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APPLICATION AND CERTIFICATE FOR PAYMENT ma document C702 on reverse side) tacc oki Of 2 fACfSTO (OWNER): Kraus-AnJerson Construction525 South Eighth Street Minneapolis, MN 55404 PROjECT: City Hall f. Public WorksGarage Orono, HN APPIICAIION NO: 2PERIOD TO: 2/1/93FROM (CONTRACTOR): Ackley-Dornbach, Inc.716 N. 109th Street Wauwatosa, W1 53226 CONTRACT FOR: Detention Er|uipment VIA (ARCHITECT):ARCHITECT'S PROJECT NO;Distribution to:□ OWNER□ ARCHITECT□ CONTRACTOR□□CONTRACT DATE: August 31, 199 <br />CONTRACTOR'S APPLICATION FOR PAYMENT Application is made for Payment, as shown below, in connection with the Contract. <br />Continuation Sheet, AIA Document G703, is attached. <br />AC; <br />CHANCE ORDER SUMMARY <br />Change Orders approved in <br />previous months by Owner <br />TOTAL <br />ADDITIONS DEDUCTIONS <br />Approved this Month <br />* 1,452.00 <br />Number Date Approved <br />-•< , f <br />1 <br />1 '' m <br />'D■ 1112192 <br />J <br />TOTALS 1,452.00 <br />Net change by Change Orders 1,452.00 <br />1. ORIGINAL CONTRACT SUM.......................................$ 31 »000»00 <br />2. Net change by Change Orders.....................................^ I,432.()0 <br />3. CONTRACT SUM TO DATE (Line 1 ±2).........................S 32,452.00 <br />4. TOTAL COMPLETED & STORED TO DATE......................S 28,000.00 <br />(Column G on G703) <br />5. RETAINAGE: <br />a. _L2- % of Completed Work $ 2,800.00 <br />(Column D + E on C703) <br />b. --% of Stored Material $ <br />The undersIgne^'Contractor certifies that to the best of the Contractor's knowledge, <br />information and belief the Work covered by th's Application for Payment has been <br />completed in accordance with the Contract Documents, that all amounts have been <br />paid by the Contractor for Work for which previous Certificates for Payment were <br />issued and payments received from the Owner, and that current payment shown <br />herein is now due. <br />(Column F on C703) <br />Total Retainage (Line Sa + 5b or <br />Total In Column I of C703)....................................S 2,800.00 <br />6. TOTAL EARNED LESS RETAINAGE.................................S 25,200.00 <br />(Line 4 less Line 5 Total) <br />7. LESS PREVIOUS CERTIFICATES FOR <br />PAYMENT (Line 6 from prior Certificate)................S 4,680.00 <br />8. CURRENT PAYMENT DUE.............................................$ 20,520.00 <br />9. BAUNCE TO FINISH, PLUS RETAIN/ 3E......................S 7.252.00 <br />(Line 3 less Line 6) <br />CONTRACTOR: Ackley-Dornbach, Inc. <br />; 1-21-93 <br />Stale of: Wlsconein <br />By <br />Subscribed and sworn »•> before me thi^,21st' <br />Notary Public: <br />My Commission expires: i&^perraanent <br />County of; Milwaukee <br />day of January ,19 93 <br />ARCHITECT'S CERTIFICATE FOR PAYMENT AMOUNT CERTIFIED <br />In accordance with the Contract Documents, based on on-site observations and the <br />data comprising the above application, ll.e Arrhilect certifies to the Owner th.it to the <br />best of the Architect's knowledge, information and belief the Work has progressed as <br />indicated, the quality of the Work is In accordance with the Contract Documents, and <br />the Contractor is entitled to payment of the AMOUNT CERTIFIED. <br />(Attach explanation if amount certified differs from the amount applied for.) <br />ARCHITECT: <br />By:Date: <br />This Certificate Is not negotiable. The AMOUNT CERTIFIED Is payable only to the <br />Contractor named herein. Issuance, payment and acceptance of payment are without <br />prejudice to any rights of the Owner or Contractor under this Contract. <br />AU OOCUMENT C7tl • APPl ICATIOI'l AND CianriCAlE FOR PAYMENT • KSAV 198J EDITION‘AIA* • 9 1981 <br />THE AMkICAH IKSmUU Of ARatlUCIS, 1/1$ KIW 10RK AVlKUf. N.W, VV‘<i«INCTO T. D.C.C702-1983