date that this document is signed by the claimant, are waived and released by this document, unless listed as an Exception below. This document is effective only on the claimant’s receipt of payment from the financial institution on which the following check is drawn:
Maker of Check: ________________________________________________ Amount of Check: $______________________________________________ Check Payable to:________________________________________________ Exceptions:
This document does not affect any of the following:
(1) Retentions.
(2) Extras for which the claimant has not received payment. (3) The following progress payments for which the claimant has previously given a conditional waiver and release but has not received payment:
Date(s) of waiver and release: __________________________________________ Amount(s) of unpaid progress payment(s): $_____________________________ (4) Contract rights, including (A) a right based on rescission, abandonment, or breach of contract, and (B) the right to recover compensation for work not compensated by the payment.
Claimant's Signature:___________________________________ Claimant's Title:_______________________________________ Date of Signature:______________________________________ C&B forms effective 7-1-2012
NOTICE: THIS DOCUMENT WAIVES THE CLAIMANT’S LIEN, STOP
PAYMENT NOTICE, AND PAYMENT BOND RIGHTS EFFECTIVE ON
RECEIPT OF PAYMENT. A PERSON SHOULD NOT RELY ON THIS
DOCUMENT UNLESS SATISFIED THAT THE CLAIMANT HAS RECEIVED PAYMENT.
Contractor Date:
Project Contract No. 2021-05
Project No. Spec. Section No.
& Description
Field Order No.
NO. UNIT RATE COST TOTAL
1 HRS
1 HRS $73.25 $293.00
1 HRS $0.00
1 HRS $0.00
1 HRS $0.00
$0.00
1 $0.00
1 $0.00
$293.00
UNIT
1 LOT $7,175.00 $7,175.00
TAX 1 UNIT $663.68 $663.68
1 LOT
1 LOT
UNIT
1 LOT
1 UNIT
$7,838.68
$7,838.68
1 1
1 1
1 UNIT
FUEL MICELLANOUS UNIT
SUBTOTAL
`
OVERHEAD TOTAL
$8,131.68
$8,131.68
SCHEDULE IMPACT:
Signature Date Date
Electrical Journeymen 4.00
2021-05
CHANGE ORDER 02-
DESCRIPTION QTY.
IO: This is price proposal of voltage change for new genset from 227/480 to 208 VOLT- The materials are quoted directly from BCE and there is (4) HR LABOR CHARGE
FROM DELTA ELECTRIC
Delta Electric LLC 1/11/24
Generator Replacement at Fire Station 363
BCE QUOTE- ATS BREAKER/COIL/ NAMEPLATES
TOTAL LABOR
MATERIALS
SUBTOTAL
D. MATERIALS
E. EQUIPMENT
TOTAL MATERIALS
Signature
NOTES:
1 - Public Liability & Property Damage Insurances, Social Security & Federal Unemployment Taxes, Workmen's Compensation & State Unemployment Contributions.
TOTAL
TOTAL
Schedule extension of 4 days required
Prepared by: Reviewed and Accepted:
Name & Title of Contractor's Authorized Representative
TOTAL EQUIPMENT
OVERHEAD
Name, Title & Company of State's Authorized Representative 13625 Danielson Street, Poway, CA 92064 (HQ)
8647 Helms Ave, Unit #100, Rancho Cucamonga, CA 91730
322 Lindbergh Avenue, Livermore, CA 94551
Phone – 866.938.8200 Fax – 619.938.8202
www.BCEW.com
KOHLER GENERATOR SALES - SERVICE - PARTS - RENTALS
To learn more, visit our website at www.BCEW.com
REFERENCE: 152629
City Of Barstow
Voltage Correction
Voltage Change from 277/480 to 208V items needed to make the change.
Thanks
Cheryl Hallmark
Project Manager
619-247-1848
[email protected]
KOHLER GENERATOR SALES - SERVICE - PARTS - RENTALS
To learn more, visit our website at www.BCEW.com
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