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<br />=�-_ DQcument G702 —199Z
<br />292-4-1600-4530
<br />� vv��
<br />Applrca#ron and Certr�'rc�te for Payment
<br />TO OW�fER: City of Elk Rive�• PROJECT: EEk River Ciiy Hal] Reresof APPLICATION' N0; 004 F'inal Distribution to:
<br />13065 Orona Parkway i3065 Qrono Parkway pERIOD TD: 7uly 31, 2(l23 OWNER: ❑
<br />Elk River, MN 5533a Elk River, �N 55330 CONTRACT FOR: Roofing ARCHITFGT• f—I
<br />FROM Palmer West Constre�ctioa� Campany, VIA
<br />CONTRACTOR: inc. ARCHITECT:
<br />14595 James Road
<br />Rogers, MN 55374
<br />CONTRAGT�R'S r�PPLfCATiON FOR P'AYM�NT
<br />Application is made for payment, as shawn below, in connection with ihe Contract.
<br />AIA Doeunnent G7Q3�', Continuation Sheet, is attached.
<br />7. ORIGINAL CONT�ACT SlJM ................................................................................ �853,ioo.ao
<br />2. NET CHANGE BY CHAN6E ORDERS ................................................................. $8,715.00
<br />3. C�ONTRACT SUM TO DATE {Line 1� 2} ............................................................ 5861,$15.00
<br />4. TOTAL COMPLETED & S�ORED T� DATE (Cc�lumn G on G7a3) ................. $861,815A0
<br />5. RETAINAGE:
<br />a• 0 °lo of Cornpleted Work
<br />(Column D = E an G703) $0.�0
<br />b. 0 % of Stored 1vlaterial
<br />(Column F on G7Ct3} $0.40
<br />Total Retainage (Lines 3a + Sb ox Total in Column I of G703) ................. $0.!}0
<br />6. 70TAL EARNED LESS RETAINAGE ................................................................... $861,815A0
<br />{3.ine 4 Less Line S Total)
<br />7. LESS PREVIOUS CERTIFICATES FOR PAYMENT ............................................ $818,724.25
<br />{Line 6 from prior Certificate)
<br />$. GURRENT PAYMENT DU� .......................................................................... $43,090.75
<br />9. BALANCE TO FIN'1SH, INCLUDING RETAINAGE
<br />(Line 3 9ess Line 6)
<br />$0.00
<br />CHANGE ORDER SUMMARY ADDITI�NS DEDUCTIONS
<br />�'ota[ changes approved in previa�s monihs by pwner $&,715.00 50.00
<br />Total approved this Month $p_p{} $p,Qq
<br />TOTALS $8,715.�0 $O.pp
<br />ET CHANGES b Chan e Order $8,715.0€}'
<br />C4NTRACT DATE: 7anuary i 7, 2Q23
<br />PROJECT NOS: � z3-lo� r C�NTRACTOR: ❑
<br />FIEL€?: ❑
<br />OTHER: 0
<br />The undersigned Cqntractor eerti%es that to the best of the Contractor's knowledge,
<br />inforrnation and belief the Work covered by this Application for Payment h�s been
<br />compieted 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 rece�ved from the Owner, and that current payment shown herein is naw due.
<br />CflNTR9t� R:
<br />By�.
<br />SFate of MN
<br />Date; July 25, 2023
<br />County of: Hennepin
<br />Su6scribed and sworn to before
<br />me this �� day of Ju�•n ���'�
<br />..�, �,r,�,; KIM FiEN�E WRIGF�T
<br />;���'�,;,: !�lote�ry Public
<br />� �,��.�,��;= N�innesata
<br />Nota�y Pub1�^•,,.��--t
<br />��� - ,� �rCommisaio� E�piresJa�uary 31, 2624
<br />My Commission expires: p� j•� � C�p �1.{
<br />ARCH�TECT'S CERTIFICATE F4R P�AYMENT
<br />In accordance with the Contract Docurnents, based on on-site olaservations and the data
<br />comprising this applicatian, the Architect certi�cs to the Qwner that tQ the best oF the
<br />Architect's knowledge, information and belief ihe Work has progressed as indieated, the
<br />c�uality of the Work is in accordance with the Contract Docut�ents, and the Contractor is
<br />entitled to paym�nt of the AMOLJNT CERTIFIED.
<br />AMQUi�fT CERYIFIED ..................................................a................................... $43,090.75
<br />(.4ttach �planatio�z if amaunt certifred differs from the amount appliea'. Initial allfigures on this
<br />�Ip�lication and on the Continuation Sheet that are chm�ged to conform tivitl� the amount certifred.}
<br />ARCHITECT:
<br />By: Date:
<br />This Certificate is not negotiable. The AMOUNT CBRTIFIED is payable only to tl�e Contractor
<br />named herein. Issuanee, payment and acceptance of paymen[ are without prejudice to any ri�;hts of
<br />the Owner or Contraetor under this Contract.
<br />AIA Document G7D2 — 1992. Copyrlghf � 1953, 1963, 1965, 1971, 1978, 1983 and 1982. All rights r�served. "The American Institute of Archite�t5," "American Institute of Architects," "AEA," the AIA LQgo, and "AIA
<br />Cantraci Documents" are trademarks af The American Institute oF Architects. This doc�ment was produced at 13:00:23 CT on 07/2512423 under Order No.3104237269 which expires on 08/2Q12023, ia not far resale,
<br />is licensed foe one-time use only, and may only be used in aceordance with the AIA Contraat Docurnents� Terms of 5ervice. 7o report co,�yright violaticans, e-mail docinfo@aiaeantracts.eam.
<br />User Nates: (3B9A�A49)
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