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APPLICATION AND CERTIFICATE FOR PAYMENT aia doc ument C702 (instructions on reverse sido paccomor / CACts XTO (OWNER):City of Orono 1335 Brown Road South <br />Crystal Bay, i»N 55323 <br />FROM (CONTRACTOR): <br />NORIHSIOEOOfBniUCnONMCl <br />1SI27 FOREST BUm <br />CONTRAa FOR: RQL MIX 321 <br />PROJECT:Orono City Hall/Police and Public Works Buildings APPLICATION NO: / Distribution to:/ / DOWNERPERIOD TO: P'/Y ^ □ ARCHITECT□ CONTRACTOR <br />VIA (ARCHITECT): ARCHITECT'S □ <br />Boarntan Kroos Pfister and Assoc. PROJECT NO: 1124.04 □ <br />222 North Second Street <br />Minneapolis, MN 55401 CONTRACT DATE: <br />t <br />CONTRACTOR'S APPLICATION FOR PAYMENT <br />CFIANGE ORDER SUMNIARY <br />Change Orders approved in <br />previous months by Owner <br />TOTAL <br />ADDITIONS DEDUCTIONS <br />Approved this N\onth <br />r <br />• <br />Number Dale Approved <br />TOTALS <br />Net change by Change Orders <br />Application is made (or Payment, as shown below, in connection with the Contract. <br />Continuation Sheet, AIA Document G703, is attached. <br />1. ORIGINAL CONTRACT SUM..........................................$------- <br />2. Net change by Change Orders ......................................$ <br />3. CONTRACT SUM 30 DATE (Line 1 S 2).........................$-------^ <br />T. TOTAT completed & STORED TO DATE.....................S----------7/. <br />(Column C on C703) <br />5. RETAINACh: Do O <br />a. /O % of Compleled Work S-----— <br />(Column D 4 E on G703) <br />b. _% of Slorcc! Material $------------------------------ <br />llic undersigned (.’ontra( lor ccriifies dial lo llie best of llie Conlracior^ knov\leilgc, <br />information and belief the Work covered by this Application for l*jymenl has been <br />compleled in accordance with ihe Conlrati Docuinent^, that all amounts have been <br />paid by Iho Conlraciof lor Work lor which previous Certilicates (or Payment were <br />isvucd and payments received (rum Ihe Owner, and that current payment sliown <br />herein is now due.fWMI <br />CONTRACTOR <br />OONNAJ.MMEAUIY <br />NOTAirr PUBLIC MNNCSOIA <br />WASHINGTON COUNTY <br />My Comm EwpirM 3-B*97 <br />(Column F on 0703} <br />Total Keiainage (Line 5a t 5b or <br />Total in Column I of C703)......................................S - <br />6. TOTAL EARNED LESS RETAINACE..................................$ - <br />(line *1 less Line 5 Total) <br />7. USS PREVIOUS CEKTiriCATES FOR <br />PAYMENT (l ine 6 from prior Ccrlilicalc)...............S - <br />8 CURRENT PAYMENT DUE...............................................S_ <br />0. BALANCE TO FINISH, PLUS RETAINACE.......................% <br />(line 3 less line G) ____________________________________ <br />Slate of; (A *Couniyof: (iliESVl i JTCyircsrl- <br />Date.9/^ <br />Subscribed and svvprn lo before me this Yh day of .V> HTl <br />WnOjJiJL/lujthNotary Pubjic . _ __^ ^, <br />My Commission expires: <br />ARCHITECT'S CERTIFICATE FOR PAYMENT AMOUNT CCRIIIIEU <br />(Aii.ich c\pljn,Uion if amount certified differs from the amount applied for.) <br />In aciofdartce with the Cdiitraci Documents, irased on nr»-silc ol)y:*rvalions and the ARCHITECT: BOtirinan KroOS Pfistcr nnd ASSOCldfCS <br />data comprising tbc above application, the Aichiieci cerliiies lo the Ovvner that to the <br />licvl of the Architect's knmvieilge, information arrrihcliel ifie Work has (•rogrevscil a> By; _________________________—------------Dale: . .............. <br />indicated, Ihe <|ualily of Ific Work is in accordance with Ihe Contract Documents, and yj ; Certificate is not negotiable. The AMOUNT CERTIFIED is payable only lo Ihe <br />Ihe Coniracior is cniilled lu pjyineni of ihc AMOUNT CERTlf fEO. Coniracior named herein. Issuance, payment and acceptance of payment are vvilhout <br />prejudice lo any rights of llie Ovvner or Contractor under llsis Contract. <br />*?i riricoMiM r,?#i • iM'iti<'*no'i a.so riKTifii *?! toil rvwiNi • m\> 11.11 toino'i • ai\* • i. vmi C','02-1981