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APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOCUMENT G702 (Instructions on reverse side) PAGE ONE OF PAGES <br />TO OWNER: PROJECT. BFXS9211E-0 <br />RIM CONST J ELK RIVER ICE ARENA APPLICATION NO.: 018Qsltribution to: <br />830 BOONE AVE N 1000 SCHOOL ST NW PERIOD TO: 11/30/2019 ❑ OWNER <br />ELK RIVER MN J El ARCHITECT <br />GOLDEN VALLEY, MN 55427 PROJECT NOS.: <br />FROM CONTRACTOR: Molin Concrete Products Co VIA ARCHITECT: /19/2019 El CONTRACTOR <br />415 Lilac Street CONTRACT DATL ❑ <br />Lino Lakes, NfN 55014-1005 19-9211 ❑ <br />CONTRACT FOR: <br />CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, infor- <br />mation and belief the Work covered by this Application for Payment has been completed <br />Application is made for payment, as shown below, in connection with the Contract. in accordance with the Contract Documents, that all amounts have been paid by the <br />Continuation Sheet, AIA Document G703, is attached. Contractor for Work for which previous Certificates for Payment were issued and pay- <br />1. ORIGINAL CONTRACT SUM ... 1,013,283.00 ments received from the Owner, and that current payment shown herein is now due. <br />2 . Net change by Change Orders ............... $ 47,642.00 <br />CONT fACTOR: Molin Concrete Products Co <br />3 CONTRACT SUM TO DATE (Line 1 t 2) ........ $ <br />4. TOTAL COMPLETED & STORED TO DATE ...... $ <br />(Column G on G703) <br />5. RETAINAGE: <br />a• —fig4% of Completed Work <br />(Columns D + E on G703) <br />b. % of Stored Material <br />(Column F on G703) <br />Total Retainage (Line 5a + 5b or <br />Total in Column I of G703) ....... <br />1,060,925.00 <br />106,092.50 <br />5,304.64 <br />$ 5 304.64 <br />6. TOTAL EARNED LESS RETAINAGE , , ........ 8 Inn 787.86 <br />(Line 4 less Line 5 Total) <br />7. LESS PREVIOUS CERTIFICATES FOR PAYMENT <br />(Line 6 from prior Certificate) $ 0.00 <br />8. CURRENT PAYMENT DUE ...... , .. , . $ 100,787.86 <br />9. BALANCE TO FINISH, INCLUDING RETAINAGE <br />(Line 3 less Line 6) $_ 960,137.14 <br />CHANGE ORDER SUMMARY_ ADDITIONS DEDUCTIONS <br />Total changes approved in <br />previous months by Owner 47,642.00 <br />Total approved this Month 47,642.00 <br />TOTALS 47.642.00 <br />NET CHANGES by Change Ordert <br />By: Date: I aW l q <br />State of: MINNESOTA <br />County of: ANOKA <br />Subscribed and sworn to before <br />me this day of <br />Notary Public: <br />My Commission expires: <br />ARCHITECT'S CERTIFICATE FOR PAYMENT <br />In accordance with the Contract Documents, based on on -site observations and the data <br />comprising this application, the Architect certifies to the Owner that to the best of the <br />Architect's knowledge, information and belief the Work has progressed as indicated, the <br />quality of the Work is in accordance with the Contract Documents, and the Contractor <br />is entitled to payment of the AMOUNT CERTIFIED. <br />AMOUNT CERTIFIED ............:.................. $ <br />(Attach explanation if amount certified differs from the amount applied for. Initial <br />all figures on this Application and on the Continuation Sheet that are changed to <br />conform to the amount certified.) <br />ARCHITECT: <br />By: — Date: <br />This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Con- <br />tractor named herein. Issuance, payment and acceptance of payment are without <br />prejudice to any rights of the Owner or Contractor under this Contract. <br />AIA DOCUMENT G702 - APPLICATION AND CERTIFICATE FOR PAYMENT - 1992 EDITION - AIA° - ©1992 - THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK <br />AVENUE, N.W., WASHINGTON, D.C. 20006-5292 - WARNING: Unlicensed photocopying violates U.S. copyright laws and will subject the violator to legal prosecution, G702-1992 <br />r_ <br />CAUTION: You should use an original AIA document which has this caution printed in red. An original assures that changes will not be obscured as may occur when documents am rpnrnrlurrul <br />