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ANU 1:LK I IHiAl L HJU VA\MLN 1 AL\ iMM.liMkNl i« /o/ (ln»inii itoiit i»ii irvri^r tutr)r\<.» C»NM>I-l*Ac;i'STOOWNUI: OirofOroao PROjrCf;Orono City llall/l'olka and AirUt Al ION NO ;Dittrlbucion mkISSI Brown Rond South Puldic Works Building ITKIOD lO r~l OWNEROnvnlBnr.MN SSS2S PROJECT NO:f~l ARClirTECrraOMOONTIUCrOIL UodormBln VlAARaHTECr;Boar man Kiooa PAsicrNorth Secotid Sireei ('X)N'rRACr DA IT fT CONTRACTORMiniiea^wilis, KfN &S401QONTRACTFOR:CONTRACTOR'S APPUCATION FOR PAYMENT <br />Appttcstai b lor Pfefin€tti« Mthown below. In connection %i4ih the Ccnttact ConumiAtk»n Sheet, <br />AIA Documcm CTOS. Is aiiicticd. <br />1 OMCIN AL OONHACr SUM <br />t Net chnngc bf Ghange Ordera. <br />COKTRACT SUM TO DATE (Une I k t)................ <br />TOTAL CX)MnXTlDlc STORED TO DATE------ <br />I <br />I <br />I <br />I <br />7.811 00 <br />The undersigned Cx>nif actor < eriinet that to the best of tfie (xmtracior'i linusdedge. <br />Information and belief the Work covered by this Application for Payment hat been <br />completed In accordance with the Contract Ducumenta, that ail amounu have been <br />paid by the C^ontracior for Work for which previous Ceriincates for Payment vrerc <br />Issued and payments received from the Owner, and that current payment shown <br />herein Is now due. <br />COfTTRACTOR Modem lln <br />7.841 00 <br />lUie; <br />7,841 00 <br />RETAINACt: <br />a.ot Completed Wcwk <br />(Column D It E on CTOS) <br />Sure of: <br />County of: <br />Subscribed and sworn to before <br />me this day d <br />of Stored Material <br />(ColumFooCTOS)Notary Public: <br />My Ciommlsslon eapiret <br />Totid Rtialnagc (tint %a It SB or <br />Toad In Coliasa 1 of CTOS)________ <br />TOTAL EARNED LESS RETAINAGE.. <br />(UfM 4 kaa UfM I Total) <br />7,841.00 <br />LESS PREVIOUS CERTIFX:ATIS for PA^MlifT <br />(line A from prior Ctiiifkaie) <br />7,05690 <br />ARailTECT'S CERTinCATE FOR PAYMENT <br />In accordance %dih the Contract Oociiments. based on on site observations and the <br />dau compilsing die above apfdicailon. titc Architect certifies to the Owner that to the <br />best of the Archlieci's knosdedgr. Information and belief the Work has progressed as <br />IrsdUaied. the rpuliiy c^ the Wuik Is in acct>rdance with the Conirac i D im umenia, <br />the Contractor Is cni'*lcd to payment of the AMOUNT CERTIFIED. <br />ClWltNT PAYbfENT DUE • •a* •• - - ♦•••••••••«••«•• <br />t tALAN'XTOnNISH.n.l*5lirrAINACB <br />UIM SIM Line 6) <br />784 10 AMouHrriKnnut. <br />(Aitaih tKplanat%m i/ ^mmin4 enUfisd dtjfmt fitm At rnmtmnt *pflttdfm IhUmI <br />mU figure* 0m Au .4ppfica.'iaii mmd At Csmhmttst»0m Sktti rA<«l mt la <br />•aw/ima la At tmU/ud.) <br />mjjrf____ SUMMARY <br />(iiumf c Or jert approved In <br />•Mili ADmrioNS <br />mm moiitha by owner <br />craved thk Month <br />Touli <br />DEDUCTIONS <br />Nft cKanft w Change Orders <br />ARUirrKTr <br />Date: <br />This Oriifcata is n«*< negotiable The AMOUhTT CERTIFIED is payable only to the <br />(iomraciof named lierein IwuatKe. payment and aicepiancc of (ka^mrni are wiiKosst <br />prejudue to ui)' riglitsof the Owner t»r (A>niratior under ihisC4Miuact <br />imts ^affUCanoNAM>cxanncATi roa fs>'MtNT*iwf ir>rnoN*AU*iMi*THi AraiarraN iNmnnf or sit jurtcTs i74s niw wjul kw <br />riRMjrtws. RC liiaaaaM * WAOwotc* u«n«aaMa fawa«»^fiag twiiwa us (•fiugwi law ms »ai hw w i«g«i r.Torim