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la-11AIADocument G702° -1992
<br />Application and Certificate for Payment
<br />TO OWNER: City of Elk 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 River Fire Station #3 APPLICATION NO: 20-705-012 Distribution to:
<br />PERIOD TO: January 31, 2022 OWNER:
<br />CONTRACT FOR: General Construction ARCHITECT:
<br />VIA B22 N Group
<br />St, #101 CONTRACT DATE: October 19, 2020 CONTRACTOR:
<br />ARCHITECT: PROJECT NOS: /20-705 /
<br />MInneapolis, MN 55401
<br />FIELD: ❑
<br />CONTRACTOR'S APPLICATION FOR PAYMENT
<br />Application is made for payment, as shown below, in connection with the Contract.
<br />AIA Document G703®, Continuation Sheet, is attached.
<br />1. ORIGINAL CONTRACT SUM ..............
<br />2. NET CHANGE BY CHANGE ORDERS
<br />$6,898,246.00
<br />$0.00
<br />3. CONTRACT SUM TO DATE (Line 1 t 2)............................................................ $6,898,246.00
<br />4. TOTAL COMPLETED & STORED TO DATE (Column G on G703) ................. $5,260,041.79
<br />5. RETAINAGE:
<br />a. 5.00 % of Completed Work
<br />(Column D + E on G703) $263,002.09
<br />b. 0 % of Stored Material
<br />(Column F on G703) $0.00
<br />Total Retainage (Lines Sa + 5b or Total in Column I of 0703) ................. $263,002.09
<br />6. TOTAL EARNED LESS RETAINAGE .....................
<br />(Line 4 Less Line 5 Total)
<br />7. LESS PREVIOUS CERTIFICATES FOR PAYMENT
<br />(Line 6 from prior Certificate)
<br />8. CURRENT PAYMENT DUE ...............................
<br />9. BALANCE TO FINISH, INCLUDING RETAINAGE
<br />(Line 3 less Line 6)
<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 fro the er, and that current payment shown herein is now due.
<br />CONTRACTOR: p
<br />By: Date:
<br />State of: Minnesot
<br />County of. Hennepin
<br />Subscribed d sworn to bef�en
<br />Z TERESA L JENSEN
<br />me this day of INotary Public, State of Minnesota
<br />My Commission Expires
<br />January 31, 2026
<br />Nota resa LJe
<br />My Commission xpires: January 31, 2026
<br />............................................ $4,997,039.70 ARCHITECT'S CERTIFICATE FOR PAYMENT
<br />In accordance with the Contract Documents, based on on -site observations and the data
<br />............I.............................. $4,440,701.32 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 is
<br />...................................... 1 $556,338.38 entitled to payment of the AMOUNT CERTIFIED
<br />$1,901,206.30
<br />CHANGE ORDER SUMMARY
<br />ADDITIONS
<br />I DEDUCTIONS
<br />Total changes approved in previous months by Owner
<br />$0.00
<br />$0,00
<br />Total approved this Month
<br />S0.0ol
<br />$0.00
<br />TOTALS
<br />$0.001
<br />$0.00
<br />NET CHANGES by Change Order
<br />$0.00
<br />AMOUNT CERTIFIED...................................................................................... $556,338.38
<br />(Attach explanation if amount certified differs from the amount applied. Initial all figures on this
<br />Application and on the Continuation Sheet that are changed to conform with the amount certified.)
<br />ARCHITECT:
<br />By: Date: 02/10/2022
<br />This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor
<br />named 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 G7026 — 1992. Copyright @ 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 />"G7Z and "AIA Contract Documents" are registered trademarks and may not be used without permission. This document was produced by AIA software at 09:02:59 CT on 02109/2022 under Order No.1547896054
<br />which expires on 04/24/2022, 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:
<br />(369ADA66)
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