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APPLICATI N 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: 5 Disbribution to: Address 1300 NICOLLET MALL, Address 33RD AVE & PERIOD TO 2-Oct-97 R OWNER Address SUITE 219 Address SILVER LAKE RD PROJECT NO: CONSTRUCTION MPLS, MN 55403 CONTRACT NO: MANAGER FROM CONTRACTOR: DKH Excavating, Inc. CONTRACT DATE: X ARCHITECT .7700 Hwy. 101 8 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 4 TOTAL COMPLETED&STORED TO DATE...... $ 213,665.00 By: -� " �L/- Date: g 7 (Column G on G702) State of nnesota 5 RETAINAGE: County of: Dakota A. 5 %of Com letec Work $ - Subscribed and sworn to before ,,,,,; J TARP P UNE M SMITH P NOTARY PUBUC-WINtIESOTA `mot;. ,' (Columns D+Eon G703) RAMSEY COUNTY pp�� p r� tJ.Y COMM.DT.01131120M B. %of Stored Material $ - me this 13 day of 4Q(� I&X4 9 9 (Column F on G703) Total Retainago(Line Sa+Sb or $ - Notary Public. Total in Column I of G703) MY Commission ires: an.31,2000 6. TOTAL EARNED LESS RETAINAGE............. $ 213;665.00 CERTIFI ATE FOR PAYMENT (Line 4 less Line S Total) e� Cf 3.� In accordance with the Contract Documents,based on on-site observations and the data 7 LESS PREVIOUS CERTIFICATES FOR PAYMENT $ '°"-, 1= comprising this applications,the Construction Manager and Architect certify to the Owner (Line 6 previous certificates) I S ►'t A.5 0{ that to the best of their knowledge,information and belief the Work has progressed as 8 CURRENT PAYMENT DUE..................... 46; 2 6'g indicated,the quality of the Work is in accordance with the Contract Documents,and the Contractor is entitled to payment of the AMOUNT CERTIFIED. 9 BALANCE TO FINISH,INCLUDING RETAINAGE $ O -CO. AMOUNT CERTIFIED......... . ....... . .... .. $ ( J I//c / ?2,UO (Line 3 less Line 6) (Attach explanation of amount certified differs from the amount applied for. Initial all figures on this Application and on the Continuation Sheet that changed to confonn to the am int certified.) CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARC Total changes approved in By: Date: ZLIL 17 previous months by Owner $ - O R: Total approved this Month $ - Date: Totals $ - his 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.