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= �AIA Document G702" -1992
<br />Application and Certificate for Payment
<br />TO OWNER: City of Elk River PROJECT: Elk River City Hall Reroof
<br />13065 Orono Parkway 13065 Orono Parkway
<br />Elk River, MN 55330 Elk River, MN 55330
<br />FROM Palmer West Construction Company, VIA
<br />CONTRACTOR: Inc. ARCHITECT:
<br />14595 James Road
<br />Rogers, MN 55374
<br />CONTRACTOR'S APPLICATION FOR PAYMENT
<br />Application is made for payment, as shown below, in connection with the Contract.
<br />AIA Document 6703t, Continuation Sheet, is attached.
<br />1. ORIGINAL CONTRACT SUM...........................................................................I....
<br />$853,100.00
<br />2. NET CHANGE BY CHANGE ORDERS.................................................................
<br />$8,715.00
<br />3. CONTRACT SUM TO DATE (Line 1 f 2)............................................................
<br />$861,815.00
<br />4. TOTAL COMPLETED & STORED TO DATE (Column G on G703) .................
<br />$861,815.00
<br />5. RETAINAGE:
<br />a. 5.00 % of Completed Work
<br />(Column D + E on G703) $43,090.75
<br />b. 0 % of Stored Material
<br />Column F on G703 $0.00
<br />t
<br />Total Retainage (Lines 5a + 5b or Total in Column I of G703) ........I........
<br />$43,090.75
<br />6, TOTAL EARNED LESS RETAINAGE...................................................................
<br />$818,724.25
<br />(Line 4 Less Line 5 Total)
<br />7. LESS PREVIOUS CERTIFICATES FOR PAYMENT ............................................
<br />$651,453.95
<br />(Line 6 from prior Certificate)
<br />8. CURRENT PAYMENT DUE........................................................................ $167,270.30
<br />9. BALANCE TO FINISH, INCLUDING RETAINAGE
<br />(Line 3 less Line 6)
<br />$43,090.75
<br />CHANGE ORDER SUMMARY
<br />ADDITIONS
<br />DEDUCTIONS
<br />Total changes approved in previous months by Owner
<br />$0.00
<br />$0.00
<br />Total approved this Month
<br />$8,715.00
<br />$0.00
<br />TOTALS
<br />$8,715.00
<br />$0.00
<br />ET CHANGES by Change Order
<br />$8,715.00
<br />Code- 292-4-1600-4530
<br />rv-v' —)�
<br />APPLICATION NO: 003 Distribution to:
<br />PERIOD TO: June 30, 2023 OWNER: 0
<br />CONTRACT FOR: Roofing ARCHITECT: ❑
<br />CONTRACT DATE: January 17, 2023 CONTRACTOR: ❑
<br />PROJECT NOS: / 23-103 I
<br />FIELD: ❑
<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 from the Owner, and that current payment shown herein is now due.
<br />CONTRACT
<br />By:Date: June 22 2023
<br />State of:
<br />County of: Hennepin
<br />Subscribed an sworn to before
<br />me this day of Jtl K% raOay
<br />Notary Public:-__
<br />My Commission expires: C. 1 % 1 aox{
<br />KIM RENEE WRIGHT
<br />Notary Public
<br />Minnesota
<br />My Commission Expires January 31, 2024
<br />ARCHITECT'S CERTIFICATE FOR PAYMENT
<br />In accordance with the Contract Documents, based on on -site observations and the data
<br />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 />entitled to payment of the AMOUNT CERTIFIED.
<br />AMOUNT CERTIFIED...................................................................................... $167,270.30
<br />(Attach explanation if amount certified differsfrom 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:
<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 G702 1992. Copyright © 1953, 1963, 1965, 1971, 1978, 1983 and 1992. All rights reserved. "The American Institute of Architects," "American Institute of Architects," 'AIA," the AIA Logo, and "AIA
<br />Contract Documents" are trademarks of The American Institute of Architects. This document was produced at 14:08:44 CT on 06/2212023 under Order No.3104237269 which expires on 08/20/2023, is not for resale,
<br />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 docinfo@aiacontracts.com.
<br />User Notes: (369ADA51)
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