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APPLICATION AND CERTIFICATION FOR PAYMENT <br />CUSTOMER: City of Elk River PROJER: Ek RIVer Muti-Purpose 5tadiu APPLICATION NO: 1 DistributlOn Via Email: <br />13065 Orono Parkway 304 Lions Park Drive INVOICE NO: 41497 DOWNER <br />Elk River, MN 55330-5600 Elk River, MN 55330 ❑ARCHITECT <br />PERIOD TO: 11/29/2019 ❑CONTRACTOR <br />CONTRACTOR: Peterson Companies, Inc, VIA ARCHITECT: ❑ <br />8326 Wyoming Trail PROTECT NO: 19175E O <br />Chisago City, MN 55013 <br />COMRAR FOR: <br />CONTRACTOR'S APPLICATION FOR PAYMENT <br />Application is made for payment, as shown below, in connection with the Contract. <br />Continuation Sheet Page 2, is attached. <br />1. ORIGINAL CONTACT SUM <br />2. Net change by Change Orders <br />3. CONTRACT SUM TO DATE ILine 132) <br />4. TOTAL COMPLETED &STORED TO <br />DATE (Column Gon G703) <br />6. RETAINAGE: <br />a. On Completed Work $2,099.37 <br />(Column 0+ E an G703) <br />b. On Stored Material 0.00 <br />(Column F on G]03) <br />Total Retainage (Line 9a+6h or <br />Total In Column I of G703) <br />6. TOTAL EARNED LESS RETAINAGE <br />(Line 41ess Line 5 Total) <br />]. LESS PREVIOUS CERTIFICATES FOR <br />PAYMENT (Line 6 from prior Certificate) <br />8. CURRENT PAYMENT DUE <br />9. BALANCE TO FINISH, INCLUDING RETAINAGE <br />(Line 31ess Line 6) <br />$133,955.00 <br />36,304.00 <br />170,259.00 <br />41,987.60 <br />2,099.37 <br />39,888.13 <br />D.oD <br />39,888.13 <br />130,370.87 <br />Change Order Summary <br />Additions <br />Deductions <br />Total Changes approved <br />in previous months by Owner. <br />0.00 <br />0.00 <br />Total approved this Month <br />36,304.00 <br />0.00 <br />NET CHANGES by Change Order <br />$ 36,304.00 <br />CONTRACT DATE: <br />The undersigned Contractor certifies that to the best of the Contractor's Knowledge, <br />information and belief the Work covered by this Application For payment has keen <br />ompleted in accordance with the Contract Documents, chat ail amounts have been paid 6y <br />the Contractor for Work far which previous Certificates for Payment were issued and <br />payments received from the owner, and that current payment shown herein is now due. <br />CONTRAROft: <br />BY: 1 Date: 11/25/2019 <br />State of. MN County of: is, pg, Id <br />Subscribed and sworn to before me th' s "'k��g��IbFDKd4N165R•&6N9TEA <br />Notary Public: �( ¢ NOTABY PUBLIC <br />My Commission Expires: .. .1l�t(s�" MYCwnml elonFESO,ijA al ppf2 <br />January3 � area aa. <br />ARCHITECT'S CERTIFICATE FOR PAYMENT <br />In aaortlance with the Contract Documents, based on on -site observations and the data <br />omprlsing the appllcatlon, the Architect certifies [o the Owner [hat to [he best of [he <br />Architect's knowledge, Information and belief the Work has progressed as indicated, <br />[he qualify of [he Work Is In accordance with the Contract Documents, and the Contractor <br />is entitled [o payment of the AMOUNT CERTIFIED. <br />Amount Certified $ <br />IA[tach explanation ifamount certified differs from the amount applied. Initial all figures on this � <br />Application and on the Un[Inuation 6heettha[ are changed to conform [o the amount certified.) <br />CONSTRUCTION MANAGER: <br />Date: <br />ARCHITECT: <br />This certigw[e Is no[ negotiable. The gmount Certified Is payable only [o [he contractor named <br />herein. Issuance, payment and acceptance of payment are without prejudice [o any rights of [he <br />Owner of contractor under this ContraR. <br />