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APPLIS'~,ATION AND CERTIFICATION FOR PAYMENT ArA DocuNrENT c~o2 PAGE ONE OF PAGES TO OWNER: City, of Ellc River 13065 Orono Parkway Ellc River, MN 55330 FROM CONTRACTOR: RJM Construction, Inc. 5455 Highway 169 Plymouth, MN 55442 (`tINTR ACT FnR: General Construction PROTECT: Ellc River YMCA VIA ARCHITECT: BWBR Architects 380 St. Peter Street, #600 St. Paul, MN 55102 The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and belief the Work covered by this Application for Payment has been completed in accordance with the Contract Documents, that all amounts have been paid by the Contractor for Work for which previous Certificates for Payment were issued and payments received from the Owner, and that current payment shown herein is now due. Distribution to: OWNER ARCHITECT CONTRACTOR 0 0 CONTRACTOR'S APPLICATION FOR PAYMENT Application is made for payment, as shown below, in connection with the Contract. Continuation Sheet, AIA Document G703, is attached. ORIGINAL CONTRACT SUM Net change by Change Orders CONTRACT SUM TO DATE (Line 1 f 2) TOTAL COMPLETED & STORED TO DATE (Column G on G703) RETAINAGE: a. % of Completed Work (Column D + E on G703) b. % of Stored Material (Column F on G703) Total Retainage (Lines Sa + Sb or $ 10,926,201.00 $ 0.00 $ 10,926,201.00 $ 1,911,447.00 $ 84,392 Total in Column I of G703) 6. TOTAL EARNED LESS RETAINAGE (Line 4 Less Line 5 Total) 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT (Line 6 from prior Certificate) 8. CURRENT PAYMENT DUE 9. BALANCE TO FINISH, INCLUDING RETAINAGE (Line 3 less Liue 6) $ 84,392.00 $ 1,827,055.00 $ 613,674.00 $ ~21t .1;381:00:`: $ 9,099,146.00 CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS Total changes approved in revious months b Owner $0.00 Total a roved this Month TOTALS $0.00 $0.00 NET CHANGES by Change Order $0.00 CONTRACTOR: RJM Construction, Inc. .+~~ By. _ ~ _ Date: 12/10/2007 State of: Minnesota County of: Chisago Subscribed and sw to b~ re e this 10 day of Dec bero~~+,, SARA L HOI.T Notary Public: :~" ~_ My Commission a pires: 1/ /2010 ~ ~ NOTARY PUBLIC APPLICATION NO: Three PERIOD TO: 11/30/2007 PROJECT NOS: 207197 CONTRACT DATE: ARCHITECT'S CERTIFICATE FOR """""""'"" Irt accordance with the Contract Documents, based on on-site observations and the data comprising the application, the Architect certifies to the Owner that to the best of the Architect's knowledge, information and belief the Work has progressed as indicated, the quality of the Work is in accordance with the Contract Documents, and the Contractor is entitled to payment of the AMOUNT CERTIFIED. i AMOUNT CERTIFIED ........... $ ~ ZI Y (Attach explanation if amount certified differs from the amount applied. Initial all figures on this Application and onthe Continuation Sheet tha are changed to conform with the amount certified.) ARCHITECT: APC~11$~CtS, ~Clti. 1 By; Date: !~ ~^'' This ertific a is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of the Ov~mer or Contractor under this Contract. AIA DOCUMENT G702 ~ APPLICATION AND CERTIFICATION FOR PAYMENT ~ 1992 EDITION •AIA®~ ®1992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE., N.W., WASHINGTON, DC 200065292 Users may obtain validation of this document by requesting a completed AIA Document D401 -Certification of Document's Authenticity from the Licensee.