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1. Document G702" -1992 Application and Cerdficate for Payment TO OVYNER: ee` PROJECT: !va ounh APPLICATION NO: 6 Building Deparonent 9950 165thAveNW D1SdibUl�Ofl tq: tdlk River, NON 55330 PERIOD TO: 12.272021 i 30faS Orono Parkway OWNER Q Elk River, MN 55330 21a CONTRACT FOR: ARCHITECT [I FROM CONTRACTOR: Ebert Construction VIA ARCHITECT: 1 23350 County Road 10 42044�vs"rae S CONTRACT DATE: CONTRACTOR Q Corcoran,MN 553577 PROJECT NOS: 6484 F; LD a OTHER O CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned CaratructeT cenifles that to the hest of the Contructnr's knowledge, information Application it; made for payment, as shown below, in connection with the Contralti, and belief the Work covered by this Application for Payment has been completed in ,accordance AIA Ihuument (i703T", CnntjnUatkM Sheet, is attached, with the Contract Documents, that all amoums have been pond by the Contractor for Work far 1.ORIGINAL CONTRACT SUM ................................................ 2 NET CHANGE BY CHANGE ORDERS. ............................ 3. CONTRACT SUM TO DATE (Liar I k l)............................... ... 4. TOTAL COMPLETED 6 STORED TO $Rl! jl:olaist a 0 at GM) ...... S. RETAINAC+ a, i.flf! oe „f Conarketed Work (i olumpa 1) + k an G703) _ . of Stored Material 7c lumn Fan G'703) 26A,20000 which previous Certificates for Paymert were iEs!!ed and paymems received from the Owner. and $ that current payment shown heroin is no,v due. $ 22.44t17 CONTRACTCONTRACT0.1k E:bwConstru lion s zs t:lstz5 By. 7,Dart. SS T State of.. Minnesota IZ117_07- Total Retalnage flans Sa + Sh, err Toral in Cnluntn 1 ofG703)...... S— L' Il- OI_, 8 TOTAL EARNED LESS RETAINAOE.................................... f (Liner 4 mfmrl Line S Taal) 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT ..................... i 14Liw3"78 /Larne h from prior ('ert�cta) B. CURRENT PAYMENT DUE ............................................. 9 BALANCE TM Fl►RS61 1NCLU Country of: Hcmwpm Suhscribcd and ww" me this f CANDACE LEE GREEN r ° ! NOTARY PUBLIC (1�9 �i rt Notary Publ[C: �'� afj � V� MINNESOTA Nf}'cammissnrnl ayCCoonatnenLVku Jrn.11,My ARGMIFFEG:Fg CERTIFICATE FOR PAYMENT In acccrdartte with the LDoclttnentsr based on art -situ observations prising ►�{pnprising this application, the Eittf"to the Owner that to the best of rhe' Q owiedge, information and bdicf the Wark 1ws pnug-swd as indicated, the gawlity of the Work Is in accOrdmcc with the Contract Documctim and the Contractor is entitled to payment of the AMOUNT (ERTIFIED. Dd46 meAINAGE AMOUNT CERTIFIED ...... ................... 3 ......,... .«...» ..._................ {Lena 3 minor f ore dJ 6149,�'�1 fAacch erplarratian {faeossv aarl�IMnldi,�rt. fiva■ rhr ommrnr �pfted �ndna�aJl ffgwea oa fhit - m B ORDER $ i --- — -- C.aMilier SA ws rer dmr e charged to conjarm with nine amou t c r fif mL) CHANG-- — �M i_.__ _._. AL1Dl17* i3 DEDUCTIONS c!!I6mg0S !eon •ingseviaesratoftbyOwner S- F.D mar s�3 r, y� S E _ ad thht month . This Is*W agadable. Tam AMOUNT CE.RTIFIis payable only to the Contractor TC7iAL f 'xTAlf : T named Inmeia Itgtsnc+c. plvTncnt and acceptance of payment are withetu pn*atdice to any rights of I T CHAN'OES by Chiles e Order i " the Owner or Lkmtractnr under this Contract. CAUTICINt You should Or an O!,10nal AIA Contract Oocurnarnt, on which pda tact appaam in RED. An original assures that change" will not bo obscured- AIA Docurnent GM- - ML Copynlht a 1953, IM 1966, 1971. 19M 1g93 aia 1922 by The ArneAran inshMii of Ar&Aads. AN d9tti" rsa■rv■d. WARNING: This A O Dacamern Is liprayaard aY U.S. Copyrl�lt law d toles" ane""I Tlaaaw. Nniarthorraad repmdu iiDn Or dbbibWm *it* AIArDoewnwIL or any potion on It may mntlt In ■evera evil and crlrntnel pen■Iaea, ■nd wla M pnaapllad b flee meskeum eafeaa pea■tbM under the ass•. Purcnatwro err onnrlslad tp rapddbee ten (to I wplvs of this doarmrm! when eiv'apl!'. To report oaeyn�rt vroWtrarn aI AIA Contact Oew �t5, �lrta:l 1"tro Aallattean I1rrGute of A•chpnns' legal nmalaaf. eapytlydOtlaom. m arvun.