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Application and Certificate for Payment <br />(substitute for AIA Document G702) <br />Project Name: CITY HALL/PUBLIC WORKS FAC <br />Application No.: <br />Application Date; <br />Period To; <br />La Force Job No.: <br />02 <br />10/22/92 <br />10/25/92 <br />14151 <br />TO; KRiXUS ANDERSON BLDG DIV. <br />2500 MINNEHAHA AV. <br />MINNEAPOLIS, MN 55404 <br />FROM; LA FORCE HARDWARE & MFG. CO. <br />P.O. BOX 10068 <br />GREFN BAY, WI 54307-0068 <br />TRADE PAYMENT BREAKDOWN IS ATTACHED. <br />1. Original Contract Sum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 35,465.00 <br />2. Net Change by Change Orders . . . . . . . . . . . . . . . . . . . . . . . . . . . $ .00 <br />3. Contract Sum to Date (line 1 2) . . . . . . . . . . . . . . . . . . . . . . . $ 35,465.00 <br />4. Total Completed & Stored to Date (column G) . . . . . . . . . . . . . . . $ 6,700.00 <br />5. Retainage: <br />a. lO.OOZ of completed work (column D + E) . . . . . $ 670.00 <br />b. 10.002 of Material Stored (column F) . . . . . . . $ .00 <br />Total Retainage (line 5a 4 5b; or total column I) . . . . . . . . . . . . $ 670.00 <br />6. Total Earned Less Retainage (line 4-5 totals) . . . . . . . . . . . . . $ 6,030.00 <br />7. Less Previous Certificates for Payment . . . . . . . . . . . . . . . . $ 4,246.20 <br />(line 6 from prior certificates) <br />8. Current Payment Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 1,783.80 <br />9. Balance to Finish, Plus Retaxnage . . . . . . . . . . . . . . . . . . . . . . $ 29,435.00 <br />(line 3 less line 6) <br />The undersigned Contractor certifies that to the best of the Contractor's knowledge, <br />information and belief the Work covered by this Application for payment has been <br />completed in accordance with the Contract Documents, that all amounts have been paid by <br />the Contractor for Work for which previous Certifi^tes for Payment were issued and <br />payments received from the Owner, and that current^Myment shown hertv Is now due. <br />CONTRACTOR: LA FORCE HARDWARE & MFG. CO. .t : 10/22/92 <br />State of: Wisconsin County of: Brown / / ^1^ j / ( / ^ <br />Subscribed and swid^n to befgre me t^ . oJ^/Y/nl.____ day of ( X* /» 19 ^O/ <br />Notary Public: //n^jyLf'TTr '7^. _____ My Commission expires: /i^9~9'S . <br />ARCHITECT’S CERTIFICATE FOR PAYMENT <br />In accordance with the Contract Documents, Based on on-site observations and the data <br />comprising the above application, the Architect certifies to the Owner that to the best <br />of the Architect's knowledge, infotmation and belief the Vi’ork has progressed as <br />indicated, the quality of the Work is in accordance vxth the Contract Documents, and the <br />Contractor is entitled to payment of the AMOUNT CERTIFIED. <br />AMOUNT CERTIFIED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$_ _ _ _ _ _ _ _ _ _■ <br />ARCHITECT;By:Date: <br />This Certificate is not negotiable. The .\M0UNT CERTIFIED is payable only to the <br />Contractor named herein. Issuance, payment and acceptance of payment are without <br />prejudice to any rights of the Owner or Contractor under this Contract.