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APPLICATION AND CEKTIFKA I t KOK I'AYNIENTW OWNIM Qif ol Oiooo ~~IIM Bcmm Road South OnmalR^r.MN MSIS iKojkcr Orunu City llali/rolkc and Public WotIttUuildijig IW IMMII lltll 1AmjtAIIUN NO: IT HIOD TO: PKOjKTf NO:rAi«t irrrt tip 4059 IktMribulion lo:OWNER tndM CONTRACTOR: W. 1. Hall VlSAJiainECT:lioaiinin K/oosPrisier □ARClirrECi <br />CX>N7mACT FOIL <br />'IT/ North Second Street Minneapolis. MN 65<401 CONTlL\Cr DATE.□CONTRACTOR ’• <br />for Fapncfii. as thown below. In connecilon %»tih ihe Contraci Comlnuailon Sheei, <br />AlA Document CTOS, li iitacheit. <br />I <br />t <br />S <br />I <br />I <br />OKICMAL oohmucr sum. <br />Net chMi(e bf Chan|c <br />CONTRACT SUM TO IMTE (lJ»e I S J) <br />TOTALCOMPUTtO li SIOKtUIO ( ATI <br />•••••«• •• •• ••• •« « <br />12.656 00 <br />The under^giied Conn at lor cciiifio ihai to the bcM of ihc Coniracior'i knowledge. <br />Information and belief ihe Work rmered by ihit Application for Payment haa been <br />curnpleicd in .ccoidaiue wiih ihe Camiraci Ikocutnenu. ihai all amounts have been <br />paid by the Cioniractor for Woik for whUh previous Ceiiificaies fur Payiiieni were <br />Issued and paynienis received from ihe Owner, and that current payment shown <br />herein Is now due <br />290 00 coismt^rroR w. L. lliill <br />12,01600 <br />Br Dale <br />12.916 00 <br />RtTADIACL <br />i.ol GMUpletcd Work <br />(CoHimn D li t on CTOS) <br />Slate of: <br />Ckmnty of: <br />Sul>scrit»etJ and fwoni lo before <br />ma this day of <br />ol Stored Miifrtil <br />fCoKan f on CTOS) <br />Tmal Iciainage (tine %a A SB or <br />total Ui Column I of C70S) <br />Noury Public: <br />My Commission eiplres <br />« TOTAL lAHNID US> RCTAINACE..... <br />(U m 4IM U m I Total) <br />• ••••» •«*#•#«•• •«« sa«s 12,916 00 <br />7 tJsrscviouscnrnncATisFc«PAVMEKr. <br />(D m a Roto ptiof Ccf ilAcatc) <br />I2.6r.6 00 <br />ARaiiTEcrr's certihcicte for payment <br />In acc«HdarKe with the (imuati IhMuinenis. based on on-aiie observations and ihc <br />dau compf iaing ihe above application, the Architect cerliflet to the Owner that lo the <br />best of the Architect i knowledge. lnf«*fmaii«»n and tsetief the Wc»rk has prcigreaaed as <br />indicated, the t^iuliiy id the Woik is in accordaruc with the Contract Ducumenis. and <br />the Comiacior is entitled to payment of the . MOUNT CIKIIFIED <br />i <br />f <br />CUmiKf PATMEKT DUE ______ <br />BAt ANCI TO FINtSIl. PLUS RETAINAGI <br />(line S km line Sy <br />290 00 AMoi/Hr c j:b nm n. <br />(AUmikmpU tni utUfmd dtQm% ^mm lAa mmmuni fm <br />aOfigutm an rio and an rie Cmttmmsttm Sk^gt ikmt mt dkmnfad ia <br />can/ana la l4a atmtmni tmU/tmd ) <br />RnOSKT ADDfl IONS <br />■rm<Mm i <br />|^eiw»td <br />[WtAai <br />By owner <br />^hlnniK <br />Totals <br />rkanje ly flmnge OrJers <br />IktnUCTlONS ARtiirikCl <br />Daie <br />Tins Cterufcaic ii not neguiublc The AMOUNf i EK f IHID b payable only to the <br />Conn actor named herein list tame, p.cymeni and ancpiAiue «»f |*aymeni me witlmiM <br />prejudice to any iighu ol die Owner or <a>nttaci«>r under this (kaiiract <br />•affutanusiaMbcitnncAiiiiia rAYstircT«i»wt ynrnowAiA'iayiMMi AMrauAN iNvrrririT or asi iini«n i nfw u»hs cvtsi i nw <br />• wanNisHa Uama—a pdf "wiMa* u a c*eftns« wm *«sfar« nw w iRfAi GT0iiS«|