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ANU iihK I I K K>K l*AVMl-.N I AL^ K‘.t (MIN r C»7r‘^ (Iiiftii ut iiMiii Mil ir^ci»c lulr)TAC.K ONK 0^TO OWNER: UqrofOrono PHtyter:Oroiiu City llall/Putke and APPUC'AIION NO :Distribution to:lEM blown Road Souih Public Works IluiidUig PKRIODTO n OWNERCrytwIBar.MN 5S3E9 PKOJICI NO ;4059 1 1 ARClirfECTFROM CONTRACTOR: Swanson it Youngdale vu AKtuirricr Boatman Kr*»os Pfitier222 Nufdi Second Siteei (i)NIKACI DA IK n CONTRACTORMinneapoliE. NfN SS401CONTRACT FOR: <br />CONTRACTOR'S APPLICATION FOR PAYMENT <br />Appttaikm b made for P^^nnent. isthotm below. In cooncciion iriih ihe CLmuAU (4inilnu«iion Sheet, <br />AIA IkKumcM C70S, b attached. <br />I OIU'INALCONTItACTSUU.. <br />t Nei cliaiige by Oian|e Ord«re... <br />CONTHACT SUM TO DATt (Utw I fc 2)..... <br />TOTAL OOMPtrrtD || STORED TO DATE <br />21,891 00 <br />314 00 <br />25,208 00 <br />25,208 00 <br />RITA^ACt. <br />a.of Completed Work <br />(Column D A C on G70S) <br />of Stored MaterUI <br />(Cohiro F on C705) <br />Total Reulniff (Une %a A SB ot <br />Total in Column 1 of CTOS) <br />• TOTAL EARNED LESS RETAINACE.. <br />(U m 4 IcM Line I Tout) <br />LESS PREVIOUS CLRimTATES FOR PAYMENT <br />(Line 9 bom pdor CeiiUiuic) <br />25.208 00 <br />22.315 50 <br />I <br />9 <br />CURRENT PAYblEKT DUE *••»«••«•••• »*« • • • • •••• <br />RALANCI to finish , plus retain Ai.E <br />(Une SteM Line 9| <br />2.802 50 <br />atoeiaiBa tiiMUASv additions DEDUCTIONS <br />Qiangt ftrdm approved ia <br />prtsdaut as—she by owner <br />AfpfovW thit bioiiih <br />toiab <br />|Nt« ebange by Qsangc Orders | <br />Tlie undeisigned Omtractor cettifiet that to the tieu of the Contractor*s knoidedge. <br />Information and t>elief die \V»»rk cenered liy ihit Application for Payment has been <br />completed In accordance %«rith the Ctintraci Documents, that all amounts have been <br />paid by the CV>ntractor for \SV»ik for which previous Ortiricatesfor Payment were <br />issued and payments received from the Owner, and that current payment shovm <br />herein is now due. <br />CONTRACTOR: <br />Date: <br />Stare of: <br />Cmmty of: <br />Subscribed and iitnjrn to bcfuie <br />ma iNa day of <br />Noury i^lblic: <br />My C«»mniiisioii expires <br />ARCHITECT'S CKRTinCATE FOR PAYMENT <br />III aicordame with die Cimiraci D ckurnenis. based on on siie observations and the <br />data comprising the aUive application, the Architect ceriines to the Oimer that to the <br />best of the Architect's knowledge, iiifoiinAiioii and belief the Wc»fk lias progressed at <br />Indicated, die i^uality of die Work It in accordance with the Contract Documents, and <br />the Ck>mracior Is eniiiled u> payment of the AMOlfN f Cl KTIIIFD <br />••♦••••♦•••a•oa#*AMouhrr fijiniiiji....... <br />(AlUuM oip/«n«ifsan »f mmkmunt utuftsd ft mm l4a mmmtni fm lim$mi <br />•0/Sgurat mm iku Affiumt»mm mmd mm Am CmmUmuttmm Skmmt Ami mtt Amngrd tm <br />tm^anm Im At mmmmmi imUfmA ) <br />ARC jirricT <br />Date: <br />Tlas Get life ate is not neguiiable The .\KlUl »NI C.kKl IHiD is parable only to the <br />f.omrarior named herein Iwuance. payment and a«ce(>4ame o((»a>meiii arc «dihoui <br />pfrjudi<e lo any rights uf the Owner or Coriiractor under dus('ajtitract <br />«Ni ^affucATiowaNOctaTincATiPoafAYMPm*iwirnrTioN*AU*iwi*fHi AMrRKANiNtrmnior ASutrrFcTs i7mnfww »fx c\tni inw <br />DC tom IM * WAANINCi U«A w«m4 ytRiaMyflaf tkatewa U S !*«• mrS wW Rntl|airt ita Hatwt w Ir|rJ pt«R«nMMa.G7021S9a