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AIA Document G702TM -1992 <br />Application and Certificate for Payment <br />TO OWNER: <br />PROJECT: <br />APPLICATION NO: <br />Distribution to: <br />City of Hugo <br />Beaver Ponds Park Stormwater R <br />PERIOD TO: <br />3 OWNER ❑ <br />14669 Fitzgerald Ave. N. <br />12786 Fondant Trail <br />CONTRACT FOR: <br />10/31/2016 <br />ARCHITECT ❑ <br />FROMgg <br />COorITRACTOR 8 <br />1�NS <br />VIA AREAITECT: 5038 8488 <br />7. LESS PREVIOUS CERTIFICATES FOR PAYMENT ...................... <br />Beaver Ponds Park Stormwater R <br />(Line 6Jrom prior Certificate) <br />ror <br />CONTRACT DATE: <br />CONTRACTOR ❑ <br />Peterson Companies, Inc. PROJECT NOS: FIELD ❑ <br />8326 Wyoming Trail 16066F <br />Chisaoo City, MN 55013 INVOICE NO: 3 RR9 OTHER ❑ <br />CONTRACTOR'S APPLICATION FOR PAYMENT 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. and belief the Workcovered by this Application for Payment has been completed in accordance <br />AIA Document G703Tr", Continuation Sheet, is attached. with the Contract Documents, that all amounts have been paid by the Contractor for Work for <br />which previous Certi icates for Payment were issued and payments received from the Owner, and <br />1. ORIGINAL CONTRACT SUM ................................................. $ that current pa shown herein is now due. <br />2. NET CHANGE BY CHANGE ORDERS .............................. $�7}in CONTRA <br />3. CONTRACT SUM TO DATE (Line 1 t2) -000 y. etelson Companies, Inc. Date: 10 <br />4. TOTAL COMPLETED & STORED TO DATE (Column G on G703) ...... $�8 State <br />5. RETAINAGE: <br />�r,r,It VHARri <br />a. 5% of Completed Work <br />(Columns D + E on G703) $-�-c�e-n <br />b. 8% of Stored Material <br />u,625.QD <br />(Column F on G703) $0.10 <br />Total Retainage (Lines 5a + 56, or Total in Column I of G703)...... <br />$8-635--0@ <br />6. TOTAL EARNED LESS RETAINAGE .................................... <br />r <br />$� <br />(Line 4 minus Line 5 Total) <br />7. LESS PREVIOUS CERTIFICATES FOR PAYMENT ...................... <br />$ , �� .,,,, �, <br />—yrs, <br />(Line 6Jrom prior Certificate) <br />ror <br />6. CURRENT PAYMENT DUE ............................................. <br />$ <br />9. BALANCE TO FINISH, INCLUDING RETAINAGE <br />(Line 3 minus Line 6)8,625.00 <br />r <br />RANGE ORDER SUMMARY ADDITIONS DEDUCTIONS <br />Total changes approved in previous months by Owner $ $ <br />DOD O-rin <br />Total approved this month $ $ <br />TOTAL $ $ <br />T CHANGES by Change Order $ <br />00 <br />CAUTION: You should sian an oriainal AIA Contract Document. an which this text aooears in <br />County of: MItN, <br />Subscribed�n <br />ang(�l1�WQRo before <br />me this ;kCrday <br />Notary Publi�+ <br />My commission expues: t I3f f (Q <br />L.A1J RIE R L' <br />t;ommission Expires <br />January 31, 2019 <br />ARCHITECT'S CERTIFICATEfOR PAYMENT <br />In accordance with the Contract Docuhrues, based 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 />AMOUNT CERTIFIED............................................................................. $ <br />(Attach explanation if amount 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 />RED. An original assures that changes will not be obscured. <br />AIA Document G792T° -1992. Copyright © 1953, 1963. 1965, 1971. 1978, 1983 and 1992 by The American Institute of Architects. All rights reserved. WARNING: This Al a Document Is protected by U.S. Copyright Law <br />pnd International Treaties. Unauthorized reproduction or distribution of this Ale Document, 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. o;maacaa <br />