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;., i. r :1i :r:: ; ~ . :1 ~ ;: 'AIA~~b~~l~t G702M -1992 .. "'. :!C., I Application and Cetti.@,:: . '. I If.ment TO OWNER: City Of~~, "iilY;,' ,!~' ",;' PROJECT: 101 Fa ~f!...t! . i55033~1~5 ~ ;:j , \.:l I Ebertic~ctimi : , ' 233S~:Co~ Ro~ to Loretib, MN!i SS3S? ' iL ; ~~~ ~.~ i ". '.. II', , "1 CONTRACTOR'S APPLlCArlONFOR PAYMENT Application is made for payment;iai, sb~ ~iow. in~nDection with the Contract. Continuation Sheet, AlA Docum# G7Q3. is~~ed.: I 1. ORIGINAL CONTRACT SUM ....1. i'. j. ....:.... .H';c.' f........ .........,.... $ 198.300.00 2. Net change by Change Orde~~.i"+.'.'''i'''''v~.tH~..j,..................... $ , 0.00 3.CONTRACTSUMTODATE(Line~ :t:2~.~(: . . In.,...!...................... $ 19A ~oo 00 4. TOTAL COMPLETED & STORED '" IJ~~ ..1~4o~0703) ............. $ 4'44000 5.RETAlNAOE' :t,~t' :: Ii! i i . I . :;: ;!!! 1 i . a. 10.00& ofC . ." i 1; :i! i i i ....... . ,.... . I b. (column..9-;t'..:L ~al : i.' ;! I' [1 '\.VJ.igU i, r. ..; ;, ( . .' on 0703) . i ! I,: i; ,~ ; l"; 'j.; i~ Total Retainage (Lines Sa + Sb or t.<t~ in GolJrnt 1 of 0703).. .. ... $ ~ ~ ; :j}. : : ! 6. TOTAL EARNED LESS RETAlNAGE .1~~......t.L...~..... ............ $ (Line 4 Less Line 5 Total) 1 : i :1 I :1 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT!.... .:................. $ (Line 6 from prior Certifi~te) ;:t: Ii 8. CURRENT PAYMENT DUE .....L....; .;~..... LL..j.... ,....... .... I $ 9. ~CE TO F1N1~H, INCLUDl~G RET'~O: : :~! i:~ (Line 3 less Line 6) i . U~.t'~.~ i $ 194,304.00 I . . ~l:=:ff'; '~l);~ :~: ! ~: :~~~t;~~:. VI-12 ~~ HastinRS Salt Sand St0ra2c 122S Progress Drive Hastings, MN 55033 DistrIbu~on tQ: OWNER 0 j' AlA Document G'f02'III-1812. Copytl t! Oh963; 19613. t!$!!, ~7', 1978,1983 and 1992 by The AmerIcan In8tltute of Archltect8. All rlghts....-d. WARNING: This AlA' Dooument I. proteCted by U,S. Copyright Law .nd International Treatle.. UnauthOrl~lkhesirodlict1On: ct dIStr~utIon ofthle AlAI Document. or any portion of It, may result In HYfIfe clvlland criminal pen.It.....nd will be prosecuted to the mllllmum extent pouIble under' the law. Purchas818 arcl:pe~ t!) reo~ ter (10) copies of this document when comple\lld. To report copyright violations of AlA Contract Documents, e-mail The American Institute of Archltects' legal coull8el, copyrlghtOala.org.; ~ j . . VIA ARCHITECT: """~ $ 444.00 $ 444.00 3.996.00 3,996.001 DEDUCTIONS $ $ $ NETC 0.00 APPLlCA nON NO' PERIOD TO: CO ARCHITECT ~ CONTRACTOR 0 FIELD 0 OTHER 0 The undersigned Contractor certifies that to the best of the Contractor's knowledge, infonnation and belief the Work covered by this Application for Payment has been completed in accordance with the Contract Documents, that all amounts have been paid by the Contractor for Work for which previous Certificates for Payment were issued and payments received from the Owner, and that c t t sh erein is now due. CO RAC By: State of- County Subscribed and s me this 2lP 6357 I I D~:~ STACV JOV BURSCH NotClfY PUbliC state of IIAlnnesotd My Comml"lon Expires January S " 2009 ,., ARCHITECT'S CERTIFICAT In accordance with the Contract Documents, based on on-site observatiolll! and the data comprising this application, the Architect certifies to the Owner that to the best of the Architect's knowledge information and belief the Work has progressed as indicated. the quality of the Work is i~ accordance with the Contract Documents, and the Contractor is entitled to payment of the AMOUNT CERTIFIED. ............. $ ~~.OO t applied. Initial aU figures on this ged to coriform with the amount certified..) "j, · 0- f8frh 'Ie. The AMOUNT CERTIFIED is payable only , the Contractor yment and acceptance of payment are without prejudice to any rights of r under this Contract