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l,7 <br />AIADocument G702rM 1992 <br />Application and Certificate for Payment <br />TO OWNER: PROJECT: APPLICATION NO: Distribution to: <br />City of Hugo 2 <br />Beaver Ponds Park Stormwater <br />14669 Fitzgerald Ave. N. 12786 Fondant Trail <br />R PERIOD TO: <br />9/30/2016 OWNER ❑ <br />Hugo, MN 55038 Hugo, MN 55038-8488 <br />FROM CONTRACTOR: <br />CONTRACT FOR: Beaver Ponds Park Stormwater R ARCHITECT ❑ <br />VIA ARCHITECT: <br />Peterson Companies, Inc. <br />CONTRACT DATE; CONTRACTOR ❑ <br />8326 Wyoming Trail <br />PROJECT NOS: 16066E FIELD ❑ <br />Chisago City, MN 55013 <br />INVOICE NO: 32565 OTHER ❑ <br />CONTRACTOR'S APPLICATION FOR PAYMENT <br />The undersigned Contractor certifies that to the best of the Contractor's knowledge, information <br />Application is made for payment, as shown below, in connection with the Contract, <br />and belief the Work covered by this Application for Payment has been completed in accordance <br />AI.A Document G703TM, Continuation Sheet, is attached <br />with the Contract Documents, that all amounts have been paid by the Contractor for Work for <br />1. ORIGINAL CONTRACT SUM $ <br />which previous Certi ates for Payment were issued and payments received from the Owner, and <br />................. _... ............ _........ 1 u im nn <br />that current pay shown herein is now due. <br />2. NET CHANGE BY CHANGE ORDERS ................ $ n nn <br />""' <br />CONTRAC <br />3. CONTRACT SUM TO DATE (Line 1 t 2) .................................... $_ � 7p SUS n0 <br />Peterson Companies, Inc. <br />By Date: <br />4. TOTAL COMPLETED & STORED TO DATE (Column C on G703) _. _. $ 1 A4 dS4 7n <br />State . <br />5. RETAINAGE:—�`-""'—"-" <br />C MN <br />a. 51. of Completed Work <br />(Columns D + E on G703) <br />b. 0'/o of Stored Material <br />(Column F on G703) <br />$o9Q <br />r <br />$_ —O -n0 <br />Total Retainage (Lines 5a + 5b, or Total in Column I of G703)...... $ 8222 Rq <br />r <br />6. TOTAL EARNED LESS RETAINAGE ...... _ .................._ ........ $ 11 01 <br />(Line 4 minus Line 5 Total) <br />7. LESS PREVIOUS CERTIFICATES FOR PAYMENT ............. ......... $ 125 A5507 <br />(Line 6 from prior Certificate) <br />8. CURRENT PAYMENT DUE ....._.................................. $ <br />9. BALANCE TO FINISH, INCLUDING RETAINAGE <br />(Line 3 minus Lute 6) $ 16,268 99 <br />SUMMARY <br />ADDITIONS DEDUCTIONS <br />approved in previous months by Owner <br />$ 0.00 $ 0.00 <br />FRDER <br />d this rnonth <br />$ $ <br />TOTAL <br />$o.fln $ omGES <br />by Change Order <br />$ 0.00 <br />entry of Chisago <br />Subscribed a d sworn to before <br />me this 2 $1' <br />Notary Public: L4U" <br />My commission expires: I <br />rp I 4�ARYPUB NOTrUiYUBL1C-MINNESOTA <br />•-q;�. Nv Commission Expires <br />Jenudry31 2019 <br />ARCHITECT'S CERTIFICA E FOR PAYMENT <br />In accordance with the Contract Docume ba on on-site observations and the data comprising <br />this application, the Architect certifies to the Owner that to the best of the Architect's knowledge, <br />information and belief the Work has progressed as indicated, the quality of the Work is in <br />accordance with the Contract Documents, and the Contractor is entitled to payment of the <br />AMOUNT CERTIFIED. <br />AMOUNTCERTIFIED_.............__.._............,...._.._.._.....,....._.............. $ <br />(Attach explanation rfamount certified differs from the amount applied Initial all figures on this <br />Application and on the Continuation Sheet that are changed to conform with the amount certified.) <br />ARCHITECT: <br />By <br />Date: <br />This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor <br />named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of <br />the Owner or Contractor under this Contract. <br />CAUTION: You should sign an original AIA Contract Document, on which this text appears in RED. An original assures that changes will not be obscured <br />AIA Document G702"- - 1992. Copyright © 1953, 1963, 1965, 1971, 1978, 1983 and 1992 by The American Institute of Architects. All rights reserved. WARNING: This AIA' Document is protected by U.S. Copyright Law <br />and international Treaties. Unauthorized reproduction or distribution of this AIADocument, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent <br />possible under the law. Purchasers are permitted to reproduce ten (10) copies of this document when completed. To report copyright violations of AIA Contract Documents, e-mail The American Institute of Architects' legal <br />counsel, copyright@aia.org. <br />mm,+<coaa <br />