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���/� T �
<br />� ��� 1 Document G702� - � 992
<br />Application and Certificate for Payment
<br />TO OWNER: City of Elk River PROJECT:
<br />] 3065 Orono Parkway
<br />Elk River, MIV 55330
<br />FROM Palrner West Construction Company, VIA
<br />CONTRACTOR: Inc. ARCHITECT:
<br />14595 James Road
<br />Rogers, MN 55374
<br />�Ik River City HatI Reroof
<br />13065 Orono Parkway
<br />E1k River, MN 55330
<br />CCINTRACTOR'S APPLICATION FOR PAYMENT
<br />Application is made for paytnent, as shown below, in connection with the Contract.
<br />AIA Duoumenl G7Q3�, CuutinuaLii�n Slieet, i� aLLaclieil.
<br />1. ORIGINAL CONTRAGT SUM ...............................................................
<br />2. NET CHANGE BY CHANGE ORDERS .......................�........................
<br />3. CONTRACT SUM TO DATE (Line 1 t 2) ...........................................
<br />4. TOTAL COMPLETED & STORED TO DATE (Column G on G703)
<br />5. RETAINAGE:
<br />a. S.OQ % of Completed Work
<br />$853,IQ0.00
<br />$0.00
<br />$853,100.00
<br />$685,741.00
<br />(Column D + E on G703) $34,287,05
<br />b. 0 % of Stored Material
<br />(Column F oo G7�3)
<br />Total Retainage (L'mes Sa+Sb or Total in Colu�n I of G703)
<br />8. TOTAL EARNED LESS RETAINAGE .....................
<br />(Line 4 Less Line 5 Total)
<br />7. LESS PREVIOUS CERTIFICATES FOR PAYMENT
<br />(Line 6 from prior Certificate)
<br />8. CURRENT PAYMENT DUE ................................
<br />9. BALANCE TO FtNISH, INCLUDING RETAINAGE
<br />(Line 3 less Line 6)
<br />Cod e: 292-4-1600-4530
<br />� vv��
<br />APPLICATION N0: 002 Distribution to:
<br />PERIQD T0: May 31, 2023 OWNER: ❑
<br />CONTRACT FOR: Roofng ARCHITECT: ❑
<br />CONTRAC7 DATE: January 17, 2023 �pNTRACTOR; ❑
<br />PROJECT NOS: / 23-103 /
<br />FIELD: ❑
<br />OTHER:�
<br />Thc undersigned Contractor certifies that to the best of the Contractor's knowledge,
<br />inforniation and heiief the Work covered by this Applicatian for Payment has been
<br />completed in accordance with the Contract Documents, that all amounts have been paifl
<br />by the Contractor for Work for which previous Certificates for Payment were issued and
<br />payments received from the Owner, and that current payment shown herein is now due.
<br />CONTRAC R•
<br />By: � Date: May 23, 2023
<br />State of: M
<br />County of: Hannepin
<br />Subscribed and sw m to before ��� RENEE WRIGHT
<br />me this �? 3` `day of �Y�s¢c.� ,.��'J �"�;=, Notary Public
<br />`��'��= Mknnesota
<br />:� +1�.t .s�=
<br />$o.00 NotaryPubl��`- ��'F��u.-�.•• NfyCGmmissionE�p�resJanuary31,2024
<br />•,....,,..,
<br />........ $34,287.05 My Commission expires: p� � g���i��
<br />......... $6s�,453.95 ARCHITECT'S CERTIFIGATE FOR PAYMENT
<br />In accordance with the Contract Dacuments, based on on-site observations and the data
<br />....,.... �354,466.85 comprising this application, the Architect certifies to the �wner 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 Coutractor is
<br />� 1 d f h A T CERTIFIED
<br />.. �296,987.] p'�ntrt e to payment o t e MOLTN .
<br />AMOUNTCERTIPIE� ...................a.................................................................. �296,487.1fl
<br />$201,64bA5 (Rttack explanarion if amount cert�ed ddffers from the amount applied. Initia! a!1 fig�ires ora this
<br />Applicatian artd on ahe Contirt�ation Sheet that are changed to conform with the amount certified.)
<br />CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARCHETECT:
<br />Total chan�es approved in previous months by Owner $0.00 S0.00 $y: Date�
<br />Total approved this Month $0.00 50.00
<br />TO'TALS $0.00 50.06 This Certifacate is not negotiable. The AMOUlVT CBRTIFIflD is payable only to the Contractor
<br />named herein. issuance, payment and acceptance of payment are without prejudice to any rights of
<br />� E'C CHANCsES b Chan e Order $0.00 the Owner or Co�ttactoi uhdei' this Contract.
<br />AIA Document G702 — 1992. Copyright OO 1953, 1363, 1965, 7979, 1978, 1983 antl 1992. All rigAts reservetl. "The American Institute oi Architects," "American InstiWFe of Architects," "AIA," the AIA Logo, and "AIA
<br />Contract DoCumeRts° afe t�ademafks of The American InstiWte of Architects. This document was produced at 15:�6:07 CT on 05/23/2023 under Order No.3'104237269 which expires on 08/2 012 0 2 3, is not for resale,
<br />is licensed for one-time use only, and may only be used in accordance with the AIA Contrac[ Documents'B Terms of Service. To report copyright violations, e-mail docinfo@aiaconhacts.com.
<br />User Notes: (3B9ADA50)
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