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APPLICATION AND CERTIFICATE FOR PAYMENT- Ain Document olu (OWNER)i City Of St. Anthony — PROJECTS S1. fg111.I1111Y CUNMUNITY CENTERr APPLICATION 110s.. 16 DISIRIBUTIVI 10: 3301 Silver Lake Rd. DNIfER St.. Anthony, MI( 55418 FERIUD 10:8-17-98 _ARCIIITECT _CUNIRneloR FRUN ICONT)s GRAUS CONSTRUCTION Vin (niun TECD: Williams/0111rien Assoc. ARDIIIECT'S 360 HIGITWAY 61 N. PROJECT NDs 9214 _ IMST1NGS, M)( 55033 CONTRACT FORS General Construction CONTRACT DA1Es 10124/95 Application is node for Payment, as shown below, in connection CONTRACTOR'S APPLICATION FOR PAYMEN'1 with the contract. . Continuation Sheet is attached. -----_---------------------—-------------------------- 1 101ANGE ORDER SUMMARY 1 1. ORIGIirt CONTRACT SUM ........................ ) 31519PP.00. ---- -- -------------------=-------------------------I 2. Net Change by Change Orders .................. t 109,308.00 (Change Orders approved In -1 ADDITIONS I DEDUCTIUNS 1 3. CONTRACT SUM 10 DATE ..........................1 3,261,208.00 (previous months by owner . 1 I 1 4. TOTAL COI(UTED I STORED 10 DATE ............. 1 3,261,208.00 TOTAL 1 109,308.00 1 1 (Column G ) I--- ,----------------------------------------=-1 5. RETAIthus (Approved this.Month I I i a. 5.@0 % of Completed Work. 1 .00 l___. I I (Column DIE ) (Number (Date Approved 1. I 1 b. 5.N9 % of Stored Material t .0D I I I I I (Column F) Total Retainage ILTne 5a+5b) or • ----=-------- ----------------------------------------I (Total In Column 1) ...................... 1 00 TOTALS I 1 1 6. TOTAL FARTED LESS RETAIIIAGE .................. 1 3,261,208.00 -- ------ ------------------=---------------I ILIne 4 less Line 5 Total) ----_------------- ---- ----=---------------I PAYMENT ILine 6 from prior Certificate)(Net Change by Change Orders f 109 308 00 1 7. LESS PREVIOUS CERTIFICATES FOR ------- irate) .. i 3228479 .(P . The undersigned Contractor certifies that to the best of the Con- 0. CURRENT Myli NI DUE .......................... I 32,729.00 tractor's knowledge, information, and belief the Work covered by 9. BALANCE TO F1N1SI1, PLUS RETAINAGE .............I .(hi this Application for Payment has been completed In accordance with (Line 3 less Line 61 the Contract Documents, that all amounts have been paid by the Con- tractor for Work for which previous Certificates for Payment were Issued and.payeents received from the Owner, and that current pay- • • rent shown herein is now due. ------------------------------ - •i41�N1.dOM�VS©(1�- N0TARYFUBUC-f TA MN CWft ExpWs Jan.M.2000 CUNTRACTORsGRAUS CONST ION State ofs Minnesota County ofsDakota _Subscribed and Sworn to before this 17 .day of Aug.,130 Notary Publics � t�, ossrti Dys Dater 8/17/98 My Commission expires 1-1-31— 00 -- _---------—---------------------------- --- -----—-----7------ A1MCERTIFIED ............................... 1 2j'�s72�'(,caD A R C H.1 T E C T'S C E R T I F C A T E F O R -P A Y M E N T (Attach explanation if amount certified differs from the amount applied for.) In accordance with the Contract Documents, based an on-site observa- AWIITECT- Iliams/0' ' fen Ass c. ations and the data comprising the above application', the Architect �rtifies to the Owner that to the best of the Architect's know Dyr Dates_ �- le, information, and belief the Work has progressed as Indicated, 1 s ertificate is not nego (able. iTre A1fiUNT CERTIFIED tre quality of the Work is in accordance with the Contract Documents, ay le only to the Contractor named herein. Issuance, pay- and the Contractor is entitled to payment of the AMOUNT CERTIFIED. ■ t and acceptance of payment are without prejudice to any ghts of the Owner or Contractor under. this contract.