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On ANU CLKl Hii^Al 1: I UK ivvnviiiivi aia uu^unimi o/t/.liiisiiucitons on rcvcr&c aact ia JTO (OWNER):PROjECT:APPMCATION NO: S Distribution lo:City of Orono Orono City llall/Police iind PERIOD TO:n OWNER1335 Drown Road Soutli Public Works Duildings □ ARCHITECTCrystal Day, MN 55323 FROM (CONTRACTOR):VIA (ARCIINfCT):ARCHITECT'S □ CONTRACTOR□/y'Df^H^iOtr 0€A/$7XUC7to^y Doarman Kroos Pfister and Assoc.PRO)ECT NO: 1124.04 □ <br />CONTRACT FOR: <br />222 North Second Street <br />Minneapolis, MN 55401 CONTRACT DATE: <br />CONTRACTOR'S APPLICATION FOR PAYMENT Applicaiion 1$ made for Paymeni, as shown below. In connection with the Contract. <br />Continuation Sheet, AIA Oocumeni C703, is attached. <br />CHANGE ORDER SUMM.\R''• <br />Change Orders approved <br />previous months by Owner <br />TOTAL <br />ADDITIONS .DEDUCTIONS <br />Approved this Month <br />Number Dale Approved <br />r • <br />Vi.iiAlS <br />Net change by Change ' •.d.us <br />1. ORIGINAL CONTRACT SUM.......................................$ <br />2. Net change by Change Oidcrs...................................$_____________ <br />3. CONTRACT SUM TO DATE (Line 1 i2).......................S ^7? <br />4. TOTAL COMRLETEO & STORED TO DATE...................S <br />(Column C on C703) <br />5. RETAINACE; , , <br />a. ,J!£. % ol Completed Work S -Sr* /o <br />(Column D T E on C703) <br />b. _% o( Stored Material t_________________ <br />( <br />t g>o <br />Tlie undersigned Contractor certifies that to the best o( the Contractor's knowledge, <br />information and belief the Work covered by lliis Applicaiion for Payment has been <br />completed In accordance willi the Contract Documents, that all amounts have been <br />paid by the Contractor for Work for which previous Ceilificales lor Paymeni wore <br />issued attd payments received from the Owner, <br />if herein Is now due. <br />and that cuiruni paymeni shown <br />CONTRACTOR: <br />,> ■ / /P <br />OOWHAJMIRIAUIT <br />notary PUBUC-MINNE80DL <br />WASHINGTON COUNTY <br />My Comm. Eapiraa 3-6-B7 <br />‘ ‘ ------------rcrffij <br />(Column F on C703) <br />Toial Retalnagc (line 5a + 5h or <br />Total It) Column I of C703)................................ <br />6. TOTAL EARNED LESS RETAINACE............................ <br />(Line 4 less Line 5 Total) <br />7. LESS PREVIOUS CERIlflCATES FOR <br />PAYMENT (line 6 from prior Certificate)................% Idl 37^,^ <br />8. CURRENT PAYMENT DUE......................................... t .? 7. Xo'7. C'O <br />9. BALANCE TO FINISH, PLUS RETAINACE.......................< La 7 ?</ <br />(line 3 less Line 6) <br />D.Ue:- 2 a - ^ <br />Stale of: y\ Vt£.Soh3- <br />Subscribed and ssvorn to before me this <br />Notary Public: Q- 'i fr»<n/ rf4- <br />My Commission cxf)ircs: 2^" PS - <br />County of: u3/>-fik’)3Ta,*foll. <br />day of C)e£« .19^5 <br />ARCHITECT'S CERTIFICATE FOR PAYMENT <br />In accordance with the Contract Documents, based on on site ol >etvalions and the <br />data comprising the above application, the Atcbiicci cctiilics to ibe Owner that lo ihc <br />best ol the ArchItcci's knowledge, Information and belief the Work has pi. v^rcsscd .is <br />indicated, the quality of the Work Is In accordance with the Contract Documents, and <br />the Contractor Is entitled to payment ol Ihc AMOUNT CERlIflED. <br />AMOUNT CERTIFIED $ <br />(AU»ch c*p/anaf/on if amount ceitificd diffeis (torn the amount appfied for.} <br />ARCHITECT: Doarinan Kroos Pfister and Associates <br />Oy:Dale: <br />This Ccrtllicale is not negotiable. The AMOUNT CERTIFIED Is payable only lo the <br />Contractor named herein. Issuance, paymeni and acceptance of paymeni arc without <br />prejudice to any rights of the Owner or Contractor under this Contract. <br />AIA OOCUMINT C701 •AmiCAIION AND CIRliriCAlE rOR rAYMI NT • ».vAV mi IOmON*AIA* •€» mi <br />ini AARIUCAN INSIIIUII Of AXatmCIS. 17iS HIW YORK AVDJUI, N.W., WASHIHCION. D.C. JOOOt G70M903 <br />*«f« MtM**«* vtrYfntoR f| Cnrvvflriht ltW9 lod fl fub|fCl lo pnjlfCUttoil.