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,-O.AIA Document 4 ' 992 49,0 -14- s>-5 530
<br />Applicadon and Certificate for payment
<br />TO OWNER: 14011171ver PROJECT: U il,r iver but omo v APPLICATION NO; 4
<br />Building Del> ntment 98. 0 165 t1i Ave N W Distrfttloll to:
<br />• 13065 Orono l'arl,way
<br />Elk Rivc°r. MN 55330 PERIOD TO: 1T21202f OWNER O
<br />Elk River; MN 55330 CCIMCT FOR: ARCHITECT ❑
<br />FROM CONTRACTOR• Ebvrt Construction VIA ARCHITECT: Hagen. Christensen. Mellwain
<br />23.350 County Road 10 4201 Cedar Avenue S CONTRACT DATE: CONTRACTOR ❑
<br />Corcoran, MN! 55357 Minneapolis. <NIN 55407 PROJECT NOS: 6484 / / FIELD ❑
<br />OTHER ❑
<br />CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, information
<br />Application is trade for payment, as shown below, in connection with the. Contract. and belief the Work covered by this Application •for Payment has been completed in accordance
<br />AIA Document 0703TM, Continuation Sheet, is attached. with the Contract Documents, that all amounts have been paid by the Contractor for Work for
<br />1. ORIGINAL CONTRACT SUM ........................ 2%200.b0 which pnwious Certificates for Payment were issued and payments received from the Owner, and
<br />$ that current payment shown herein is now dire
<br />2. NET CHANGE BY CHANGE ORDERS ..................................................... 22,951.25 QR• Ebert Construction
<br />3. CONTRACT SUM TO DATE (Line .1 � 2) ....:...... ....................... $ 291.151.25 fry s t, ♦ - 2 f _
<br />4. TOTAL COMPLETED & STORED TO DATE (Cohmrn Gate G703) ..., $— 150,278.35 State op. Minnesota
<br />AGE` County of: Hennepin,
<br />a 5.00 afl of Completed Work
<br />(Coltt»rns. D +Eon G703)
<br />Subscribed and sworn _tq before
<br />.f
<br />b. 4 of Stored Material $ 7S 13.92 me this �d0o0—
<br />a
<br />CANDACE LEE GREEN
<br />(Crilutnn F on f 703) $ emu- Notary Public; NOTARY PUBLIC
<br />(, MINNESOTA
<br />M commission ex s o4vj My Cantrimw Expecs Jant 31.2t127
<br />Total Retainage (Liner 5a f• 56, or Total in Column f of G703)...... $ - ®? 5 t 3 �a I ' .-
<br />S. TOTAL EARNED LESS RETAINAGE
<br />................................'.. S CERTIFICATE FOR PAYMENT
<br />(Line 4 minus Line 5 Total) In accordance with t 'otura, te, cuments, based on on -site observations ,c¢mgrising
<br />7. LESS PREVIOUS CERTIFICATES FOR PAYMENT ...................... $ 101-236.2 this application, the 'fees to the Owner that to the best of the ` wl icing
<br />(Line 6 from prior Cerrifcure) information and belief the Work has progressed as indicated, the quality of the Work is in
<br />_ accordoce with the Contract Documents, and the Contractor is entitled to payment of the
<br />--�
<br />$. CURRENT PAYMENT DUE.........................:...............AMOUNT CERTIFIED. .... S .��1.5z8.13 I
<br />9. BALANCE TO FINISH, INCLUDING RETAINAGE AMOUNT CERTIFIED
<br />(Line 3 minus (ire ts) Sw____ 148,33tn.x t (attach errpkmation if amount ce:rtifieddi, jars from the amount applied Ini1#at all figures on this
<br />_ i liCation and on the Continuation Sheet that are changed to g conform with the amount c�ertifia
<br />HATIGI ORDER SUMMARY _ Alll)1T1QN.4 DEDUCTIONS r•h.•.<,., n A�,•ti..
<br />..�.-.ems{' ems.•...
<br />Total changes approved in previous months by Owner I I "i9z 1� T ;na c j
<br />`+,h 9� � EY Date:
<br />Total appromed this -month $
<br />_ — TOTAL $ � Th' Certificate is nbt tpegodable. The AMOUNT CERTIFIED is payable only to the Contractor
<br />l _- �TT147iPs P yab Y
<br />S rained herein. Issuance, payment and acceptance of paymcat are without prejudice to any rights of
<br />'L'I` CHANGES by Chan,, Order $ '= T' --- the Owner or (?antractor under this Contract.
<br />CAU_TWN: You should slgo an original A A Contract Document, on which this teat appears in RED. An original assures that changes will not be obscurest._
<br />AIA DocuMorlt GM•-1982. Copyright G 1953, t983, 1865, 1071, 1978, 1983 and 1992 4y The American Inalfute of Architects. All rights mserved, WARNING: This A10 Document is protected by U.S. Copyright Lam
<br />and International Treatles. Unauthorized reproduction or distritsut�n of thle AlO Doemeni, or arty portion of it, may result In sewOro Civil and criminal penalties, and will be prosecuted to the msxhman extent
<br />poaslhis raider the Favr. Purr are permitted to reproduos ten (10) copies of this document when oc
<br />eoumei, �.o%. died. To report copyright vIWallnns s�tilA Contract GoCtxrwr�ls, a mail lira F�rrseri rr Incttkaia ctAtdtiteds' legal
<br />oanvcaw
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