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...,, ,,,,,,i !sAIA Document G7021CMaTM - 1992 ;SRN o 7 2011 20406 Application and Certificate for Payment Construction Manager-Adviser Edition TO OWNER: CITY OF NEW BRIGHTON PROJECT: FAMILY SERVICE CENTER APPLICATION NO; 3 Distribution to: 803 OLD HIGHWAY 8 NW 400 - 10TH ST NW PERIOD TO: 01/05/11 OWNER 0 NEW BRIGHTON, MN 55112 NEW BRIGHTON MN 55112 RR-BUR 385 SOS CONSTRUCTION MANAGER ❑ FROM CONTRACTOR: McPhillips Bros. RoofingVA•CONSTRUCTION MAMA:INC CONTRACT DATE: 05/17/1D ARCHITECT 0 2590 Centennial Drive 5801 DULUTH ST PROJECT NOS: / / CONTRACTOR 0 St Paul, MN 55109 VIA ARCHITECT: MINNEAPOLIS MN 55422 FIELD ❑ CONTRACT FOR: ❑ CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge,information and Application is made for payment,as shown below,in connection with the Contract. belief the Work covered by this Application for Payment has been completed in accordance with the Continuation Sheet,AIA Document G703,is attached. 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 1.ORIGINAL CONTRACT SUM $ 540,000.0D payment shown herein is now due. 2.Net change by Change Orders $ ou CONTRACTO 3.CONTRACT SUM TO DATE(Line I ±2) $ B : ,J.t;'(-C XA.GC,*4L� S I s4s.000.00 Y Date: J� —U - t � 4.TOTAL COMPLETED&STORED TO DATE(Column G on G703) $ 548,000.00 State of: h0 I,..j .u- -r 1r� ,�'44'Q KIMBERLY J.PLEAU 5.RETAINAGE: County of: r ! a. 0610 of Completed Work `0.m � v NOTARY PUBLIC-MINNESOTA Subscribed and sworn to before i My Commission Expires Jan.31,2015 (Column D+Eon G703) $ .00 me this �41— y of . .G�,n�xvh`i o: — b. .o1%of Stored Material Notary Public: 1 . (Column F on G703) $ .oo My Commission expires: b\ — ;jy)j 4 U/1 Total Retainage(Lines 5a+5b or Total in Column I of G703). $ .no CERTIFICATE FOR PAYMENT In accordance with the Contract Documents, based on on-site observations and the data comprising 6.TOTAL EARNED LESS RETAINAGE $ saa,coo on this application,the Construction Manager and Architect certify to the Owner that to the hest of their (Line 4 Less Line 5 Total) knowledge,information and belief the Work has progressed as indicated,the quality of the Work is in 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT $ accordance with the Contract Documents,and the Contractor is entitled to payment of the AMOUNT 52°.6o0.OG CERTIFIED. (Line 6 from prior Certificate) ^� 00 8.CURRENT PAYMENT DUE $ 2i Q„o and AMOUNT CERTIFIED $ t 4c. , 9.BALANCE TO FINISH,INCLUDING RETAINAGE (Attach explanation if amount certified differs the amount applied. Initial all,figures on this Application and on the Continuation Sheer that are changed to conform with The amount certified) (Line 3 less Line 6) $ .oo CONSTRUCTION MANAGER: By: Date: CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARCHIT • Total changes approved in previous months by Owner $ oo $ oo By: Date: 1 I I Total approved this Month $ as $ n0 This Celt c e is not negotiable. The AMOUNT CERTIFIED is payabl only to the Contractor TOTALS $ nn $ nn named herein.Issuance,payment and acceptance of payment are without prejudice to any rights of NET CHANGES by Change Order $ 00 the Owner or Contractor under this Contract. CAUTION:You should sign an original AIA Contract Document,on which this text appears in RED.An original assures that changes will not be obscurca. AIA Document G702/CMan,-1992.Copyright CI 1992 by The American Institute of Architects.All rights reserved.WARNING:This AIA''Document is protected by U.S.Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AIA' Document,or any portion of it,may result In severe civil and criminal penalties,and wln be prosecuted to the maximum extent possible under the law. Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract Documents,e-mail The American Institute of Architects'legal counsel,copyright@aia.org.