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APPLICATION AND CERTIFICATE FOR PAYMENT AIA Document TO (OWNER): City Of St. Anthony PROJECT: ST. ANTHONY COMMUNITY CENTER APPLICATION NO: 13 DISTRIBUTION TO: 3301 Silver Lake Rd. OWNER St. Anthony, M 55418 PERIOD TO: 12/31/96 ARCHITECT _CONTRACTOR FROM (CONT): GRAUS CONSTRUCTION VIA (ARCHITECT): Williams/O'Brien Assoc. ARCHITECT'S 360 HIGHWAY 61 N. PROJECT NO: _ HASTINGS, MN 55033 CONTRACT FOR: General Construction CONTRACT DATE: 10/24/95 — ------ -------------------- ---------------- ----------------------- Application is made for Payment, as shown below, in connection C0NTRA.CT0R'S APPLICATION FOR PAYMENT with the contract. Continuation Sheet is attached. --------------------------------------=------------------I ICHANGE ORDER SUMMARY 1 1. ORIGINAL CONTRACT SUM ........................ f 315190'3.00 1---------------------------------------------------1 2. Net Change by Change Orders .................. $ 119114.00 !Change Orders approved in 1 ADDITIONS I DEDUCTIONS 1 3. CONTRACT SUM TO DATE ..........................$ 3271@14.00 (previous months by owner . ! 1 1 4. TOTAL COMPLETED a STORED TO DATE............. f 3218239.00 I TOTAL 1 119114.00 1 1 (Column G l I------------------------------------------------------------1 5. RETAINAGE: !Approved this Month I I 1 a. 5.00 % of Completed Work $160,911.95 I---------------------I I I 1 Col uan D+E ) INuaber (Date Approved I I I b. 5.00 % of Stored Material $ .04� I I I I I (Column F) I I I 1 I Total Retainage (Line 5a+5b) or I----------------------------------------------------I (Total in Column I) ...................... $160,911.95 1 TOTALS I I 1 6. TOTAL EARNED LESS RETAINAGE ................... $3,057,327.05 1-------------------------------------------------------1 (Line 4 less Line 5 Total) INet Change by Change Orders $ 119114.00 1 7. LESS PREVIOUS CERTIFICATES FOR I-------------------------------------------------------I PAYMENT (Line 6 from prior Certificate) .. 1 2734498.05 The undersigned Contractor certifies that to the best of the Con- B. CURRENT PAYMENT DUE .......................... $ 322,829.00 tractor's knowledge, information, and belief the Work covered by 9. BALANCE TO FINISH, PLUS RETAINAGE .............1 213,686.95 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 PAMELA M.SCHMITT issued and payments received from the Owner, and that current pay- 4 . NOAK�C-MINNESOTA Ant, -- ------------------- sent shown herein is now due. -- - .. - � WIJUNTY------ 6pkes Jan.31,2000 CONTRACT"CONSTRUCTI State af: � � A b Cocunty of: DMK04-46 Subscribed a orn to before me this,P day of 3kev ,19c4ly Notary Public: 16--o,By: Date. Y My Commission expires_ ti 31, x000 -- AMOUNT CERTIFIED ............................... 1 3Zy$ZY•cp 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 if amount certified differs from the amount applied for.) . In accordance with the Contract Documents, based on on-site observa- ARCHITECT: illiass/O'Brien Assoc ations and the data comprising the above application, the Architect certifies to the Owner that to the best of the Architect's know- By: ✓l/�+ Date:�Z ledge, information, and belief the Work has progressed as indicated, Thi rtificate is not negotiable. The AMOUNT CERTIFIED is the quality of the Work is in accordance with the Contract Documents, p le only to the Contractor named herein. Issuance, pay- and the Contractor is entitled to payment of the AMOUNT CERTIFIED. 9 and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this contract.