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APPLICATION AND CERTIFICATE FOR PAYMENT <br /> r <br /> t:i1RT; CTTY (iF SATNT ANTHf1NV IN 7436 ENZIR TRRAA�R A?PIICA"ION N0; 1 Page; 1 <br /> 3301 SILVER LAKE ROAD PERIOD ENDING : 06/30/97 <br /> INVOICE NUMBER: 20610 <br /> SAINT ANTHONY, MN 55418 ST. ANTHONY, MINNESOTA <br /> FROM: BELAIR EXCAVATING ARCHITECT: CONTRACT NO: <br /> 2200 OLD HWY 8 CONTRACT DATE: <br /> NEW BRIGHTON, MN 55112 JOB R: 6310 <br /> JOB TESCRIPTION: <br /> ------------------------------------------------------- <br /> CHANGE ORDERS <br /> -----------------------------------------------------� <br /> ADDITIONS DEDUCTIONS 1. ORIGINAL CONTRACT AMOUNT.......................... $ 8,794.00 <br /> 2. Net Change by Change Orders....................... $ .00 <br /> PREVIOUS.TOTAL .00 .00 3. CONTRACT SUM TO DATE (Line 1 +/- 2(............... $ 8,794.00 <br /> -----------------------------------------------------� <br /> -----CURRENT----- 4. TOTAL COMPLETED & STORED TO DATE.................. $ 8,194.00 <br /> ----------------------- 5. RETAINAGE .00% OF WORK COMPLETED................ $ .00 <br /> Number Date .001 OF STORED MATERIAL <br /> ----------------------- 6. TOTAL EARNED LESS RETAINAGE ...................... $ 8,794.00 <br /> 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT............ $ .00 <br /> S. CURRENT PAYMENT DUE............................... $ 8,794.00 <br /> 9. BALANCE TO FINISH, INCLUDING RETAINAGE............ $ .00 <br /> -----------------------------------------------------� <br /> I. TOTALS TO DATE . 1 .00 1 .00 <br /> -----------------------------------------------------� <br /> NET AMOUNT 1 .00 � <br /> ----------------------------------------------------------------------------------------------------------------------------------- <br /> The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and belief the Work covered by <br /> this Application for Payment has been completed in accordance with the Contract Documents, that all amounts have been paid by the <br /> Contractor for Work for which previous Certificates for Payment were issued annd payments received from the Owner, and that current <br /> payment shown herein is now due. <br /> CONTRACTOR: BELAIR EXCAVATING <br /> By: '1.44 Date: <br /> State of: KiniesoM Controller - <br /> County of: Ramsey <br /> Subscribed and sworn to before /fins, STACY A. SJAAHEIM <br /> me this M' day of �'77 7 - •� NOTARY PUBLIC MtNNESOiA <br /> t '..` RAMSEY COUNTY <br /> Notary Public: "► ` '`' MY Commission Expires Jan.31,2000' <br /> My Commission expires: <br /> o�?/ <br /> / <br /> ARCHITECT'S CERTIFICATE OR PAYMENT <br /> In accordance with the Contract Documents, Based an on-site observations and the data comprising this application, the Architect <br /> certifies to the Owner that to the best of the Architect's knowledge, Information and and belief the Nark has progressed as <br /> indicated, the quality of the Work is in accordance with the Contract Documents, and the Contractor Is entitled to payment of the <br /> AMOUNT CERTIFIED. <br /> AMOUNT CERTIFIED BY: AMOUNT: DATE: <br />