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lZilt-AIADocument G792 —1992
<br />Application and Certificate for Payment
<br />TO OWNER: City of Ctk River
<br />13065 Orono Parkway NW
<br />Elk River, MN 55330
<br />FROM Terra General Contractors
<br />CONTRACTOR: 21025 Commerce Blvd Ste 1000
<br />Rogers MN 55374
<br />Code:421-4-2310-4520
<br />PROJECT: 20-705 Elk [fiver Fire: Station #3 APPLICATION NO: 20-705-011 Distribution to:
<br />PERIOD TO: December 31, 2021 OWNER:
<br />CONTRACT FOR: General Construction ARCHITECT:
<br />VIA BKV Group CONTRACT DATE: October 19, 2020
<br />ARCHITECT: 222 N 2nd St, #101 PROJECT NOS: / 20-705 / CONTRACTOR:
<br />Mlnneapolis, MN 55401 FIELD: ❑
<br />CONTRACTOR'S APPLICATION FOR PAYMENT
<br />Application is made for payment, as shown below, in Connection with the Contract.
<br />AiA Document G70311, Continuation Sheet, is attached.
<br />1. ORIGINAL CONTRACT SUM................................................................................ $6,898,246.00
<br />2. NET CHANGE BY CHANGE ORDERS ...... ....... .............. ................ I..................... $0.00
<br />3. CONTRACT SUM TO DATE (Line 1 ± 2)............................................................ $6,898,246.00
<br />4. TOTAL COMPLETED & STORED TO DATE (Column G on G703) ................. S4,674,422.44
<br />RETAINAGE:
<br />a. 5,00 % of Completed Work
<br />(Column D + E on G703) $233,721.12
<br />b. 0 % of Stored Material
<br />(Column F on G703) $0.00
<br />Total Retainage (Lines 5a + 5b or Total in Column I of G703) ................. $233,721, I
<br />OTHER: ❑
<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 been
<br />completed in accordance with the Contract. Documents, that all amounts have been paid
<br />by the Contractor for Work for which previous Certificates for Payment were issued and
<br />payments received -on tic Owner, and that current payment shown herein is now duc.
<br />CONTRACTOR:
<br />By: Date: ii f 6176 7,Z
<br />State of: Minne.1to
<br />County of: Hennepin : b TERESA L JENSEN
<br />Subscribed, S�F'oTll t0 bC rC 1 Notary public, State of Minnesota
<br />me this day of yV +- �"' My Commission Expires
<br />-J. January 31, 202it
<br />7Nolary'WresaL.Jensen
<br />2Commission xpires: January 31, 2026
<br />6. TOTAL EARNED LESS RETAINAGE...................................... I ......... ..,.,......... ...,, $4,440,701.32 ARCHITECT'S CERTIFICATE FOR PAYMENT
<br />(Line 4 Less Line 5 Total) In accordance with the Contract Documents, based on on -site observations and the data
<br />T LESS PREVIOUS CERTIFICATES FOR PAYMENT ............................................ $4,044,002.75 comprising this application, the Architect certifies to the Owner that to the best of the
<br />(Line 6 from prior Certificate) 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 is
<br />S. CURRENT PAYMENT DUE................................................................. ........ 1 $396,698.571 entitled to payment of the AMOUNT CERTIFIED
<br />9. BALANCE TO FINISH, INCLUDING RETAINAGE
<br />(Line 3 less Line 6) $2,457,544.68
<br />CHANGE ORDER SUMMARY
<br />ADDITIONS
<br />DEDUCTIONS
<br />Total changes approved in previous months by Owner
<br />$0.00
<br />50.00
<br />Total approver) this Month
<br />S0.00
<br />S0.00
<br />TOTALS
<br />S0.00
<br />50.00
<br />NET CHANCES by Change Order
<br />S0.00
<br />AMOUNT CERTIFIED...................................................................................... $396,698.57
<br />(Attach explanation if amount cerlifled then from. the amount applied, Initial all figures on this
<br />Application and on the Continuation Si et that are changed to conform with the amount certified.)
<br />ARCHITECT:
<br />By: 14� Datc: 01 /07/2022
<br />This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor
<br />muted herein. Issuance, payment and acceptance of payment are without prejudice to any rights of
<br />the Owner or Contractor under this Contract.
<br />AIA Document G70211— 1992. Copyright Q 1953, 1963, 1965, 1971, 1978, 1983 and 1992 by The American Institute of Architects. All rights reserved. The "American Institute of Architects," "AIA," the AIA Logo.
<br />`G702; `and "AIA Contract Documents' are registered trademarks and may not be used without permission. This document was produced by AM software at 15:4810 CT on 0110512022 under Order No.1547896054
<br />which expires on 04/2412022, is not for resale, is licensed for one-time use only, and may only be used in accordance with the AIA Contract Documents" Terms of Service. To report copyright violations, e-mail
<br />copyright@aia.org.
<br />User Notes: i3B9ADA5Q
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