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PPI ICATION AND CERTIFICATE FOR PAYMENT AIA Document (G►acR): City Of St. Anthony PROJECT: ST. ANTHONY CONUITY CENTER APPLICATION NO: 4 DISTRIBUTION TO: 3301 Silver Lake Rd. OWNER St. Anthony, AN 55418 PERIOD TO: 4/30/96 REVISE ARCHITECT CONTRACTOR CM (CONT): GRADS CONSTRUCTION VIA (ARCHITECT): Williams/O'Brien Assoc. ARCHITECT'S P.O. BOX 34 PROJECT NO: _ HASTINGS, AN 55(M NTRACT FOR: General Construction CONTRACT DATE: 10/24/95 Application is made for Payment, as shown below, in connection 0NTRACT0R'S APPLICATION FOR PAYMENT with the contract. Continuation Sheet is attached. NAME I ORDER SUMMARY 1 1. ORIGINAL CONTRACT SUM ........................ t 3151900.00 1 2. Net Change by Change Orders .................. t .00 :hange Orders approved in I ADDITIONS I DEDUCTIONS 1 3. CONTRACT SUM TO DATE ..........................1 3151900.00 )revious months by owner I 1 1 4. TOTAL COMPLETED b STORED TO DATE ............a f 450273.00 TOTAL I I I (Column 6 ) ---- 1 5. RETAINAGE: approved this Month 1 I I a. 5.00 % of Completed Work 1 21538.65 -- 1 1 1 (Column D+E ) Vumber (Date Approved I I I b. 5.00 % of Stored Material i 975.00 I I I 1 (Column F) I I I 1 Total Retainage (Line 5a+5b) or - ------- — I (Total in Column I) ...................... f 22513.65 TOTALS 1 I 1 6. TOTAL EARNED LESS RETAINAG£ .................. i 427759.35 I (Line 4 less Line 5 Total) iet Change by Change Orders $ .00 17..LESS PREVIOUS CERTIFICATES FOR ------- I PAYMENT (Line 6 from prior Certificate) .. f 247380.00 ie undersigned Contractor certifies that to the best of the Con- 8. CURRENT PAYMENT DUE .......................... f 180379.35 ractor's knowledge, information, and belief the Work covered by 9. BALANCE TO FINISH, PLUS RETAINAGE .............f 2724140.65 nis Application for Payment has been completed in accordance with (Line 3 less Line 6) ie Contract Documents, that all amounts have been paid by the Con- ractor for Work for which previous Certificates for Payment were slued and payments received from the Owner, and that current pay- . ��•., J{a�t dUi. C'a��Pl ent shown herein is now due. s' MY COMMISSION EXPIRES �. JANUARY 31,2000 OF 0AAAAAAAAA to Who W to ONTRACTOR:GRAUS CONSTRIETI State of M in h a County of: � Subscribed and Sworn to before me this day of Mct ,19 0 C0 �y Notary Publicci/ —�.`e� y: Date:, :/ Z My Commission expires: i AMW CERTIFIED ............................... R C H I T E C T'S C E R T I F I C (/E F 0 R P A Y M E N T (Attach explanation if amount certified differs from the amount applied for.) n accordance with the Contract Documents, based an on-site observa- ARCHITECT: illiams/0' r n oc. tions and the data comprising the above application, the Architect / ertifies to the Owner that to the best of the Architect's know- By: Date: s.lam q ed, nformation, and belief the Work has progressed as indicated,rent ifica a is not negotiable. The AMOUNT CERTIFIED is he , .,ity of the Work is in accordance with the Contract Documentsnly to the Contractor named herein. Issuance, pay- nd the Contractor is entitled to payment of the AMOUNT CERTIFIED. acceptance of payment are without prejudice to any f the Owner or Contractor under this contract.