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AIA Document G702' - 1992 <br />Application and Certificate for Payment <br />PROJECT: <br />TO OWNER: <br />FROM <br />CONTRACTOR: <br />VIA <br />ARCHITECT: <br />APPLICATION NO: 001 <br />PERIOD TO: <br />CONTRACT FOR: . <br />CONTRACT DATE: <br />PROJECT NOS: / / <br />Distribution to: <br />OWNER: ❑ <br />„T^_ARC H I_TECT:._❑ <br />CONTRACTOR: ❑ <br />FIELD: 0 <br />OTHER: 0 <br />CONTRACTOR'S APPLICATION FOR PAYMENT <br />Application is made for payment, as shown below, in connection with the Contract. <br />Continuation Sheet, AIA Document G703, is attached. <br />1. ORIGINAL CONTRACT SUM $ <br />2. Net change by Change Orders $ <br />3. CONTRACT SUM TO DATE (Line 1 ± 2) $ <br />4. TOTAL COMPLETED & STORIED TO DATE (Column G on G703) $ <br />5. RETAINAGE: <br />a. 0 % of Completed Work <br />(Column D +Eon G703) $ <br />b. 0 % of Stored Material <br />(Column F on G703) $ 0.00 <br />Total Retainage (Lines 5a + 5b or Total in Column I of G703) $ <br />6. TOTAL EARNED LESS RETAINAGE $ <br />(Line 4 Less Line 5 Total) <br />7. LESS PREVIOUS CERTIFICATES FOR PAYMENT $ <br />(Line 6 from prior Certificate) <br />8. CURRENT PAYMENT DUE <br />9. BALANCE TO FINISH, INCLUDING RETAINAGE <br />(Line 3 less Line 6) <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />The undersigned Contractor certifies that to the best of the Contractor's knowledge, information <br />and belief the Work covered by this Application for Payment has been completed in accordance <br />with the Contract Documents, that all amounts have been paid by the Contractor for Work for <br />which previous Certificates for Payment were issued and payments received from`the-Owner; and <br />that current payment shown herein is now due. <br />CONTRACTOR: <br />By: <br />State of: <br />County of: <br />Subscribed and sworn to before <br />me this day of <br />Notary Public: <br />0.00 My Commission expires: <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />CHANGE ORDER SUMMARY <br />ADDITIONS <br />DEDUCTIONS <br />Total changes approved in previous months by Owner <br />$ <br />0.00 <br />$ 0.00 <br />Total approved this Month <br />$ <br />0.00 <br />$ 0.00 <br />TOTALS <br />$ <br />0.00 <br />$ 0.00 <br />NET CHANGES by Change Order <br />$ <br />0.00 <br />ARCHITECT'S CERTIFICATE FOR PAYMENT'` <br />In accordance with the Contract Documents, based on on-site observations and the data comprising <br />this application, the Architect certifies to the Owner that to the best of the Architect's knowledge, <br />information and belief the Work has progressed as indicated, ;theLquality_-of the—Work .-is ,in <br />accordance with the Contract Documents, and the Contractor is entitled to payment of the <br />AMOUNT CERTIFIED. <br />AMOUNT CERTIFIED $:0:00"✓ ��`"" -.- <br />(Attach explanation if amount certified differs from the amount applied Initis[ all gures-on this <br />Application and on the Continuation Sheet that are changed to conform"with the amount certified.) <br />ARCHITECT: <br />By: <br />Date: <br />This Certificate is not negotiable. The AMOUNT CERTIFIED isi payable only to the Contractor <br />named herein. Issuance, payment and acceptance of payment are withouf prejudice fo any`rights of <br />the Owner or Contractor under this Contract <br />AIA Document G702" — 1992. Copyright ® 1982 and 1992 by The American Institute of Architects. A11 rights reserved. WARNING: This AIA Document is protected by U.S. Copyright Law and <br />International Treaties. Unauthorized reproduction or distribution of this AIA` Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to <br />the maximum extent possible under the law. This draft was produced by AIA software at 10:53:20 on 03/02/2005 under Order No.10001424321 which expires on 10/20/2005, and is not for resale. <br />User Notes: — <br />(3711514675) <br />1 <br />