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‘•It*’J ^• • • •. t <br />application and certificate for payment AlA DOCUMENT G702 (Insirucilons on reverse side) page one of 2 <br />TOOWNKR CITY OF ORONO <br />City Hall <br />P. 0. Box 66 <br />Orono. MN 55323 <br />FROM CONTRAClOU <br />AUTOMATIC SYSTEMS CO. <br />P.O. Box 120359 <br />CONTRACr FOR 55112 <br />PROJECT: SCADA Project <br />Orono, MN <br />APPLICATION NO: I <br />PERIOD TO: 12/5/02 <br />PROJECT NOS : <br />139-01-113 <br />VIA ARCHITECT: CONTRACT DATE: <br />BONESTROO, ROSENE, AMDERLIK & ASSOC. <br />2335 W. Trunk Highway 36 <br />Roseville, MN 55113 <br />Dlsiribuiion to: <br />□ OWNER <br />□ ARCHITECT <br />□ CONTRACTOR□□ <br />CONTRACTOR’S APPLICATION FOR PAYMENT <br />Application Is made for payment, as shown below, in connection with the Contract. <br />Continuation Sheet, AlA Document >1703, is attached. <br />17A.328.00______ <br />0.00 <br />1. ORIGINAL CONTRACT SUM......................................I. <br />2. Net chrnge by Ctiange Orders .............................I. <br />3 . CONTRACT SUM TO DATE (Line I t 2)................I___1?^ 132.8_. Qfl. <br />4 . TOTAL COMPLETED A STORED TO DATE...........t___^ IVf.LZJj.QQ. <br />(Column () on G703) <br />5 RETAINAQE: <br />The undersigned Conininor ccriific s ihai to the best of the Contractor's knowledge, infor­ <br />mation and hclicf the covereil by this Application for Payment has been completed <br />in accordance with the Contpct Documents, that all amounts have been paid by ihr <br />Contractor tor Work for whicli previous Certificates for Payment were issued and pay­ <br />ments received from the Owner, and that current paymem shown herein Is now due <br />Date: December 5, 2002 <br />^ of Completed Work 5.556.40 <br />State of Minnesota <br />County of Ramsey <br />Subscribed and sworn to before <br />me this 5th day of December, 2002 «. <br />(Columns O ♦ E on G703) <br />b. ______% of Stored Material <br />(Column F on G703) <br />Ibtal Reialnage (Line 5a ♦ 5b or <br />Toial in Cotuinn 1 of G703).................................... <br />'hc>^URlE F. KR/OIS <br />5.556.40 <br />Notary Public: <br />My Commission expires <br />m <br />Janu,^ry 31, 2005 <br />^uhie f. k /Iaus <br />NoiaiyPuMeMtno.Sr <br />6 TOTAL EARNED LESS RETAINAQE.........................t 105.571.60 <br />(Line 4 less l.mc 5 Total) <br />7 LESS PREVIOUS CERTIFICAFES FOR PAYMENT <br />(Unc 6 from pnot Ccrti(icate)....................................I. <br />H CURRENT PAYMENT DUE <br />0.00 <br />105,571.60 <br />9. GiALANCE TO FINISH. INCLUDING RETAINAQE <br />(Line 3 le«s Line 6) I-------- <br />CHANCii- OKDFK SUMMARY ADDITIONS DEDUCTIONS <br />HHal changes a|iprovcd in <br />previous months by Owner <br />liiial approved this Month <br />TOIALS <br />NF'I CHANGIiS l>y Clungc Order <br />ARCHITECT’S CERTIFICATE FOR PAYMENT <br />In accordance with (he Contract Documents, based on on-sItc observations and the data <br />comprising this application, the Archiieci certilies lo (he Owner (hai (o (he best of (he <br />Aichi(ec(*!» knowledge, iiiformadon and belief (he Work has progressed as indicated, the <br />(]uality of the Work is in accordance with (he Coninct Documents, ana (he Coiuractor <br />is entitled uj payment of the AMOUNT CERTIFIED <br />AMOUNT CERTIFIED .................................................................l '(jS .(aO <br />fAiUiclf e,\i>lanation if amount cvrtificd di//vr% Jrom the amount apidicit for fnttuii <br />ait figurvy ON thi^ppinatmn and on thv Cunnnuation Sheet that are changed to <br />Date \T^-\C3-qX <br />This Cenipcate is not negotiable The AMOUNT CERTIFIED is payable only to the Con­ <br />tractor named herein. Nsuance. payment and acccpance of payment are without <br />prejudice to any rights of the Owner or Contractor under tins Contract <br />Al <br />eSrnoH <br />AlA DOCUMgHt am • AmiCATloN ANO CeimFICATE pod FAYMOrr • 1992 EOmON • AU* • M92 • THE AMERICAN INSTITUTE OF AACIIITECTS, 175S NtW YOlUt <br />AVENUE. NW. WASII1NC7TON. DC /«iUU6-S292 • VtANNMQ: UfUlMflMd phOliBEdylm Ut. iMl Md «Ni tuta|Wl tiM vIOtolQr lO G702-1992 <br />Ebu thouM UM an orlfinal AlA documanl wtiteh H m thia cautfon pHwtad in sad. An original aaaurot that diangaa will not ba obteurad aa may occur when documenti art rtproduetd*