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;1 � RPpL N AND CERTIFICATE FOR PRYMENT AIADorument —_----- — TO (OWNER))—: City Of St. Anthony —PROJECT: ST. ANTHONY COMMUNITY CENTER APPLICATION NO: 1 DISTRIBUTION TO: 3301 Silver Lake Rd. OWNER 5t. Anthony, MN 55418 PERIOD TO: 11/30/95 ARCHITECT CONTRACTOR FROM (CONT): GRAUS CONSTRUCTION VIA (ARCHITECT): Williams/O'Brien Assoc. ARCHITECT'S P.O. BOX 34 PROJECT NO: _ HASTINGS, MN 55033 CONTRACT FOR: General Construction CONTRACT DATE: 10/24/95 -- --------------------------- ----- -- Application is made for Payment, as shown below, in connection CONTRACTOR'S APPLICATION FOR PAYMENT with the contract. Continuation Sheet is attached. I----------------------------------------------------------------I )CHANGE ORDER SUMMARY 1 1. ORIGINAL CONTRACT SUM ........................ f 3151920.@0 I--------------------------------------------------------------1 2. Net Change by Change Orders .................. f .00 t )Change Orders approved in I ADDITIONS 1 DEDUCTIONS 1 3. CONTRACT SUM TO DATE ..........................1i 3151900.00 = ; )previous months by owner I 1 1 4. TOTAL COMPLETED b STORED TO DATE ............. f 60200.00 I TOTFt I I I (Column 6 ) I-------------------------------------------------------------1 5. RETAINAGE: )Approved this Month I 1 I a. 5.00 x of Completed Work f 2895.00 I--------------------------I I I (Column D+E ) )Number (Date Approved I I I b. 5.00 % of Stored Material f 115.00 I I I I I (Column F) I I I I I Total Retainage (Line 5a+5b) or I----------------------------------------------------------------I (Total in Column I) ...................... S 3210.00 I TOTALS I I 1 6. TOTAL EARNED LESS RETAINAGE .................. t 57190.00 ----------------------------- ____________—_____________---_I (Line 4 less Line 5 Total) Change by Change Orders { .00 _1 7. LESS PREVIOUS CERTIFICATES FOR ----------------------------------------------------------- I PAYMENT (Line 6 from prior Certificate) .. The undersigned Contractor certifies that to the best of the Con- 8. CURRENT PAYMENT DUE .......................... I 57190.0 tractor's knowledge, infuriation, and belief the Work covered by 9. BALANCE TO FINISH, PLUS RETRINASE .............I 3094710.00 this Application for Payment has been completed in accordance with (Line 3 less Line 6) the Contract Documents, that all amounts have been paid by the Con- . .;:' tractor for Work for which previous Certificates for Payment were issued and payments received from the Owner, and that current pay- {act A. COW — ---------- _�107/1CJiJmUC.�AINNiiO4A :c tent shown herein is now due. ----------- ' ' MY COMMISSION EXPIRES JANUARY 31,2000 CONTRACTOR. CONST ACTION State of:Nlih1'11SD County of: Subscribed and Sworn to before me this 1bt'day of[)eG. ,19QS /Notary Publica0.�.—YV�.• • Date: My Commission expires: -31 -a OOo ' By- ------------ ----- ------------------------ ------------------------------------ AMOUNT CERTIFIED ........•• f S : O c A R C H I T E C T'S C E R T I F I C A T E F O R P A Y M E N T (Attach explanation lif,amount.certified differs from the amount applied for.) . i In accordance with the Contract Documents, based on on-site observa- ARCHITECT Williams/D' ri n s ations and the data comprising the above application, the Architect p�5 i certifies to the Owner that to the best of the Architect's know- By Date: a I ' ledge, information, and belief the Work has progressed as indicated, h' Certificate is not negotiable. The AMOUNT CERTIFIED is the quality of the Work is in accordance with the Contract Documents, p yable only to the Contractor named herein. Issuance, pay- the Contractor is entitled to payment of the AMOUNT CERTIFIED. ent and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this contract.