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04K 4Ak 14V AJADocument G702"-1992 4a.0-4--S54 -g530 Application and Certificate for Payment 1/95/@a TO OWNER: PROJECT: tv'croa ono 's APPLICATION NO: 5 Distribution to: H:nlding Dep stnteart 9850 165 tit Ave N W 13M5 Chano Parkway Flk River, MN 55330 PERIOD TO: OWNER ❑ hik River, MIN 55330 CONTRACT FOR: ARCHITECT ❑ FROM CONTRACTOR: Ebert Construction VIA ARCHITECT: I tamer. Chnsienscn, Mellwain CONTRACT DATE: 23350 County Road 10 4201 Cedar Avenue S CONTRACTOR ❑ Corcoran, KN 55357 Mimnespolis, MN 55407 PROJECT NOS: h384 FIELD O OTHER ❑ CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contracwr certifies that to the best of the Contractor's knowledge, information Application is made tier paynient, as shown below, in connection with thsContnict and belief the Work covered by this Application foT Payment has been completed in accordance A[A Document G703T , Conunuation Sbee% is attached. with the Conuact Documtms, that all amounts have been paid by the Contractor for Work for 268 which previous Certiftcatea for Payment were issued and payments mocived from the Owner, and t. ORIGINAL CONTRACT SUM ....... . _...1.1................... S_ 200 00 that current payment shown herein is now due. 2 NET CHANGE I Y CHANGE ORDERS. S 22,951.25 C Ebert COnslnact' n 3. CONTRACT SUM TO DATE (Line 1 a 2) ..... ................... _... S 291,151.15 Hy 5tlu _ Date 2Q1.151 3 - 4.70TAL COMPLETED 6 STORED TO DATE fC,'olurnn G an GM) ...... S_ State of: hlimnes+rn • i 5. RETAiNAGE: oaf Completed Wank (Columm O + E on G703) $ IQ057.57 b. %orStencil Material - (Colivim Pon G703) $ Total Retainage ✓Lines 5a + 5b, or Total in Column I of G703)...... S ID M7 S7 6. TOTAL EARNED LESS RETAINAGE.................................... S 121,M:7a (Lure 4 mimrr Line 5 Total) 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT ...................... S L42J"e 1 (Lane 6 from prior Certificate) County of: Hennepin Subscribed and sworn r') befere me this _ _ �Y of=SICANDACEE GREEN�UBLIC Notary Public: UV OTA My commission expires: Am 37. 20 ARGHMOPS iG CERTIFICATE FOR PAYMENT In accordance with the Contract Documents, based on on -site observations and the ti�fe,�ttrnp9sing This application, ehe,likollUits`lfttifitss to the Owner that to the best of the 'Iboli rli knowledge, irdbirmadon and belief the Work has progressed as indicated, the quality of the Work is in seooadaoce with the Contract Documents, and tore Contractor is entitled to payment of Ire 8. CURRENT PAYMENT DUE .... .... ., 4 3 AMOUNT CERTIFIED. 9. BALANCE TO FINISH, INCLUDING REfAINAGE AYO►NT CERTIRED............._............................- ...... _..................... s 'e 37 (Line 3 mina Lino b) S I90.Q57� (Attach csnkrnstdon *e amount applied Initial `llflgracr on thin l%noon, on 17W Conrinuadon Sheet that are rhanged Ica eenfarm with the amount certijIeid) HANGE ORDER SUMMARY ADDITIONS li]MQ CIIlOIVS v am otal changes approved m Pfevioua months by Owner S : +C f4 j- S - Z D .Cif e p 1 oral approved thus _ i. _ ) f z Date: f _ (.1 ZZ aggro tltdhth ki S Certificate is riot negotiable. The AMOUNT[ CERTIFIED is payable only to the Contractor TOTAL 3 r j=� ad /30,4�7 ssmed herein. Issuance. payment and acceptance of payment we without prejudice to any rights of I T CHANGES by Clumu c Order f Q be Owner or Contractor under this Contract. Jr /- ZS ..__7 CAUTION: You should sign an original AIA Contract Document, an whkh thla tttadappern in RFD.. An original assures Thal changes will not be obscured. XA Doeurr"t QM- -1 s92, Copyright O 1953, 1983. 11985. 1971. 1978, 1t18.9 srtm 1992 by T1ta Amelutt Vdg&ft al A d-Ucl& All Mylih ne.rv.d. WARNING: This Ala° Doeunearn b nrot..ted by U.B. Copyr hl tow and tnlwnattonst Tnwnts. Unauthorized mproauetim w - - gYgss et MN A10 ererty P ~ern. mw r.sf$ In sewer elves ind erMeinai panels", and w111 bs tums.eueea to ea rnisantmt.staq possible under the taw. P,;c..rperms+.,ro to rspmduce sm (10) coon d@M es Gallslanrltan gellbMlae. To report 00PIsig A vfolati d AIA Cantrerd Document', 0-mail The Amedan InstinAe or Archl"' togas counsN, oopyr1gV%hle.orq. — m