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APPLICATION AND CERTIFICATE FOR PAYMENT am docukiint C7mlO (OWNER):City of Orono1335 Brown Road South I’KOjECf: City Hall & Public Works CJarage.Orono, MN (InstiiKlinm on rpvrtse side) TACI ONI Of PACili APmCATIONNO: ^I’ERIOIT TO: 1/18/93 <br />VIA lARtimECT); <br />I^roy Signs, Inc., G325 Welcome Ave. No., Mpls., MN 55429 <br />CONTRACT FOR: SKterior & Interior Signage <br />ARCIIIIECTS <br />PROlfCT NO: <br />Distriliulion lo:IJ OWNER□ ARCIIIUCT□ CONTRACTOR□□ <br />CONTRACT DATE: 5/11/92 <br />CONTRACTOR'S APPLICATION FOR PAYMENT Ai'()Iic.ilion is m.idc for I’dymonl, ns shown Ih ’Iow, in connection with Ihc Conlracl. <br />Conlinualiun Shed, AIA DucumenI G703, is nll.M lu*d. <br />Cc <br />CHANGE ORDER SUMMARY <br />Chanf’c Orders approved in <br />previous montlis by Owner <br />lOIAI. <br />ADDITIONS <br />$120.00 <br />-vVpp^oved (his'Month <br />Number Dale Approved <br />s!AN V'J i1m:r>. I S V.l <br />5iojals si20.no <br />Net change by Ciaiige Orders $120.00 <br />DIDUCTIONS <br />1. ORI 'INAL CONTRACT SUM......................................S 2,538.00 <br />2. Nd change by Change Orders..................................$ __±2QlDft. <br />J. CONTRACT SUM TO DATE (Iine 1 ± 2)......................$ 2 .fiSR.nn 25^e.«o <br />4. TOIAl COMPLtlED i STORED TO DATE...................$ 2.fiSR.n n <br />(Column C on G70)) <br />r>. RETAINAC.E: <br />a.— % o( Completed Work t <br />(Column D + E on (;7l)i) <br />h.------% of Stored Material $ <br />(Column r on G70.I) <br />Total Retninagp (Line 5a + 5b or <br />Total in Column I ol G701) <br />The undersigned Contractor certifies that lo the best of ihe CotrIraclor's knowledge, <br />iidoimation and belief Ihe Work covered Iry this Application for Payment has been <br />completed in accordance with the Conliatl Documents, that all amounts have been <br />paid by the Contractor for Work for which previous Cerlilicale% (or Payment were <br />issued anc( payments received join Ihe Owner, and that curieni payment shown <br />hcreii i is "*u«v due. <br />TOIAL EARNED LESS RETAINAGE...........................S a .finft--nn dSTA.oo <br />(Line 4 less Line 5 Total) <br />7. LESS PREVIOUS CERTIFICATES FOR ^ <br />PAYMENT (Line 6 from prior Ccrlificalc)................$_______-Q-___________ <br />CO nirac L'OR: Lecoy Signs,Inc. <br />«. CURRENT PAYMENT DUE.................................................. <br />BALANCE TO FINISH, PLUS RETAINAGE ....................$ _ <br />(Line 3 less Line 6) <br />^0^ <br />Date:Jan. J.Q,.1993 <br />Slate ol: Minnesota <br />Subscribnd b(^)rf imfUiis <br />Notary »’ublic:^-^j|^^ / <br />My Commission ex^i^ v/lG <br />County of: <br />ARCHITECT'S CERTIFICATE FOR PAYMENT <br />In .iccordance with die Conlrac : Documents, based on on sile ohsetvalions and Ihe <br />data com|>nsing Ihe ahove applii alion, the Art hilerl ceililies lo Ihe C)wncr lhal lo the <br />Ik 'SI of the Archilet I s knowledge, inloimalion and beliet the Work has progiessed as <br />indicalt'd, Ihc c)uality of Ihe Work is in accordant c with die Conliacl Uotumenis, and <br />the Contractor is entitled to parinenl of Ihe ,\MOUNT cTRIII 1(1). <br />• • • • • <br />lASdhtDU^ <br />iMIlflWHMI <br />EEtrwMpIn County <br />flowm. gi»i ? 18 9 ? <br />AMOUNT CfcRTIFlEO.................... <br />(Attach explanation if amount cerfffted di//cfs from the amount applied (or) <br />ARCHIIECT: <br />By;Dale: <br />this Ccrlificalc Is not negoli.ible. The AMOUNT CtRIlFIFD Is payable only lo the <br />Contractor named herein. Issuance, paymenl and acceplanccof paymenlaic without <br />prejudice In any ghis nf the Owner or Contractor under this Conliacl. <br />AlA OOCUMINT C.TfJ • AITlICAnON ANU ClRttf ICAU fOR nSYMlNI ♦ MM rmi IDllK)N • AIA- • I'WI <br />Till AMIRICAN INSIITUU Of AKClU'tCiS. I7JS NIW VOKIl AVir^UI. NW. WASIIINC,ll)N. II C Jniiiii. <br />WAnNtNQ: UnOcenstci ptMlocofiirIng violale* US. copyiigM I«m and !• Mib|«cl lo l*«al pniMcution. <br />C702-I9t3 <br />I <br />4