Laserfiche WebLink
APPLICATION AND CERTIFICATE FOR PAYMENTlO (OWNER):City of Orono1335 Brown Road SouthCrystal Bay, MM 55323 <br />FROM (CONTRACTOR): <br />PKOItCl:Orono City Hall/Police and Public Works Duildimjs <br />CONTRACT FOR: <br />CONTRACTOR'S APPLICATION FOR PAYMENT <br />‘ chance order summary" <br />VIA lAKCHITECT): <br />Boarman Kroos Pfister and Assoc <br />222 North Second Street <br />Minneapolis, MN 55401 <br />ARCHITECTS <br />PROIECT NO: 1124.04 <br />Disinbiilion tt»;□ OWNER□ ARCHITECI <br />□ CONIRACTOR□ <br />n <br />CONTRACT IMTE: <br />Change Orders approved in <br />previous months by Owner <br />TOTAL <br />ADDITIONS <br />Approved this Month <br />Number Dale Approved <br />TOTALS <br />Net chaoRe by ChanKc Orders <br />DFDUCnONS <br />Application is made (or Payment, as shown below, m conncclion with the Contract. <br />Continuation Sheet, AIA Document G703, is attached. <br />1. ORIGINAL CONTRACT SUM........................................... $ 181,827.^00._______ <br />2. Net change by Change Orders........................................$____5,596 .00 <br />3. CONTRACT SUM TO DATE (Line 1*2)..........................S 187,423.00 <br />A na r • _______________________________ ______A TOTAL COMPLETED & STORED TO DATE......................$ 177.423 00 <br />(Column C on 0701) <br />5 RETAINAGE; <br />a. IXL % o( Completed Work S 17,742. IQ <br />(Column D + E on G70J) <br />h.------% ol Stored Material $ ______________ <br />(Column F on G703) <br />Total Retainage (line 5a f 5b or <br />lotal in Column I o( G703)........................................$ 17,742.30 <br />Ihe undersigned Contractor certilies that to Ihc best ol tin- Contrar loi s knowleilee <br />miorinalion and belie! the Work covereo by this Application lor Payment has been <br />completed in accordance with the Contract Documents, that all amounts have been <br />paid by Ihe Contractor (or Work (or which previous Ceilduates (or Payment were <br />issued and payments received (rom the Owner, and thai (urreni payment shoyvn <br />herein is now due <br />GEORGE Q. POLUSNY ' <br />6. TOTAL EARNED LESS RETAINAGE...............................S 159,680.7 0 <br />(line 4 less Line 5 Total) <br />7. LESS PREVIOUS CERTIFICATES TOR <br />CONTRACTOR: <br />By: <br />PAYMENT (line (> (rom prior Cerli(icale)................$ 139.8 81.60 <br />fl. CURRENT PAYMENT DUE...........................................$ 19.7QQ 10 <br />5 BALANCE TO FINISH, PLUS RETAINAGE....................$ 27,742.30 <br />_____(line 3 less Line h) <br />notary public • MWNCSOTA <br />HENNEPIN COUNTY <br />My CoflMMlOn EiVBH Oc L IS. 1997 <br />ARCHITECT'S CERTIFICATE FOR PAYMENT <br />In accordance with the Conrad Documents, based on on site ohservations and the <br />data comprising the above application, the Architec t ceitilies to tlie ()wner tliat to the <br />best o( Ihc Architect s knowledge, information and beliel Itie Woik has progressed as <br />indicated, Ihc tiualily o( the Work is in arc ordain e with Ihe Coniiad D.n umenis. and <br />the Contractor is entitled lo payment ol the A,\touNT O Rill It D, <br />Slate ol: Minnesota County o(; Fiennepin <br />Subscribed and syvorn lo before me this 24 th day o( Jnlv <br />Notary I’ublic; ^|Q N ^ ^ <br />My Commission expires: ^ ^ \7—v <br />AMOUNT CERTIFIED............................................................... s_______________ <br />(Atl.ich expl.in.Uion if .imount certified differs from the .irnoorU .ipphvd tor.) <br />aklmhec T: Boarman Kroos Pfister and A<?.<?or-i n t-oc <br />Bv:Dale: _ <br />nu ''■’■"^''"15‘^ ANIHI kiiik .Ml I»>K i \y Ml Ml • M yy rmi n iiiMM- mv • • i -ni <br />Miniiii* IS. i.-r, siyv vn«x .yyra-, M... v sm..-;. to............... <br />This Ccililicale is nol negotiable. The AMOUNT CEKIlfllD is payable only lo Ihe <br />Conlrarlor named herein. Issuance, payment and ac ceplarn e ol payment are yyilhoul <br />(ne|cidice lo any rights ol the Oyviier or Contractor undef this Contract