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i APPLICATION AND CERTIFICATE FOR PAYMENT AIA Document TO (OWNER): City Of St. Anthony PROJECT: ST. ANTHONY COMMUNITY CENTER APPLICATION NO: 2 DISTRIBUTION TO: 3301 Silver Lake Rd. _OWNER St. Anthony, MN 55418 PERIOD TO: 0/29/96 ARCHITECT _CONTRACTOR FROM (COM): GRAUS CONSTRUCTION VIA (ARCHITECT): Williams/O'Brien Assoc. ARCHITECT'S P.D. BOX 34 PROJECT NO: _ HASTINGS, MN 550333 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 ICHANGE ORDER SUMMARY 11. ORIGINAL CONTRACT SUM ........................ S 3151900.00 1-----------------------------------------------------------------1 2. Net Change by Change Orders .................. t .00 (Change Orders approved in I ADDITIONS 1 DEDUCTIONS 1 3. CONTRACT SUM TO DATE ..........................6 3151902.00 (previous months by owner I 1 1 4. TOTAL COMPLETED & STORED TO DATE ............. 5 101200.00 I TOTAL I I I (Column G ) I-----------------------------------------------------------------1 5. RETAINAGE: )Approved this Month I I I a. 5.00 % of Completed Work { 3010.00 1-----------------------------I I I (Column D+E ) (Number (Date Approved 1 I I b. 5.00 % of Stored Material i 2050.00 I I 1 I I (Column F) I I I i I Total Retainage (Line 5a+5b) or I-----------------------------------------------------------------I (Total in Column I) ...................... f 5060.00 I TOTALS I 1 1 6. TOTAL EARNED LESS RETAINAGE .................. f 96140.00 1------------------------------------------------------I (Line 4 less Line 5 Total) )Net Change by Change Orders 4 .00 1 7. LESS PREVIOUS CERTIFICATES FOR I-----------------------------------------------------------------I PAYMENT (Line 6 from prior Certificate) .. E 57190.02 The undersigned Contractor certifies that to the best of the Con- 8. CURRENT PAYMENT DUE .......................... i 38950,00 tractor's knowledge, information, and belief the Work covered by 9. BALANCE TO FINISH, PLUS RETAINAGE .............f 3055760.00 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 f•ron the Owner, and that current pay- ---- -------------- •TM+ ment shown herein is now due. NOTARY PUBLIC•MINNESOTA MY COMMISSION EXPIRES •%•••� JANUARY 31,2000 CONTRACTOR:GP.AUS CONS RUC ON State of:Ml�n (,L Coupty of:��X Subscribed and Sw rn to before this day of A[h,l ?J ! Notary Public�G3U i\A_ By: -D ate: My expires:ires: ---------------- ---- ---------- --------------------------------------------- 13�� o AMOUNT CERTIFIED ............................... €Ag , oa A R C H I T E C T'S C E R T I F I A T E F O R P A Y M E N T (Attach explanation if amount certified differs from the amount ap lied for.) In accordance with the Contract Documents, based on on-site observa- ARCHITE illiam /O' ri A soc. ations and the data comprising the above application, the Architect certifies to the Owner that to the best of the Architect's know- By: Date: ledge, information, and belief the Work has progressed as indicated, is Certificate is not negotiable, The AMOUNT CERTIFIED is the quality of the Work is in accordance with the Contract Documents, ayable only to the Contractor named herein. Issuance, pay- and the Contractor is entitled to payment of the AMOUNT CERTIFIED. V sent and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this contract.