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�ro APPLICASN AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 page 1 of 2 pages TO: Owner CITY OF ST.ANTHONY PROJECT: Project Name ST. A. DEMO APPLICATION NO: 4 .Disbributionto: Address 1300 NICOLLET MALL, Address 33RD AVE & PERIOD TO 2-Oct-97 8 OWNER Address SUITE 219 Address SILVER LAKE RD PROJECT NO: CONSTRUCTION MPLS, MN 55403 CONTRACT NO: MANAGER FROM CONTRACTOR: DKH Excavating, Inc. CONTRACT DATE: B ARCHITECT 7700 Hwy. 101 CONTRACTOR Shakopee, MN 55379 VIA ARTICHECT: NAME WILLIAMS & O'BRIEN CONTRACT FOR: ATTN: NAME JAMES O'BRIEN CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge,informa- Application is made for payment,as show below,in connection with the Contract. tion and believe the Work covered by this Application for Payment has been completed in Continuation Sheet,AIA Document G703,is attached. accordance with the Contract Documents,that all a mounts have been paid by the 1 ORIGINAL CONTRACT SUM............... .... $ 166,850.00 Contractor for Work for which previous Certificates for Payment were issued and payments 2 Net Change By Change Orders................. .. $ 46,815.00 received from the Owner,and that current payment shown herein is now due. 3 CONTRACT SUM TO DATE(Line 1+2) ......... $ 213,665.00 CONTRACTOR- Date:TOTAL COMPLETED&STORED TO DATE.. .... $ 2- j_ 6' B Date: lo�% ? (Column G on G702) 20S94p,(D State of nnesota 5 RETAINAGE: County of Dakota A 5 % fCompleted Work $ tog4i-,00 Subscribed and sworn to before (Columns D+E on G703) B. %of Stored Material $ - me this ZN� day of LCD 19,!/ (Column F on G703) JACQUELINE M SMITH -Total Retainage(Line 5+5b or $ - Notary Public: INOTARY PUBLIC-MIKES= Total in Column I of G703) (��l3 pp M Commission it : Jt3 , AAMSEY COUNTY 6. TOTAL EARNED LESS RETAINAGE.. ........... $ -2- CGS�e ERTIFI ATE F ENT (Line 4 less Line S Total) In accordance with the Contract Documents,based on on-site observations and the data 7 LESS PREVIOUS CERTIFICATES FOR PAYMENT $ 173,985.51 comprising this applications,the Construction Manager and Architect certify to the Owner (Line 6 previous certifcates) '2_4 a-7.41 that to the best of their knowledge,information and belief the Work has progressed as 8 CURRENT PAYMENT DUE.................. ... 494_74-41a I indicated,the quality of the Work is in accordance with the Contract Documents,and the Contractor is entitled to payment of the AMOUNT CERTIFIED. nn 9 BALANCE TO FINISH,INCLUDING RETAINAGE $ (J, ?2 -Oa AMOUNT CERTIFIED.... . ... .. . .... ..... .. . . $ L��SO7. `7-1 (Line 3 less Line 6) -� (At tacit explanation of amount certified differs from the amount applied for. Initial all figures on this Application and on the Continuation Sheet that changed to conform to the am nt certified.) CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARC T' e? / 7 Total changes approved in $Y. Date: / D '�' l previous months by Owner $ - R: Total approved this Month $ - Date: Totals $ - is Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Con- NET Changes by Change Order $ - tractor named herein. Issuance,payment and acceptance of payment are without predjudice.to any rights of the Owner or Contractor under this Contract.