TWO HOLE PUNCH THIS SIDE ONLY
RJS CONSTRUCTION, INC.
Form Title
Form No.
Revision No.
SUBCONTRACTOR PAY REQUEST
5.2
0
CONTRACTOR
NAME: …………………
RJS Construction, Inc.
PROJECT MANAGER: …..
Stan Gilmore
EMAIL: ……………
stan.gilmore@rjsconst.com
ADDRESS: ……………
1618 Rudkin Rd, Suite B
Yakima, WA 98901
PHONE: …………………….. 509-452-0857
FAX: ………………
509-452-0784
SUBCONTRACTOR
Monarch Masonry LLC
Patrick Washington
monarchmasonry2@outlook.com
PO Box 1377
Coupeville, WA 98239
(360) 801-9964
NAME: ………………………..
PROJECT MANAGER: …..
EMAIL: ……………….………
ADDRESS: …………………..
PHONE: ……………………..
FAX: …………………………..
RJS Project Name: FAFB Flightline Fencing & Road
RJS Subcontract Number: 131116-009
RJS Project Number: 131116
For Period Ending:
Date of Request:
Request #:
Subcontractor Invoice #:
1. Original Contract Amount………………………………..
CERTIFICATE OF THE SUBCONTRACTOR:
2. Authorized Change Orders Total...………………….
I hereby certify that the work performed and the materials supplied to
date, as shown on this request represent the actual value of
accomplishment under the terms of the Subcontract (and all
authorized changes thereto) between the undersigned and RJS
Construction, Inc. relating to the above project. I also certify that
payments, less applicable retention, have been made through the
period covered by previous payments received from the contractor, to
(1) all my subcontractors (to all their sub subcontractors) and (2) for
all materials and labor used in or in connection with the performance
of this Contract. I further certify I have complied with Federal, State
and local tax laws, including Social Security laws, any applicable
union moneys owed and Unemployment Compensation laws and
Workers’ Compensation laws insofar as applicable to the performance
of this contract.
3. Adjusted Contract Amount (1 + 2) …………………
4. Total Value of Work Completed to Date ...
5. Total Value of Change Orders Completed …..
6. Total Materials Stored On Site To Date …..
7. Total Value of Work and Materials (4 + 5 + 6)
8. Total Amount Previously Requested ……………
9. Total Amount Retained ……………..…………………..
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
10. AMOUNT OF THIS REQUEST (7-8-9):
$
-
11. Balance of Contract, Including Retained (3 - 7):
$
-
LIST OF LOWER TIER MATERIAL SUPPLIERS OR SUBCONTRACTORS USED FOR THIS MONTH'S PROGRESS
WHEN LOWER TIER IS COMPLETE, PLEASE REMOVE THEM FROM THIS LISTING. IF ADDITIONAL LISTING IS NECESSARY PLEASE ATTACH ADDITIONAL SHEET.
COMPANY NAME
CONTACT NAME & PHONE
On Site/Supplied
Material This Period?
Yes - No
Complete? Yes - No
SUBCONTRACTOR SIGNATURE AND CERTIFICATION
(sign above)
SUBCONTRACTOR SIGNED BY (PRINT NAME)
Area reserved for RJS office use
TITLE
DATE
RJS Construction, Inc.
1618 Rudkin Rd * Suite B * Yakima * WA * 98901 * Phone: (509) 452-0857 * Fax: (509) 452-0784
Email: rjs@rjsconst.com * Website: www.rjsconst.com * License #: RJSCOCI945BT
SUBCONTRACTOR PAY REQUEST/SCHEDULE OF VALUES
PAY REQUEST NO:
PROJECT NUMBER:
0
131116
SUBCONTRACT NO.:
131116-009
1/0/1900
1/0/1900
PERIOD END:
DATE OF REQUEST:
RETAINAGE:
0.00%
(Retainage only held if directed to)
A
B
Item
WBS #
C
D
E
F
WORK COMPLETED
Description
(schedule #)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Scheduled Value
From Previous
Application
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Subtotals
-
This Period
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
-
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
-
G
H
I
J
K
Materials Presently
Stored
Total Completed &
Stored to Date
% Complete
Balance to Finish
Retainage
(Not in E or F)
(E+F+G)
(H/D)
(D-H)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
-
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
-
-
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
-
%
Complete
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
$
$
$
$
$
$
$
$
$
$
$
-
0.00%
$
(ONLY
IF APPLICABLE TO
THIS PROJECT)
-
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
-
-
$
$
$
$
$
$
$
$
$
$
$
-
-
$
-
ONLY LIST CHANGE ORDERS THAT HAVE BEEN APPROVED BY RJS CONSTRUCTION, INC. PER CONTRACTUAL REQUIREMENTS
Change Oder #
Subtotals
PROJECT TOTALS
Revision No.: 0
From Previous
Application
Approved
Amount
Description
RJS Mod No.
$
$
$
$
$
$
$
$
$
$
$
$
-
$
$
$
$
$
$
$
$
$
$
$
-
$
-
$
$
$
$
$
$
$
$
$
$
$
-
$
Total Completed &
Stored to Date
Materials Presently
Stored
This Period
-
-
$
$
$
$
$
$
$
$
$
$
$
-
$
$
$
$
$
$
$
$
$
$
$
-
$
-
$
-
Page 2 of 2
THIS PAGE MUST ACCOMPANY YOUR PAY REQUEST FOR YOUR PAY REQUEST TO BE PROCESSED
Retainage
(if applicable)
Balance to Finish
-
RJS Form No.: 5.2