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PAYMENT APPLICATION Pago 1 <br />TO. CltyolOfono <br />2750 Kelley Parkway <br />Orono. MN 55330 <br />Attn: Accounts Payable <br />FROM: Dow Corporation <br />2125 Century Avonue <br />North SL Paul. MN 55109 <br />FOR: <br />Application Is made for payment as stiown below. <br />Continuation Pago Is attached. <br />PROJECT 03005 <br />NAME AND Navarre Fko Station <br />LOCATION; 3^70.3790 shofBlIne Diivo <br />Orono, MN 55336 <br />AKCMITECT; BKV Group, Inc <br />222 N. 2nd SI. <br />Minneapolis. MN 55401 <br />APPLICATION U <br />PERIOD THRU. <br />PROJECT «s: <br />DATE OF CONTRACT: <br />0 Distribution to: <br />04/28/2004 (^1 OWNER <br />ARCHITECT <br />07/01/2003 IXI CONTRACTOR □ n <br />$1,138,000.00 <br />(Line 1 2) <br />$10,857.00 <br />$1,148,857.00 <br />$1,140,857.00 <br />$M,7^.(» <br />$0.00 <br />1. CONTRACT AMOUNT <br />2. SUM OF ALL CHANGE ORDERS <br />3. CURRENT CONTRACT AMOUNT <br />4. TOTAL COMPLETED AND STORED <br />(Column Cj on Continuation Pago) <br />5. RETAINAGE: <br />a. 2.?K)% of Comi)lotod Work <br />(Columns D ♦ C on Continuation Pago) <br />b. 2.50% of Material Stored <br />(Column F on Continuation Pago) <br />Total Retainago (Une 5a^ 5b a <br />Column I on Contiimation Pago) ____ <br />e. TOTAL COMPLETED AND STORED LESS RETAINAGE _____ <br />(Llno 4 minus Line 5 Total) <br />7. LESS PREVIOUS PAYMENT APPUCAT10NS ______ <br />(line 6 from prior Application) <br />B. PAYMENT DUE <br />9 BALANCE TO COMPI El ION <br />(Linn 3 minus linn b) <br />$2d.72100 <br />$28,722.00 <br />$28,721.00 <br />SUMMARY Oh CHAN(3E'oROLI<S ADDITIONS OF DUCT ions ' <br />Totiil changes approved In <br />$1U.B57.00 $0.00pre^ous months <br />Total appioMid this nHNilh $000 $000 <br />TOTM.S $10,857.00 $000 <br />NF^T CHANGES $10857.00 <br />Contractor's signature below is his assurance to Owner, concerning the payment herein applied for. <br />mat: (1) Iho Work has been performed as required in the Contract Documents, (2) all sums <br />previously pakJ to (ontractor under the Contract have been used to pay Contractor's costs for labor, <br />materials and other obllgaUons under tlie Contract for Work previously paid for. and (3) Contractor is <br />legally entitled to this payment <br />CONTRACTOR: OewC <br />By: __________ <br />Robert <br />State of: Minnesota <br />County of: Ramsey <br />Subscribed tnnd sworn to before <br />me this 28th day of April 2004 <br />—Date:04/28/2004 <br />TAMMVJ nelson <br />N0T4Pv>;aiic MWNESOU <br />Notary Public: Tammy Nebon <br />My Commission Ejrplres: January 31,2C^ <br />Srlor <br />ViW\\\V <br />ARCHITECT’S CERTIFICATION <br />Architect's signature below is tns assurance to Owner, concerr>ir>g the payment herein applied tor, <br />that: (1) AfcNlect has inspected the Work represented by this Application. (2) such Work has been <br />complelad to the extent Indicated In this Applicallori. and the qualllty of workmanship and materials <br />conforms v^th the Contract Doajments, (3) this Application for Payment accurately states the amount <br />of Work con^leted and payment duo bierefor. and (4) ArcWtect knows of no rjason why payment <br />slKHjId not be made. <br />CERTIFIED AMOUNT-...._________________________________________________ <br />(II Iho certified aimuni is diflenml tmm the (layment duo, you should attach an axpImittHgi. <br />Iniial al tho fiaures that am changed to watch Iho certifiod amnunt ) <br />ARCHI1L-CT: <br />By: <br />Neither this /Vpplication th pa <br />Date: <br />PAYMENT APPLICATION <br />,______________________ <br />Neiiner mis MppncaiKin oor pewinfm ctpiminj for heroin Is assigr\able or negotiable. Payment shall <br />be made only to Contractor, kid is without prejudice to any ri^ls of Owner or Contractor urxtor <br />iheCont^l^^Doa ^________________ <br />y pa^n^iapplteofor he <br />or. kid is without preiudii <br />OSS. INC. DOCUMENT