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A.
<br /> `al, , Credit Memo
<br /> Document G7021CNIe - 1992
<br /> 20405
<br /> Application and Certificate for Payment Construction Manager-Adviser Edition
<br /> TO OWNER: rya r op crew BRIGHTON PROJECT: NEW easGET3N VULTER TREATMENT APPUCATION NO: 4 Distribution to:
<br /> 603 OLD N1GtrWAY a NW 3001 5Tu ST NW PERIOD TO: ct/os/1t OWNER 0
<br /> NEW BRIG1rrON, MN
<br /> NEW t3RlcarTON P30 55112 105 SOS BUR CONSTRUCTION MANAGER 0
<br /> FROM CONTRACTOR: ncP1illipa Bros. RoosingVIA•CONSTRUCTION IAAIBMGLR::tic CONTRACT DATE: OS/17/10 ARCHITECT 0
<br /> 2590 centennial Drive gaol SMOOTH ST PROJECT NOS: 1 1 CONTRACTOR 0
<br /> St Paul, MN 55109
<br /> VIA ARCHITECT: NF�tPOLrs tat 5sar_ FIELD 0
<br /> teur
<br /> CONTRACT FOR: — �Qv`S E' % — De
<br /> CONTRACTOR'S APPUCATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge.information and
<br /> made for payrrrcnL as below,in connection with the Contract. belief the Wait covered by this Application for Payment has been completed in accordance with the
<br /> Continuation Application is Sheet.AIA aymeL Documents shown is low,in Contract Documents,that all amounts have been paid by the Contractor for Work for which previous
<br /> Certificates for Payment were issued and payments received from the Owner, and that current
<br /> 1.ORIGINAL CONTRACT SUM S_ _ payment shown herein is now due.
<br /> 2.Net change by Change Orders S , , ,, , CONTRACTOR:---
<br /> 3.CONTRACT SUM TO DATE(Line I±2) S ,,7 -.co ea By: /�,. i�- :.,• '
<br /> 7 Date: I I 1 l
<br /> 4.TOTAL COMPLETED&STORED TO DATE(Column G on G703) S 107,200.00 State of: Mai / Yc"
<br /> 5.RETAINAGE: * el 3115 _v County of: ��.\,\;x`1 ' • • • e-:w `,
<br /> a. ;o5e•of Completed Wo v �� Subscribed and sworn to befog42....,zi, • ,,�uoU(: MiNNESOTA(Column D+Eon G703) t DS I�5 S ,00 me this �j`L'-• ilay of S�nua,,N.y t' oZ. '.,Ce''- sa3 Ewes Jan.31,205
<br /> b•ie�of Stored Match ��..yy��� Wotan•Public:- - /�
<br /> (Column Pon G703) I��)SW S My Commission cxptres OT- �,t =
<br /> Total Retainage(Lines 5a+5b or Total in Column I of G703). S n., CERTIFICATE FOR PAYMENT
<br /> In accordance with the Contract Documents,based on on-site observations and the data comprising
<br /> 6.TOTAL EARNED LESS RETAINAGE S •., -,,, ,,,r this application,the Construction Manager and Architect certify to the Owner that to the best of their
<br /> (Line 4 Less Line 5 Total) knowledge,information and belief the Work has progressed as indicated the quality of the Work is
<br /> iii
<br /> 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT S accordance with the Contract Documents.and the Contractor is entitled to payment of the AMOUN
<br /> IMIP
<br /> (line6 from prior Certificate) -'° C0`'" CERtIttLD. A511� + ,C
<br /> 6.CURRENT PAYMENT DUE . �j'�'')' 2,700.912.0.0.1, AMOUNT CERTIFIED - OD
<br /> 9.BALANCE TO FINISH,INCLUDING RETAINA E 1y 'J 11573 (Attach uple ation if amount certified differs from rite amour_'applied.Initial all figures on this
<br /> ` 5 1,0 CO Application and on the Continuation Sheet than are changed to conform with the amount certified.)
<br /> (Line 3 less Line 6) .00 CONSTRUCTION MANAGER:
<br /> 48 By: Date:
<br /> CHANGE ORDER SUMMARY v DITIONS I DEDUCTIONS I ARCH �_�& I
<br /> Total changes approved in previous months by Owner I$ S By: Date: i I D4!
<br /> 0 ,,
<br /> Total approved this Month S o I S , ay�
<br /> : 0„ This to is not negotiable.The AMOUNT CERi.ttitia is payable linty fi nty to e Contractor
<br /> TOTALS er I S ,�, n n, named herein.Issuance.payment and acceptance of payment are without prejudice to any rights of
<br /> NET CHANGES by Change Order 15 the Owner or Contractor under this Contract.
<br /> AL ran
<br /> CAUTION:You should sign an original AIA Contract Document,on which this teat appears in RED.An original assures that changes will not be obscured.
<br /> AIA Document G702JCMz"-1992.Copyright s 1992 by The American Institute of Architect:.Al rights reserved.WARNING:This me Document Is protected by US.Copyright Law and International Treaties.
<br /> Unauthorized reproduction or distribution of this AIAa Document or any portion of IL may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law.
<br /> Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copy^gPc violations of AIA Contract Documents,e-mait The American Institute of Architects'tool counsel,eopyrgtR®ata.org.
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