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• ••lo (OWNLR):APPLICATION AND CERTIFICATE FOR PAYMENT aia document G702 on rovorso m r^^.^ cni <» PMasCitv of orcio PROita: City M.U & h.bUc Works AprucMioNNO, 2 -1335 Brown Rd. S. Orono, Minn. PtRIOD 10. io/3l/<,2 nARCIimaCrysLal liay, Minn. 35J23 □conikaciouVIA (ARCMIItCI): t, a m,,i ARC mIu CT'S □32 5 S 8th St. RROIECNO: □MPLS, Mn. 55404 <br />Bid Divisions //14 & 2 0 clrvwaU d KIFS. <br />rROMlCONlRACIOR): Mj,i.cahy, Inc. <br />CONTRACT I OR:CONTRACT DATE: <br />CONTRACTOR'S APPLICATION FOR PAYMENT <br />CHANCE ORDER SUMMARY <br />Change Orders approved in <br />previous months by Owner <br />TOTAL <br />ADDIIIONS DtDUCIIONS <br />1. <br />'Mutrrbcr*'> .])ilc*^Approvcd <br />OCT 2:1992 <br />i ^ ^ ^ • <br />TOTALS <br />Y Change Orders <br />Application is made for Payment, as shown below, in connection with the Contract <br />Continuation Sheet, AIA Document C703, Is attached. <br />1. ORIGINAL CONTRACT SUM.........................................S 165,000.00-------- <br />2. Net change by Change Orders.....................................i <br />,T. CONTRACT SUM TO DATE (Line 1 ±2)........................S i99^Q7S 'Sln' <br />-1. TOTAL COMPLETED & STORED TO DATE....................S 12Z,V/>.UU <br />(Column C on C703) <br />5. RETAINAGE: <br />a.___% of Completed Work S 12,29 7,. 0_0------- <br />(Column D + E on G703) <br />b.___% of Stored Material <br />The unclersignecl Contractor ceriincs inai lo me uesi oi imp unim.iimt > rhwwipu,;v, <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 <br />paid by the Contractorsfor Work for which previous Ccrtilicates for Paymciit were <br />issued and fiayments received from the Owner, and that current payment shown <br />rIliA <br />(Column F on C703) <br />Total Rctaiitage (Line .Sa t Sh or 19907 <br />Total in Column I of G703).....................................S —- ^ ‘ <br />(1. TOTAL EARNED LESS RETAINAGE..................................$ 110,678.00. <br />(Lino 4 less Line 5 Total) <br />7. LESS PREVIOUS CERTIFICATES TOR <br />PAYMENT (Line 6 from prior Certificate)...............$--------4,Q5Q.«_QO <br />herein is now due. <br />CONTRACIOR: Mitlcahy, Inc. <br />0. CURRENT PAYMENT DUE.........................................$ 106»62&».Q(I <br />9. BALANCE TO FINISH, PLUS RETAINAGE....................$ 54. .322 .00 <br />______(Line 3 less Line (>)__________ <br />Stale of: Minn.m,.ni.nl.M'3gl’lngton <br />D.«: <br />Subscribed ai{5 sVvor: to before me this 21 sL Lw!itO)TA <br />-------------- <br />My Commission expires: <br />mi <br />WASHINGTON COUNTY <br />AMOUNT CERTiriED...........................................................$------------- <br />iA((ac/r cxpbnajon U amount certified differs from the amount applied for.) <br />ARCmiECT: <br />ARCHITECT'S CERTIFICATE FOR PAYMENT <br />In .iccordancc with the Contract Documents, based on (m-sile observations and llte <br />data comprising the above application, the Architect certifies lo the Owner that to the <br />best of the Architect's knowledge, information and belief the Work has progressed as |jy. <br />Indicated, thequalityof the Work is in accordancewilhlheConlractDotumenls,and ,|,j, Certificale is not negotiable. The AMOUNT CtRIlFIED Is payable only to the <br />the Contractor is cnlillcd lo payment of the AMOUNI CIRIintD. Crmirar tor named herein. Issuance, payment and acceptance of payment are witlioul <br />Dale: <br />prejudice lo any rights of the Owrrcr or Contractor under tiris Contr.at t. <br />AtA UOCIIMtNt 0701 • AmtC AtrON ANO ( IRUr t( AU ruR I’AIMI Nt • MU r'Xlt IDItlON • Al.\* ♦ • rtfli <br />lUl AKttRUAN IN.MIIUII Of ARUrtIH IS. t7t', Ntw 30RX AVtNin. NW. WASrttNr,rUN. rM .r.'02-P»B1