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Liryi�! Code: 421-4-2190-4520
<br />- document G702i -1992 96t)
<br />Application and Certificate for Payment
<br />TO OWNER. City of Elk [fiver PROJECT: 20-700 Elk River Public Satcty Ptailding APPLICATION NO: 20-700-014 Distribution to.
<br />13065 Orono Parkway NW Expansion and Fire Station Na. 3 PERIOD TO: Nnvemloor 30, 20Z1 OWNER:
<br />Elk River. MN 55330
<br />CONTRACT FOR: Cseneral Construction ARCHITECT:
<br />FROM Terra Gencral Contractors VIA RICV Croup CONTRACT DATE: October 19, 2020
<br />CONTRACTOR: 21025 Commerce Blvd Sic ION ARCHITECT: 222 N 2nd St, #101 PROJECT NOS: 120-700 J CONTRACTOR:
<br />Rogers MN 55374 Mlnneapnlis, MN 55401
<br />FIELD: ❑
<br />OTHER: Q
<br />CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that tc the best of the Contractor's knowledge.
<br />Applicavan is made for paynrcn%as shown below, in connection with the Contract- information and belief the Work covercd by this Application for Payment has been
<br />ATA Docrincnl 6703', Comhaumnin:shecl,. is altached. completed in accordance with the Contact Documents, Ihat all amounts have been paid
<br />1. ORIGINAL CONTRACT SUM ..........._ ...................................
<br />2. NET CHANGE 6Y CHANGE ORDERS .................................
<br />3. CONTRACT SUM TO BATE (Lino I + 2)„........................................
<br />4. TOTAL COMPLETED & STORED TO DATE (Column G an G703)
<br />5, RETAINAGE:
<br />a. c.CO ''. ofC;omplcted Work
<br />C'olunin D— E on G703)
<br />6. iJ % nfSlured Material
<br />(C.+,lnlnn F nn (i703)
<br />Total Retainage (Lines Sa+ 51b or Total in Column I ofG703)
<br />6. TOTAL EARNED LESS RETAINAGE ..........
<br />ILinc 4 Lcss I -ire 5; I oral}
<br />7, LESS PREVIOUS CERTIFICATES FOR PAYMENT
<br />(Line F frmn prior ('crtifcahc)
<br />8, CURRENT PAYMENT DUE ...............................
<br />9. BALANCE TO FINISH, INCLUDING RETAINAGE
<br />(Line 3 less Line 6)
<br />S314.316.53
<br />$0,00
<br />by the Contractor for Work fear winch previous Certificates for Payment were Issued and
<br />S6,290,219.00 payments recci ffrroomCtOr, and that current payment shown herein is now due.
<br />$78,765,42 CONTRACTOR�`
<br />SG 368,984.42 By: Dam: 12/8/2021
<br />S6,296,330.41 Slate of° Mi nesola
<br />County of: Hennepin TERESA L.JENSEN
<br />Subscri n sworn Io re
<br />nae Ih day of i+( " p"d • State or Minnesota
<br />'0 Nq Commission Expa^B9
<br />January 31, 2326
<br />N,. crc.sa L. Jensen
<br />S314,31r5.53 My Cornrrisni;m xpvrc:5: January 31. 2026
<br />ss,972.o13.ss ARCHITECT'S CERTIFICATE FOR PAYMENT
<br />In accordance with the Contract Documents, based on on -site observations and the data
<br />S5,713.947,0t comprising this application, the Architect cal•tifies to the Owncr that to the best of (lie
<br />Architecl's knowledge, information and brlierthe Work has progressed as indicated. (he.
<br />quality of the Work is in accordance with the Contract Documents, and the Contractor is
<br />S259.066.S7 entitled to payment of the AMOLTNT CERTIFIED.
<br />AMOUNT CERTIFIED .................. ....-........................ ............. ............. ..........,. 5258.066.87
<br />S396,970.54 (:4mach explaldrtant ifamowo eertriied differs front the amnaall applied. Indlai ali figures on tiros
<br />4ppiicatrion and on the Confinfrotion Elieet Am are chnngir to conform with the amount cerii�ed.)
<br />nLl['TIC}NS ARCHITECT:
<br />50-00 13y: Date: 12/09/2021
<br />SO.t}t]
<br />50.0{} This Certificals is not negotiable The AMOUNT CERTIFti;D is payable only to the Contractor
<br />named herein. Issuance, payment and acceptance ot'payment are with -out prejudicc to any rights of
<br />$78,765.42 the Owl or Conrracrorunderthis Contract.
<br />CHANGE ORDER SUMMAPY
<br />All)DITIONS
<br />DN.
<br />Total changes approved in previous months by Owner
<br />$79,765.42
<br />Total approved this Month
<br />S0.0
<br />TOTALS
<br />S7S,76S.4"
<br />NET CHAN612Sb Change Order
<br />AIA Document Ga702r° - 1992. Copyright 0 1953, 1963, 1965, 1971. 1978. 1982 and 1992 by The Amcnean Insllluls of.ArchttecCs All rights reserved. The'American instlute df Architects.' "AIA." the AJA Logo,
<br />'G702,- ard'AIA Conlracl Darumanls' ara registered trademarks and may nul Ire used without perrnisston. This document wes produced lyy AIA software al CTA8,21 CT on IZO3r2021 under Qrdw No-1547896054
<br />which expires on 0412412022, is nol for resale, is licensed for one-time use only, end may only be used In accerance. with Owe ALA Contract Doc rnentse Terns of Service. To report copyright violations, e-mail
<br />copyright@ala.org.
<br />User Notes'
<br />(369ADA62)
<br />
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