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%APPLICATION AND CERTIFICATE FOR PAY MENT ma documl N t C702 dnstmciions on rt-veise side) rActoNtor pActs■■ ” APPLICATION NO: Eight - - -TO (OWNER);City of Orono 1335 Brown Road South Crysta’ Bay, MN 55323 FROM (CONTRACIOR):CONTRACT FOR:PROIECT:Orono city Hall/Police and Public Works BuildingsVIA (ARCHITECT):Boarman Kroos Pfister and Asscxriates 222 North Second Street Minneapolis, MN 55401 PERIOD TO; 11-30-92ARCHITECTS PROIECT NO: 1124.04 DisIfibution to:C OWNER [I ARCHITECT C CONTRACTORCONTRACTOR'S APPLICATION FOR PAYMENTChange Orders approved m previous months by OwnerTOTAL ADDITIONS DEDUCTIONSApproved this MonthNumberDate Approved <br />TOTALS <br />Net change by Chance Orders ---------- <br />The undersicned Conir.ictor cerlihes tl:at to me dcsi oi int? <br />information and behef the Work covered by this Application (or 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 />and n:iunw>nu received from thc Owner, and that current payment shownissued and pavm(*nts received from the Owner, and that current payment shown <br />herein is now due._______ r5c:oQr5C n Drii i ICMV ! <br />CONTRACTOR: l^rC-SS^/ <br />GEORGE G. POLUSNY <br />N'OTAHY FUGUC • L '.NMECOT.' <br />I2PIN fpOUNTN <br />K'yTor]* * <br />CONTRAirr DATE:Application is made for Payment, as shown below, in connection with the Contract. Continuation Sheet, AIA Document G703, is attached.1. ORIGINAL CONTRACT SUM .......................................S -----------2. Net change by Change Orders ......................................S U ot3. CONTRACT SUM TO DATE (line 1 ± 2)........................S 193,613,0 0—3-^4. TOTAL COMPLETED & STORED TO DATE.....................S -193,6 13 .00(Column G on G703)5 RETAINACE: .of Completed Work S <br />(Column D -F E on G703) <br />b.___% of Stored Material S ---------------------— <br />(Column F on G70.1) <br />Total Retainage (Line 5a + 5b or in M60S.OO <br />Total in Column I of C703)......................................S -- va-^.A ^ <br />6. TOTAL EARNED tESS RETAINACE................................ S 174,251.70 <br />(Line 4 less Line 5 Total) <br />7. LESS PREVIOUS CERTIFICATES FOR ^ <br />PAYMENT (line 6 from prior Certificate)...............S ^ <br />6. CURRENT PAYMENT DUE...............................................$ <br />9 BALANCE TO FINISH, PLUS RETAINACE.......................S 1913fa±-rjg_T^ ' <br />(Line 3 less Line 6)_______________________________________________ <br />Stale of: h-n » County of: <br />Subscribed and sworn to before me this 26Lh cay of October ,19 92 <br />Notary Public; ^ f? O 0 <br />My Commission expires: ^ /A \0— <br />ARCHITECT'S CERTIFICATE FOR PAYMENT <br />In accordance with the Contract Documents, based on on-site observ.iiions and the <br />data comprising the .ibove application, thc Archiier t certifies to the Owner that to t ie <br />best of the Architect's knowledge, information and belief the Work has progressed as <br />indicated, the quality ol the Work is in accordance with the Contract Documents, and <br />the Contractor is entitled to payment ol the AMOUNl CLKlirilD <br />AMOUNT CERTIFIED...........................................................>------------------------- <br />(Attach explanation if amount ceilified differs from the amount applied ford <br />ARCHITLCT; <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.__________