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<br />Application and Cer~rfcate for Paymen#
<br />TO OWNER: RROJEGT: APPL#GATtON NO: „ [3is#t#bution to:
<br />Cr1y or ENt E2evsr Erk Rrxn PPMiz i
<br />pER~O#~ Ta Ot1VNER I
<br />~,mp
<br />F GANTRACT FOR: ter ARCl~1TEC~ l~
<br />FROM GONTRAGTOR: at~+++~c~,~sra,«,co.,t~. V(A ARGMT'ECT; ~~ GONTRAGT [SATE:
<br />ra5sr s~,:.ne~~an swear r~ r ~~st a„~. nrortn CC)NTRAGTDR
<br />easraetr~t.atowsscirr raxssaot PROJECT NOS; '~ 1
<br />FIELD p
<br />aT}iE~ ~
<br />C©NTRACTUR'S APPLICATION F~3R PAYMENT The uncierigned Cr~nirtrtor certifies that t~, [ltc. hest of the Cantractar"s kna~3~led~e, inffarnt:stian
<br />r1pP9ic,=3uun is made far paynacnt, as shown bciaev, in eannectiott e~it}t the C°crrrtract. ancf belief the Z~'r~rk coti~cred by this A~~i?i~c.utc~Ei fcrr P;~ nient Iran been carnpletr;ci in accardanee
<br />C`,},u,tt~~,~ttart Staeet, CIA-L)acutnent C;7{~3, is attacEred. ~°itFt thc~ C:antract t),r~nn~ent'w, thaC a1I z~rn ~unt~. ha,c becn Paid by tlae Cantractar ftrr Nark tcrr
<br />which Previatts Certificates far Payment acre issued and Paytncnts r~eiveti from rite O~t~ner, .1rtd
<br />#. ORIGth1AL CONTRACT SUM ....... that earrent Payment strewn herein is ~~r, r :<
<br />2. Nt:t change by Change Orders ...: ----'~~'-,---~~~~ ~'t'~ '
<br />..........•.....,... ~+ CONTRACTOR: ~~ nCa.,tnc~ f
<br />3. CONTRACT SUM TO DATE (Line I + 2) ..:: ...... ~~ t~.s~.wi _ ~y_ ~ ~ Date:
<br />4. TOTAL COMPLETED & STORED TO DATE ("aimm~ G an C;7Ci3 ~~---~'~`7°~~- ~ -
<br />~ _ ) ...... ~ _ Starts af:
<br />5. RETAINAGE: ~ ssar.~tsto ~ , . f. ~„~
<br />a. Sc of Cantli}eted 1'~ark
<br />(C aluitin i? + ff an Ci7C):3)
<br />b• ~3 of Stared Ivtaterial
<br />(Crahtntn Fztn C;7(13?
<br />~ ass r,,a_sa
<br />aunt}-a .
<br />Strltscrilted and. 5i$n to befai•e
<br />the thin ~ daynf ~(,~t1P~~,r,
<br />l ~ ~a ~,, s~~%"
<br />iti?btary Pttbli~':.: ~ ~!%.', , ,. - ' =
<br />hey Contmi . ion exk?ire4:
<br />rj3,f/~
<br />~ ~ t ~'~~ ~ JOHN
<br />~~~, t:prRRYPUB G11~/Ij,j ~R
<br />~" ~YCrSrrr,~pE: M1ty~ESO7q
<br />first Jdm. 3e, PAPp
<br />Total iietainagc tLine Sa + 5h ar Tatal in Cahttntt f of G7CI3}......_ S
<br />6: TOTAL EAt2NED'LESS RETAINAGE ................ aresaz:ss
<br />(Line ~ Less Line 5 Tatal} 3,~+~
<br />7. LESS PREVIOUS CERTIFICATES FOR PAYMENT ....... ...............
<br />(Line ft firrm Prior' Certificate)
<br />8, CURRENT PAYMENT DUE .......................:.................... $ 311~y16 , ~~,
<br />9. BALANCE TO FINISI{, tNCLUt3iNG RETAINAGE ---
<br />~Line 3 less Line 6) S
<br />CII.r1t~3C.iL:C7ttD1^RSL'~d~i,\RZ' ~ s~I~E~IT1C)}~S DPDUC;'I'IC)NS
<br />'fatal chan~r,s aPPCat ect in luecttxis ntt?ltths by f)LVner ~~a ~~ ~
<br />Tatal aPProti'cd tlUs tii(3nt}t c~ titl.24t}.tMl
<br />°i't)TAi.S S e a.rta S
<br />Ivt:T CfiA1~1CiGS b C'han~e Order _
<br />CAUTION- Y h ~+ to raa exi>
<br />-
<br />ARCHITECT'S CERTIFICATE FOR PAYMENT "~`°"~'~-
<br />In ace;ardartee t~ith the f~anirar Dacttrnents, based an an-site ah~rvatians and the datzt camprising
<br />this aPirlicatirrn, the tlrchitect certifies to We C3wner that to the best of the At~hitect~s knot~fedge,
<br />infarnx~~ttion and belief the: Work has Pragressed as indicated; the quality of the. Nark is in
<br />aecordattce w°idt the: Cantract Dacuments, and the Cantractar is entitled to Itaymettt of the
<br />.Altsft:?UNT cERTti'IED. ~ ~ ~ ~ ~ ~, , ~'_~
<br />AMOUNT CERTIFIED ................................... ....~.,:. :::......
<br />(Attnch er~re~rt~tlprr of crrr,orrart c~crr-ti fled rtijfe~rs ft'orr€ flux cerracjrrnt er frPlied. hritiad rrCl~grrres care this
<br />~1rrPliccrifarr rrrrct rrtt thra L'r+r.f+rttrtrtirrrt Sfrc~t Heat ckr-e rircvr;~crd ttr cvr[ftzrarr lt~~itlt tfrrs rrstnterrrcerti~cr{.}
<br />ARC ~
<br />Ry ~ Date; _~
<br />_'-~~.
<br />`t'his rc ~ rs not nc~+rtiable. 'i're A~~it7l7t~F'I' Ci'RT`i~ifiD is payable aztiy rat c C~krntrttctar
<br />Warn . terein. Is~~.rutct'. h~~°ttteatt and ac~;eptance of Payrnettt <tre wititont t~rejtrdice to mnyrights of
<br />the Owtter ar Cantractar uncic;r this Contract
<br />~_ ___ ~ °n s oultl slrJn an original AIA Coniracl Document, onwhlch this text appears in RED. Alt origlnat assures that changes wits not ~e obscured.
<br />AtA Document G702ra-1992. Capyright ~~ 1953. 1903, 1965, 1971, t97i3, t983 and 1992 by Tare American Ins€iture of Archdtects. All rights reserved. wAffPAfdG: This A6As Docurrrent is protected try tl,S. Capyrighf Lavr
<br />and iniernatianal Treaties. Unautfroriaed reproducfian ar distribution of arts AIA~' Document, at any poriian of it, may result in severe civil artd criminal penalties, a€rd will be prosecuted to the maximum exfenk
<br />passible under tits law. Pushasers are permitted to repraduca tan (t tai copies of itr4s doerrmen! vrhen campieied. To repoR Capyright viaiations of AIA Coniraet Oooumenis, e-mail The Amer,eatt histituta of Arahit~is' regal
<br />ccrunsei, Capyrighi~aaa.aag_
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