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�`������"� s� �- <br /> AIA Type Document <br /> Nav 2 5 2014 Application and Certification for Payment Page 1 of 2 � <br /> TO: C�ty of Orono Project: Orono Police Dept APPLICATION NO: One-Final DISTRIBUTION TO: <br /> 2750 Kelley Parkway KRAGI�C�p�N�gN� PERIOD TO: 11/20/2014 OWNER <br /> Orono, MN 55356 ARCHITECT <br /> X CONTRACTOR <br /> FROM: Midwest Fence&Mfg. VIA(ARCHITECT): SKD Architects, Inc <br /> 525 E. Villaume Avenue 11140 Highway 55, Suite A PROJECT NO: 90447 <br /> S. St. Paul MN 55075 Plymouth, MN 55441 <br /> CONTRACT FOR: Orono Police Dept CONTRACT DATE: August 1, 2014 <br /> CONTRACTOR'S APPLICATION FOR PAYMENT The Undersigned Contractor certifies that to the best of the Contractor's knowledge,information <br /> Application is made for Payment,as shown below,in connection with the Contract. and belief the work covered by this application for Payment has been completed in accordance <br /> Continuation Sheet,AIA Type Document is attached. with the Contract Documents,that all amounts have been paid by Contractor for Work for which <br /> previous Certificates for Payment were issued and payments received from the owner,and that <br /> 1. ORIGINAL CONTRACT SUM.................................. $ 29,900.00 current payment shown herein is now due. <br /> CONTRACTOR:Midwest Fence&Mfg. <br /> 2. Net Change by Change Orders............................ $ - 525 E Villaume Ave <br /> S.St.Paul,M 5075 <br /> 3. CONTRACT SUM TO DATE(Line 1 +2).................... $ 29,900.00 .. <br /> By: Date: �\`��'�� <br /> 4. TOTAL COMPLETED AND STORED TO DATE........... $ s��o��('S� State of: MN <br /> County of: Dakota <br /> 5. RETAINAGE: Subscribed and Swo to before me this � Day of ZO�y <br /> a. 5 96 of Completed Work ���o�� Notary Public: �/���� 0 _ <br /> b. %of Stored Material My Commission Expires: �" - .-,_ . <br /> Total retainage(Line Sa+Sb)............... $ ��`�4�.7 S CERTIFICATE FOR PAYMENT ����•` ='•�ya <br /> NO�ARY PUBUC-MINNESOTq <br /> In Accordance with the Contract Documents,based on evaluations of e ��an,3�,201B <br /> 6. TOTAL EARNED LESS RETAINAGE............................ �`�^„��/ .`�—� this application,the Construction Manager and Archftect certify to the Owner a <br /> (Line 4 less Line 5 Total) knowlage,information and belief the Work has progressed as indicated,the quality of the work is in <br /> 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT accordance with the Contract Documents,and the Contractor is entitled to payment of the AMOUNT <br /> (Line 6 less prior Certificate) CERTIFIED. ` -- <br /> _-�. ��7 �, <br /> AMOUNT CERTIFIED......................................................5 a� . Jl�! <br /> 8. CURRENT PAYMENT DUE........................�....... $ �5^��,a S � (Attach explanation rf amount certified differs from the amount applied. Initial all figures on this <br /> 9. BALANCE TO FINISH,INCLUDING RETAINAGE Application and on af Sheet that are changed to conform to the amount certified.) <br /> (Line 3 less Line 6) $ �3���� CONS R <br /> CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS Date: � ,� 1. �LE.- <br /> CT: �i�Muftiple Pn ontractors are responsible for pertorming portions of the Project,the <br /> Total changes approved in 's ot required) I_ <br /> By. Date: � V <br /> previous months by owner This Certificate not negotiable. The AMOUNT CERTIFIED is payable onty to the on ractor <br /> Total approved this Month - named herein. Issuance,Payment and acceptance of payment are without prejudice to any <br /> TOTALS - - rights of the Owner or Contractor under this Contract. <br /> NET CHANGES by Change Order - <br />