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AIA Type Document '
<br /> "�,� Apptication and Certification for Payment Page 1 of 3
<br /> TO(OWNER):City of Orono ` 4 F PROJECT:�rono Police Department APPLICATION NO: 5 DISTRIBUTION TO:
<br /> 2750 Kelley Parkway ��`'�� � s r� Remodel 8 Expansion INVOICE N0:1487 _OWNER
<br /> Orono,MN 55356 `f r� �'�2�` 2730 Ketley Parkway _CONSTRUCTION
<br /> �r , �+ ' Orono,MN 55356 PERIOD T0:12/31/2014 MANAGER
<br /> � ARCHITECT
<br /> FROM Kelleher Construdio I�.P�DE��s ARCHITECTS _CONTRACTOR
<br /> (SUBCONTRACTOR):�1531 Rupp Driv�G����-�4 PROJECT NO: _SUBCONTRACTOR
<br /> Bumsviile,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 Subcontrador's knowledge,
<br /> information and belief the work crovered by this application for Payment has been completed in
<br /> Application is made for Payment,as shown below,in connection with the Contrad. accordance with the Contract Documents,that atl amounts have been paid by the Subcontractor for
<br /> Continuation Sheet,AIA Type Document is attached. Work for which previous Certificates for Payment were issued and payments received from the owner
<br /> or contractor,and that cuRent payment shown herein is now due.
<br /> 1.ORIGINAL CONTRACT SUM . . .. . . . ... .... . .. . . .$ 430,421.00
<br /> 2.Net Chan e Chan Orders $ 1,g24.00 SUBCONTRACTORi<elleher Construction,Inc.
<br /> 9 � � ' ' ' ' ' '' '' ''' '' ' � 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 ... .. . $ 408,723.00 By. Date:
<br /> Todd Kamrud / Project Manager
<br /> 5.RETAINAGE: State of:MN
<br /> a. 5.00%of Completed Work $ 20,436.15
<br /> County of: Dakota
<br /> b. 0.00%of Stored Material $ 0.00 Subscribed and Swom to befo me this Z.,?i� Day of OC��20 ��
<br /> �.� � � �. �
<br /> Notary Public: �,,,,,�,�,,,,,
<br /> Total retainage(Line 5a+5b).. . .. . . .. . . .. . . . . .. $ 20,436.15 �, ••.,, Matthew M.C3ehrman
<br /> My Commission Expires: _ NOtsry Public
<br /> 6.TOTAL EARNED LESS RETAINAGE. . . . . ... . ... . . $ 388,286.85 CERTIFICATE FOR PAYM '"""•��`��'m��'�31,Z019
<br /> (Line 4 less Line 5 Total)
<br /> 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT In Accordance with the Contract Documents,based on on-site observations and the data comprising
<br /> 378,786.85 the above application, the Constroction Manager and Architect certifies to owner that to the best of
<br /> (Line 6 from prior Certificate).. . . . . .. . . .. . . . .. .. . .$ their knowledge,information and belief the Work has progressed as indicated,the quality of the work
<br /> 8.CURRENT PAYMENT DUE . . . . . . . .. . ... .. . .. . .$ 9,500.00 � is in accordance with the Contrad 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) $ 43,758.15 AMOUNT CERTIFIED. . .. . .... ... .. . ... . . . . . . . . . . . $ �%
<br /> (Attach explanation if amount certified differs from the amount applied. Initial all figures on this
<br /> CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS Application and on the Continuafion Sheet that are changed to confam to the amount cert�ed.)
<br /> Total changes approved in previous CONSTRUC A .
<br /> months by Owner or Contractor 1,624.00 0.00 gy. Date: � ��
<br /> ARC f 1 �
<br /> Total approved this Month 0.00 0.00 BY: Date: r
<br /> TOTALS 1,624.00 0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only o the Subcontractor
<br /> named herein. Issuance,Payment and acceptance of payment are without prejudice to any rights of
<br /> NET CHANGES by Change Order 1,624.00 the Owner,Contractor or Subcontrador under this Contract.
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