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"• , „ .� AIA Type Document � <br /> °`��-..� `''°° Application and Certification for Payment Pa e 1 of 3 <br /> �!M 9 <br /> ry� DISTRIBUTION TO: <br /> TO(OWNER):City of Orono v �'�5 �U��� pROJECT:Orono Police Department APPLICATION NO: 4 <br /> 2750 Kelley Parkway ��C Remodel 8 Expansion OWNER <br /> Orono,MN 55356 2730 Kelle Parkwa INVOICE N0:1461 CONSTRUCTION <br /> K���_p,NC3���s�� Orono,MN 55356 y PERIOD T0:11/30/2014 MANAGER <br /> G�r�(`,L�T'�N" ARCHITECT <br /> FROM Keileher Construction,Inc. ARCHITECTS _CONTRACTOR <br /> (SUBCONTRACTOR):11531 Rupp Drive PROJECT NO: _SUBCONTRACTOR <br /> Bumsville,MN 55337 <br /> VIA CONSTRUCTION MANAGER: Kraus-Anderson Construction Company <br /> CONTRACT FOR:Concrete Work VIA ARCHITECT: SKD Architects,Inc. CONTRACT DATE: 7/29/2014 <br /> SUBCONTRACTOR'S APPLICATION FOR PAYMENT The Undersigned Subcontractor certifies that to the best of the Subcontractor's knowledge, <br /> information and belief the work covered by this application for Payment has been completed in <br /> Application is made for Payment,as shown below,in connection with the Contract. accordance with the Contract Documents,that all amounts have been paid by the Subcontractor for <br /> Continuation Sheet,AIA Type Document is attached. Work for which previous Certficates for Payment were issued and payments received from the owner <br /> or contractor,and that current payment shown herein is now due. <br /> 7.ORIGINAL CONTRACT SUM ... ... .. ... . . . . ... . .$ 430,421.00 <br /> 2.Net Change by Change OMers . . . . ... . . . . . . . ..$ 1,624.00 SUBCONTRACTORiCetleher Construction,Inc. <br /> 11531 Rupp Drive Bumsville,MN 55337 <br /> 3.CONTRACT SUM TO DATE (Line 1 +2). . . . . . . . . .. $ 432,045.00 <br /> 4.TOTAL COMPLETED AND STORED TO DATE . .. . . . $ 398,723.00 By. Date: !! ?�t <br /> Todd Kamrud r/ Pr ' ct Manager <br /> 5.RETAINAGE: <br /> a. 5.00%of Completed Wo�ic $ 19,936.15 State of:MN <br /> County of: Dakota <br /> b. 0.00%of Stored Materiat $ 0.00 Subscribed and Sworn to before me this Z--!� Day of Np�l�20 /T <br /> Notary Public: ��� �w,, — <br /> Total retainage(Line 5a+5b)..... .. . . . . . . . . .. . . . $ 19,936.15 Matthew M.Gehrman <br /> My Commission Expires: 4�`- Notary Public <br /> 6.TOTAL EARNED LESS RETAINAGE. . . . . . . . . . . .. . $ 378,786.85 ' <br /> (Line4lessLineSTotal) CERTIFICATE FOR PAYM �MN, �ar�n��ry31,Z019 <br /> 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT In Accordance with the Contract Documents,based on on-site observations and the data comprising <br /> Line 6 from nor Certificate . . . . . . . . .$ 314,639.05 the above application, the Construction Manager and Architect certifies to owner that to the best of <br /> � p �''' '' '' '' ' their knowledge,information and belief the Wo�lc has progressed as indicated,the quality of the work <br /> 8.CURRENT PAYMENT DUE ..... ... . . . .. . . . . .. ..$ 64,147.80 �/ is in accordance with the Contract Documents, and the Subcontractor is entitled to payment of the <br /> AMOUNT CERTIFIED <br /> 9.BALANCE TO FINISH,INCLUDING RETAINAGE � "� <br /> Line 3 less Line 6 $ 53,258.15 l '`''� 4—�—� <br /> � ) AMOUNT CERTIFIED. . . . . . . . .. . . ..... .. . .. ... . . . . . $ �I �I 1 <br /> (Attach explanation if amount cert�ed differs irom the amount applied. Initial all frgures on this <br /> CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS Application and on the Continuation Sheet that are changed to conform to the amount certi�ed.) <br /> Total changes approved in previous CONSTR E : <br /> months by Owner or Cont�actor 0.00 0.00 gy Date: 1��_��- <br /> AR � <br /> Total approved this Month 1,624.00 0.00 B Date: � <br /> Y� <br /> TOTALS 1,624.00 0.00 This Cert�cate is not negotiable. The AMOUNT CERTIFIED is payable only to the Subcontractor <br /> NET CHANGES b Chan e Order 1,624.00 named herein. Issuance,Payment and acceptance of payment are without prejudice to any rights of <br /> Y 9 the Owner,Contractor or Subcontractor under this Contract <br />