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i APPLATION AND CERTIFICATE FOR PAYMER IA DOCUMENT/4 SCUM G702 PAGE ONE OF PAGES TO (Owner):City of St . Anthony PROJECT: 871015 APPLICATION NO: 2 Distribution to: 3301 Silver Lake Road Signalized Pedestrian ❑ OWNER St . Anthony, MN 55418 Crossing PERIOD FROM:6-1-88 ❑ ARCHITECT TO:8-1-8 8 ❑ CONTRACTOR ATTENTION: CONTRACT FOR: ARCHITECT'S ❑ Lynnette Roshell PROJECT NO: 871015 CONTRACT DATE: 12-29-87 CONTRACTOR'S APPLICATION FOR PAYMENT Application is made for Payment, as shown below, in connection with the Contract. Continuation Sheet,AIA Document G703, is attached. CHANGE ORDER SUMMARY The present status of the account for this Contract is as follows: Change Orders approved ADDITIONS DEDUCTIONS ORIGINAL CONTRACT SUM . . ... .. . . .. ... ........,$ 67 , 567 .00 in previous months by Owner -TOTAL Net change by Change Orders . . . . . . . . ..... ....... .$ 650. 00 Approved this Month 6$ 217 .00 CONTRACT SUM TO DATE . .... .. .. .. .. .. .. .......$ ' Number Date Approved TOTAL COMPLETED & STORED TO DATE .. .........$ 68, 217 . 00 (Column G on G703) RETAINAGE % . . .. ... . .. . . . . .. ........$ -0 or total in Column i on G703 68 217 00 TOTALS TOTAL EARNED LESS RETAINAGE .. .. ...... ... .. ...$ ' Net change by Change Orders The undersigned Contractor certifies that to the best of his knowledge, LESS PREVIOUS CERTIFICATES FOR PAYMENT .......$ 67 , 717 . 00 information and belief the Work covered by this Application for Payment has been completed in accordance with the Contract Docu- ments, that all amounts have been paid by him for Work for which 500. 00 previous Certificates for Payment were issued and payments received CURRENT PAYMENT DUE $ .. ..... ...... ....... ..... from the Owner, and that current payment shown herein is now due. CONT TOR: State of: Min sota ounty of: Hen in' . Subscribed and swo b re t day of®�� 19�� October 3 , 1988 Notary Public: By: Date: My Commission 9/89 ARCH ECT'S CERTIFICATE FOR PAYMENT AMOUNT CERTIFIED . . . . . . . .. . . .. . . . . . . . . . . . . .. . .$ (Attach explanation if amount certified differs from the amount applied for.) In accordance with the Contract Documents, based on on-site obser- ARCHITECT: vations and the data comprising the above application, the Architect certifies to the Owner that the Work has progressed to the point - _ indicated; that to the best of his knowledge, information and belief, By -� Date: the quality of the Work is in accordance with the Contract Docu- This .Ce ificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor ments; and that the Contractor is entitled to payment of the AMOUNT CERTIFIED. named h erein. Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Coritract. AIA DOCUMENT G702 • APPLICATION AND CERTIFICATE FOR PAYMENT• APRIL 1978 EDITION AIA®• ©1978 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVENUE, N.W., WASHINGTON, D.C. 20006 G702-1978