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APPLICATION AND CERTIFICATE FOR PAYMENT ma documint cjoi (Iristruclions on reverse side*TO (OWNER):Chy of Orono I’ROIECT: Orono City Hall &Public APPLICATION NO: 3 Oisiribulion to: <br />2750 Kelloy Parkway Wo''ks Dui1dings Including Ret a inage n OWNER <br />Orono,MN 55356 PERIOD TO: 2/25/93 □ ARCHITECT <br />(ROM (CONTRACIOR):Date Tile Company VIA (ARCHIUCl):Boarman and Assoc.ARCHITECT'S <br />□ CONTRACTOR□ <br />4825 France Ave. No.PROIECT NO:□ <br />Minneapolis. MN 55429 <br />CONTRACT FOR: Ceramic Tile CONTRACT DATE: 7/20/92 <br />CONTRACTOR'S APPLICATION FOR PAYMENT <br />CHANCE ORDER SUMMARY <br />Chan^jo Ord«?rs approved in <br />previous months by Owner <br />miM <br />ADDITIONS <br />1,726.00 <br />DEDUCTIONS <br />Approved this Month <br />293.00 <br />207.00 <br />305.00 <br />Number D a IIi? ApproverJ <br />#3 <br />#4 <br />#5 <br />•OTALSj 7.531.00 <br />Net thanRc by CtiJtn;e Ok U ts _7.531.no <br />Application is niiiclo for Pjyniont, as shown below, in connection with ihc Conlracl <br />Continuation Sheet, AIA Document G703, is allached. <br />1. ORIGINAL CONTRACT SUM............................................$ 21.292.00 <br />2. Net change by Change Orders........................................| -3.931.0^ \1ZU>» <br />CONTRACT SUM TO DATE ilinc 1*2)..........................$ 23:023.00 <br />4. TOTAL COMPLETED & STORED TO DATE......................$ -23:B23.QO <br />(C()lumn C on C70J) <br />S RETAINAGE: <br />a. 3^ % o( Completed Work $ <br />(Column D + f on C70T) <br />b. --% o( Stored Material $ <br />(Column F on C701) <br />lolal Retainage (Line 5a ♦ 5b or <br />Total in Column I o( C703) <br />^b' 5.MS <br />S -0-•57'5.MS <br />The undersinned Cunlractor ccrlilM s lhal to the best of the Contractor's krurwled^e. <br />information and belief ttic Work ct vered by this Application for Payment has been <br />lumplelcd in accordance with the Contract Documents, that ali amounts li.ive been <br />paid by the Contractor for Work fnr which previous Certificates (or Payment were <br />issued and payments received from the Ownc*r, and that current payment sliown <br />herein is now due. <br />CONTRACTOk: | o Tile Company <br />By;Dair <br />ARCH^iECT'S CERTIFICATE FOR PAYMENT <br />Iti at (i<rd.'ncc with tiu? Contract Oocutnenis, based on ott-vU* uhserv.iiions and llu* <br />data t omprising iho above a|)plicalion. the Architect cerlitios to the Owner that In the <br />bcM o( Ihc Archilod's knowl«»dge, information and b'*lte( the Work lias progressed as <br />indKalcd, lhc> qualily o( the W'otk is in accordance with the ( ontraci Documents, and <br />me Cunlractor is enlilled to payment ol the AMOUNI ( IRDfllD <br />() TOTAL EARNED LESS RETAINAGE....................................\ 23.823.00 <br />(line 4 less Line 5 Total) <br />7 LESS PREVIOUS CERTIFICATES fOR <br />PAYMENT (Line 6 from prior Certificate)................$ 70.716.20 ^ <br />fl. CURRENT PAYMENT DUE..................................................$ ». ttST <br />9 BALANCE TO FINISH, PLUS RETAINAGE........................S — <br />______(liiir* ) less Line b) <br />Stale of: <br />Subscribed and sworn <br />Notary Public: <br />My Commission CKpirtiBww^l^ <br />\~tZ^35 <br />AMOUNT CER1IFIEO <br />(Anac/i e*pl.ina ion if amount certified differs from the amount applied (orj <br />AKCMIIKI: <br />l»V ..Date <br />tins Ceiliticale is not negotiable The AMOUNT CfRTIFIfD is payable only to tin <br />C (inlraclnr nanievJ herein Issuance, payment and acceptanccuf payment are wilhoiii <br />p.eiiidic e to any rigitls nl the Owner or Contractor under this Cciniracl. <br />At* ttlKUAMNI U7CI • AITtK Air IN AND Cl Kill 1C All I CJK I'M MIN I • MA> emi I Dl I ION * AIA' • . I'm I <br />MR AMinCAN INS' iidl Of Al'ClIlliC Is. I7IS NIW tOIIK AVlNI’l K W WASIIIN<,ION DC C7t3}^