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/\PP|[.|C/VTION AND CERTIFICATE FOR PAYMENT AIA document C702 (Instmciions on reverse sWe) pACi ONI Of I'ACis <br />TO (OWNER): <br />City of Orono <br />1335 Brown Rond South <br />Crystal Bay, MN 55323 <br />FROM (CONTRACTOR): <br />PROIECT: <br />Orono City Hall/Police and <br />Public Works Buildings <br />APPLICATION NO: 4 <br />PERIOD TO: 2/12/93 <br />7/0 't <br />CONTRACT FOR: <br />VIA (ARCHITECT): ARCHITECT'S <br />Boarman Kroos Pfister and Assoc. PROIECT NO: 1124.04 <br />222 North Second Street <br />Minneapolis, MN 55401 CONTRACT DATE; 5/11/92 <br />Dislribuliun 10: <br />□ OWNER <br />□ ARCHITECT <br />□ CONTRACTOR <br />□□ <br />CONTRACTOR'S APPLICATION FOR PAYMENT <br />CHANCE ORDER SUMMARY <br />I <br />Change Orders approved in <br />previous months tiy Owner <br />TOTAL <br />ADDITIONS DEDUCTIONS <br />'-3,463.00) <br />Appros*ed this Month <br />+787.00 <br />Number Dale Approved <br />Two 12/22/92 <br />TOTALS 787.00 (-3,463.00) <br />Net chanRC by Change Orders $(~2,676.00) <br />Th€ undersigrved ConIraclor certifies that 10 Ihe best of ihe Conlrartor's knowledge, <br />infurmalion and belief lire Work covered by (Ids Application (or Payment has been <br />completed in accordance with the Contract Documents, that all amounts have beetr <br />paid by the Contractor for Work (or which previous Certificates (or Payntent were <br />issued and payments received from the Owner, and that current payment shown <br />herein is now due. <br />CONTRACTOR: <br />ny-George Nims Date: 2/12/91 <br />Application is mao ayinent, as sitown below, in connection with the Contract. <br />Conlinualion Sheet, /siA Document C703, is attached. <br />1. ORIGINAL CONTRACT SUM......................................$ ——--------- <br />2. Net change by Change Orders...................................S •**) <br />3. CONTRACT SUM TO DATE (line 1 ± 2).......................$ <br />4. TOTAL COMPLETED & STORED TO DATE...................S J€. Ob 9 jOP <br />(Column G on C703) <br />5. RETAINAGE: <br />a. UQ_ % of Completed Work S ^ <br />(Colu:nn D 4- E on G703) <br />b. _% of Stored Material $---------------------------- <br />(Column F on G703) <br />Total Retainage (Line 5a + 5b or <br />Tola! in Column I of C703)...................................$ 7?^.*:** <br />6. TOTAL EARNED LESS RETAINAGE...............................$ 1 4 62 .10 <br />(Line 4 less Line 5 Total) <br />7. LESS PREVIOUS CERTIFICATES FOR <br />PAYMENT (Line 6 from prior Certificate)..............$ 6 4i 4BQ^5iL ----------- <br />8 CURRENT PAYMENT DUE............................................S -jir <br />9. BAUNCE TO FINISH, PLUS RETAINAGE.....................$ -? . 6 BET: §Q <br />(Line 3 less Line 6) ___ ____________ <br />Stale of: <br />Subscribe <br />Notary Pt <br />My Comn <br />MOfACOWlYmcotmssnNixptifs <br />ires; tmCM 17.199* <br />, ^ County of : • <br />day of ^*■4''/n .19 <br />ARCHITECT'S CERTIFICATE FOR PAYMENT <br />In accordance with Ihe Contract Documents, based on on site olrservalions and the <br />data comprising lire above application, the Architect ccridies to the Owner that to the <br />t»esl 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 />(lie Contractor is entitled to payment of the AMcTUNT (TRTIHfD. <br />AtAIMKWnIWI C7#l*AmiCAIlON ANDCiaillll All KW rntMlNl • MAY l'«H lOlIION • AIA* • C IMJ <br />inl amIhmah W4SIIIUII Of ARCIimciS. im niw vomi avinwi , nw. wasiiinc .ion , »C. Joon* <br />AMOUNT CERTIFIED........................................................t------------------------- <br />(Attach explanation if anjount ceitifieil diffeis (loin the amount applied lot.) <br />ARCHIUCI; Doarman Kroos Pfister ancJ Associates <br />Ity:Dale: <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 Ihe Owner or Contractor under this Contract. <br />C7f2*l9f]