LO S AN G EL E S CO M M UN IT Y CO LL EG E D I S T RICT
DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT PROPOSITION A/AA BOND PROGRAM
CONTRACTOR PAYMENT REQUEST
College Project Name Project No. Contractor Address DIVISION # 00610 01 02 02A 03 04 05 06 07 08 09 10 11 12 13 14 15 16 DIVISION DESCRIPTION Bond for Material and Labor and Faithful Performance General Requirements Site Work Asbestos Abatement Concrete Masonry Metals Wood & Plastics Thermal & Moisture Protection Doors & Windows Finishes Specialties Equipment Furnishings Special Construction Conveying System Mechanical Electrical Division Total Overhead and Profit @ % Performance Bond TOTAL CONTRACT $ $ $ $ $ $ $ $ Date Contract No. Contract Payment Req. No. Purchase Order No. City, State, Zip Code DIVISION TOTAL(S) TOTAL EARNED TO DATE(S)
Form CP-0190
Page 1 of 5
Rev.4_11.29.05
LO S AN G EL E S CO M M UN IT Y CO LL EG E D I S T RICT
DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT PROPOSITION A/AA BOND PROGRAM
CONTRACTOR PAYMENT CERTIFICATION
CERTIFICATION OF THE CONTRACTOR OR HIS DULY AUTHORIZED REPRESENTATIVE
To the best of my knowledge and belief, I certify that all items, units, quantities, and prices of work shown on this Payment Request are correct; that all work has been performed and materials supplied in full accordance with the terms and conditions of the construction contract on this project; that the following is a true and correct statement of the contract amount up to and including the last day of the period covered by this estimate and that no part of the “Total Amount Payable This Contract Payment Request” has been received: (a) Total Earned to date (from Page 3) (b) Total Earned to date on Change Orders (from “Change Order Data Supporting Contract Payment” form (c) Total Earned (sum of „a‟ and „b‟) (d) Total Amount to be retained (10% of „c‟ above) or Amount approved by Board of Education (e) Total Payment Allowed to Date („c‟ minus „d‟) (f) Less Previous Payment (item „e‟ from prior claim) (g) Total Amount Payable This Contract Payment Request („e‟ minus „f‟) $ $ $ $( $ $ $ )
Contractor (Please print name of company)
By (Please print name and title) (Contractor‟s Signature)
CONTRACTOR PAYMENT CERTIFICATION CERTIFIED AND APPROVED AS PER TERMS OF CONTRACT
To the best of my knowledge and belief, I certify that this progress payment does not exceed 90% of the value of the work completed since the previous progress payment, if any, plus 90% of the value of acceptable, prefabricated materials delivered to the job for incorporation into work, but not installed, if any. I further certify that this progress payment covers full payment for work completed since the previous progress payment, and that any payment for prefabricated materials stored on the site does not exceed 90% of the value of the materials.
Inspector‟s Signature
(Please print Inspector‟s Name)
Design Consultant‟s Signature College Project Manager‟s Signature
(Please print Design Consultant‟s Name) (Please print CPM‟s Name) (Please print APM/ACM Deputy‟s Name)
APM / ACM, Deputy Director Construction Operations
Form CP-0190
Page 2 of 5
Rev.4_11.29.05
LO S AN G EL E S CO M M UN IT Y CO LL EG E D I S T RICT
DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT PROPOSITION A/AA BOND PROGRAM
CONTRACTOR PAYMENT REQUEST DETAILED ITEMS OF WORK
College Project Name Project No. Contractor Address SECTI ON TOTAL $
Date Contract No. Contract Payment Req. No. Purchase Order No. City, State, Zip Code TOTAL EARNED TO DATE
SECTION TOTAL $ DIVISION TOTAL $
DIVISION/ SECTION NO.
DETAILED ITEM OF WORK
%
Form CP-0190
Page 3 of 5
Rev.4_11.29.05
LO S AN G EL E S CO M M UN IT Y CO LL EG E D I S T RICT
DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT PROPOSITION A/AA BOND PROGRAM
RELEASE OF CLAIMS
Contract No.: Project No.: Project Name:
This release is given to the LOS ANGELES COMMUNITY COLLEGE DISTRICT (“DISTRICT”) BY (“Contractor”), on , 20 . Upon acceptance of final payment by the District to Contractor for the above referenced contract, Contractor releases and waives any and all claims under or arising out of said contract excluding the following disputed claim(s). (Contractor must specify amount)
Claim Description
Amount
Contractor also agrees that he/she will not hereafter asset any claim against the District other than the claim(s) listed above. This release shall be binding upon any and all heirs, successors in interest, or assigns of Contractor. Agreed to and executed this day of , 20 .
Signature of Contractor
Typed or printed Name
Form CP-0190
Page 4 of 5
Rev.4_11.29.05
LO S AN G EL E S CO M M UN IT Y CO LL EG E D I S T RICT
DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT PROPOSITION A/AA BOND PROGRAM
CHANGE ORDER (CO) DATA SUPPORTING CONTRACT PAYMENT REQUEST NO.
Change Orders Approved by the Board of Trustees
College Project Name Project No. Contractor Address
Date Contract No. Contract Payment Req. No. Purchase Order No. City, State, Zip Code List only those Change Orders Approved by the Board of Trustees
LACCD USE ONLY
CO NUMBER
EXTRA (+)
CREDIT (-)
TOTAL EARNED TO DATE $
Total CHANGE ORDERS TOTAL (Total EXTRA Minus Total CREDIT)
$
$
Form CP-0190
Page 5 of 5
Rev.4_11.29.05