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APPLICATION AND CERTIFICATION FOR PAYMENT, Construction Manager as Adviser Edition <br />TOOWNER: PROJECT. ELK RIVER ICE ARENA& PARKtACILITIES A11111 It kHONNO* I <br />R3M CONSTRUCTION LLC ELK RIVER MN <br />930 BOON'E AVE NORTH PERIOD TO: <br />GOLDEN VALLEY MN 55427 <br />CONTRACT FOR: <br />FROM CONTRACTOR- CONTRACT DATE: <br />WELLS CONCRETE VIA CONSTRUCTION <br />PO BOX 656 MANAGER: PROJECT NOS- <br />ALTIANY. MN 56307 VIA ARCHITECT: <br />t uulreru Cur Hid PIICIuty;C:' <br />CONTRACTOR'S APPLICATION FOR PAYMENT <br />Appiiestiosi is made for payment, as shown Wow. in connection vti i:,. ; :. ; :,tract. <br />Continuation Sheet, AIA Document 6703, is attached. <br />I. ORIGINAL CONTRACT SLIM <br />z. NET CHANGE 8V CHANGE ORDERS <br />3. CONTRACT SUM TO DATE (Line 1 i 7) <br />a- TOTAL COMPLETED & STORED TO DATE (Column G on G703) <br />5, RETAINAGE: <br />a. 5% %ofCompleied Work <br />(Coliorin D I E on G703) <br />b. 0% % of Stored Mine7rial <br />(Colttmn F on G703) <br />Total Reminage (Lines 5a + % or Total in Column I ol`Ci703) <br />k TOTAL EARNED LESS RETAINAGE <br />(Line 4 Less Line 5 Total) <br />7, LESS PREVIOUS CERTIFICATES FOR <br />PAYMENT (Line 6 from prior Certificate) <br />8. CURRENT PAYMENT DUE. <br />9. BALANCE TO FINISH, INCLUDING RETAINAGE S <br />ILine 3 minus Line 6) <br />m.•l I rOt'UMENT G702 <br />Distribution toy <br />HOWNER <br />11130/2019 CONSTRUCTION MANAGI-R <br />ARCHITECT <br />CONTRACTOR <br />7110/2019 HFIELD <br />The undersigned Contractor certiles that to the beau of the Contractor's knowledgC. <br />information and lrelief the Work covered by this Application for Payment has becn <br />compteted in accordance with the Contract Documents, that all amounts have been paid by <br />the Contractor for Work for which previous Certificates for payment were issued and <br />payments received from die Owner, acid that cw=ir payinent shown herein is now due. <br />S 925,400.00 CONTRAC"70R. <br />cn tin <br />] %L J,VVV.InI <br />S 36,999.32 <br />S 1,84997 <br />S6 tk) <br />By:71 _ Date: <br />Statcof: MINN TA County or STL•ARNS <br />Suhscxibcd d s po V et r}de iW ,4 /1 25 day of November <br />Not c_ / f <br />My Comm) n expires: y� <br />i <br />11/25/19 <br />2019 <br />s 1.1W9.97 <br />CERTIFICATE FOR PAYMENT <br />In accordance with the Contract Documents, based on on -site obsmnarions acid the data <br />S 35.149,35 <br />comprising the application, the architect certifies to the Owner that to the best of the <br />.Architect's knowledge, mrionnation and hdiof the Work has progressed as indicated, <br />5 <br />the quality ofthe Work Is in accordm= with the Contract Documentn_ acid the Contractor <br />is entitled to payment of die AMOUNT CERTIFIED. <br />S 35.I49,35 <br />AMOUNT CERTIFIED . . ......... ... .. $ 35,149.35 <br />S 889.950.65 <br />{Attach explaaanon +f aroom' lerrfrfied dif irx.fram the amount appherl Initial alffignrxr ua 110s <br />Appheation and anthe CouraivanwF :freer that are changred in conform with the antnunt certtird) <br />CONSTRUCTION MANAGER: <br />CHANGE ORDER SUMMARY <br />ADDITIONS <br />DEDUMONS <br />Total changes approved in previous months by Owner <br />5 - <br />S - <br />Tmal approved this Montt <br />5 <br />5 <br />TOTALS <br />S <br />S <br />NET CHANGES by Chat,ge Order <br />5 <br />By: Pate: <br />ARCHITECT: ( NOTE If Multiple Prime consiractors are responsible for performing poniour, ofulie Project, Ilie <br />Architect's Ceitificarion is not required.) <br />I3y: Date: <br />This Certificate is not netrotiabtc. The AN40UNT CERTIFIED is payable- only to die <br />Contractor named harem. issuance, M7nrnt and acceptance of poymcm are without <br />prejudice to any rights of the Owner or Contractor under this Contract <br />AIA OOI'UMENr arOT APPPTION m40 CERTinCATIoN FOR PAYMENT 1942 U,7 0t. A'A m -99: TKy , A pERIC„M M I I I UTE or ARIZWTECT5. 1735 NEW YORK AVE N'W W. WASHINGTON. DC "OO&5292 <br />Users may obtain valldation of this document by requesting a completed MA Document D401 - Certification of Document's Authenticity from the Licensee, <br />