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APPLICATION AND CERTIFICATE FOR PAYMENT ma document G7V2 (insirucuons o.i reverse side) /PA(.I ONI or / PAC.IS/TO (OWNfR): C/^y o "f (PrZoAJOrJ TlJ S,0>*-Y /V/l/ >'>3^3 <br />FROM (CONTRACTOR):^^^^^^ <br />S, 0*~ <br />IM io O- ^ <br />Ia -T-K f ______________ <br />rROJtCI: Ctfy /ift LL 7a^c/pi<7fT^tc.Uj 0 S, <br />OtZo,\JC /'Jrj APmCAIION NO: /PIRIODIO: fof%o/<JX <br />CONIRACT FOR: <br />VIA (ARCMIILCI): ARCMIUCT'S <br />kr^oif |S/#4#aJ’RO)ICI NO: <br />;UA N <br />_________/VA.5 ___________CONIRACT OAIF: fr//,/<f^ <br />Distribution to:□ OWNIR□ ARCHIltCI <br />LJ CONIRACIOR□□ <br />CONTRACTOR'S APPLtCATION FOR PAYMENT <br />CHANGE ORDER SUMMARY <br />Change Orders approved in <br />previous months by Owner <br />T(ilAL <br />OCT K1 <br />Approved <br />199?. <br />AtW.'ir - ■ lOIAlS <br />^fVr^fyh.Vil^e Orders <br />ADDIIIONS DIUUCIIONS <br />Af)plicalion is made for PaymenI, as shown below, in connection with the Contract. <br />Continuation Sheet, AIA Document G703, is attached. <br />^<fPO, oo <br />3 9 rt:. c? O <br />/ V7 -T. 0(D <br />Ihc undcrsijjned Contractor certifies that to the best of the Contractor's knowledge, <br />information and belief the Work covered by this Application for Payment has l)Lvn <br />completed in accordance with the Contract Documents, that all amounts have been <br />paid by the Contractor (or Work lor which previous Certilicates for Payment were <br />issued and payments received from the Owner, and that current payment shown <br />herein is itow due. <br />CONIRACIOR: <br />By: i ________D.ili’; <br />1. ORIGINAL CONTRACT SUM...........................................S <br />2. Ncl change by Change Orders.......................................$ <br />J. CONIRACT SUM TO DATE (Line 1 ± 2)..........................$ <br />4. TOTAL COMPLETED & STORED TO DATE......................S <br />(Column G on G7UJ) <br />5. RETAINAGE: <br />a. -Z.Q. % ol Completed Work <br />(Column D + E on G703) <br />b. _% of Stored Material $___________________ <br />(Column F on G70J) <br />Total Retainage (Line 5a + 5b or <br />Total in Column I ol G703).......................................i <br />6. I* FAL EARNED LESS RETAINAGE...................................S <br />(Line 4 less Line 5 total) <br />7. LESS PREVIOUS CERTIFICATES FOR <br />PAYMENT (Line 6 from prior Certiliratc)................S <br />8. CURRENT PAYMENT DUE.................................................S <br />9. BALANCE i J FINISH, PLUS RETAlNAGE........................$_______________________ <br />______(Line 3 less Line b)_____________________________ _____________________ <br />State of. y/Y^ •y <br />Subscr:bed and itwor^o befeie^rm »is o* () .19 <br />Notary <br />My Comr <br />/ -ro <br />/•7 77.5 -g? <br />/77 7.>~<3 <br />a/ <br />4-—7^--.................4^.. /t^COTmisci^ <br />AMi'ACOUIflY <br />txpifM Rsi, IS, r <br />y% <br />ARCHITECT'S CERTIFICATE FOR PAYMENT <br />In accordance with the Contract Documents, based on on site observations and the <br />data cr'mprising the above application, the Architect certifies to the Owner that to (he <br />best Ol the Architect's knowledge, inf^ mation arul b(»lu*( tlu* Work has progressed as <br />inclu ated, the ({uality of the Work is in accordaru e with the (Ontract Documents, and <br />Iht* Contractor is entitled to payment of the AMOUNI CTKhllLD. <br />AMOUbLPCtRTIFIED..............B.>ft/v^AftVvv^.vwvvvWlAAfAA^-^^^ ’y <br />(Attach vxf)lanation if amount certified differs from the amount applied for.) <br />AKCHIilCr: <br />By:___________________________________________Date: ______________________ <br />Ihis Certificate is not negotiable. The AMOUNI CIRIIMID is payable only to the <br />('oniractor named herein. Issuance, payment and acceptance of payment are withrmt <br />prejudice to any rights of the Owner or Contractor under this Ccmtract. <br />AIA OOCUMINI G7a2 • AmiC AIION AND U# MK All I ()K PAY MIN I • K\\Y ira I I Dll ION • AIA* • t 1 HU <br />IMt AMIRIC:AN INSmUll of AROIIIK is .^ ;.v VORU AVINUI. NW. WASMIN(,I0N. OC; 2nr>»i6 G702-19t3 <br />WAnHiUQ: UnNc#n»ed photocoeyinq vloliites U S copyright liwt ond Is tub|scl lo Isgsl prosecution.