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APPLICATION AND CERTIFICATE FOR PAYMENT TO OWNER: NEW BRIGHTON PROJECT: APPLICATION NO: 2 Distribution to: 803 OLD HIGHWAY 8 NW TOWER REPAIR AND RECONDITIONING PERIOD TO: 7/10/2013 OWNER NEW BRIGHTON,MN 55112 CITY OF NEW BRIGHTON PROJECT NO(M): X ENGINEER CONTRACTOR FROM CONTRACTOR: CHAMPION COATINGS CONTRACT DATE: 9/14/2012 _ 7385 WEST I26th STREET _ SAVAGE,MN 55378 VIA ENGINEER: PURCHASE ORDER 6 BOLTON&MENK CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor uNfies that to the best of the Coetractor'n knowledge,Information and belief the Work Application is made for payment,as amain below,in connection with the covered by this Application for Payment has been completed In accordance with the Contract Documents,that all Contract Continuation Sheet. amounts have been paid by the Contractor for Work for which previous Certificates for payment shown herein is now due 1.ORIGINAL CONTRACT SUM S 278,000 CONTRACTOR: 2. Net change by Change Orders .. S 0 By' .,..ca_.... ........, Date: 7/11/2013 3,CONTRACT SUM TO DATE(Line l+2) $ 278,000 Robert Cox I State of Minnesota 4.TOTAL COMPLETED&STORED TO DATE 5 269,000 County of Scott - yam Subscribed and sworn to before me thin 1 Ith day of July, 2013 `� 4,.4:, SHERRI MOHN- pp ti „��' 1f' NOTARY PUBLIC-MINNESOTA 5,RETAINAOE; �� S •"%tfF T{l r My Commission Expires Jan.31,'2016 a. 5 %of Completed Work S 13,450 Notary Public: ,.,i1).D......1.—....) (Column D+E) b._%of Stored Materiel S 0 My Commission expira:C� 31 irl� (Column F) ENGINEER'S CERTIFICATE POR PAYMENT 6. TOTAL EARNED LESS RETAINAGE S 255,550 (Line 4 leas Line 5 Total) In accordance with the Contract Documents,based on or-site observations and the data comprising this application, ^ieat the Architect certifies to the Owner that to the best of the Architect's knowledge,information and belief the Work has 7.LESS PREVIOUS CERTIFICATES POR PAYMENT progressed as indicated,the quality of the Work is in accordance with the Contract Documents,and the Contractor (Line 6 from prior Certificate) S VMS' (76,300 -- is entitled to payment of the AMOUNT CERTIFIED. /� i, CURRENT PAYMENT DUE 5 793?5 / /6, Z 7 J AMOUNT CERTIFIED...............................................„._...._,........._............$ 3-Ci` S' V V (Attach explanation(f amount certified differs from the amount applied for Initial all figures on this 9,BALANCE TO FINISH,INCLUDING RE TAJNAGE Application and on the Continuation Sheet that an changed to conform to the amount certified (Line 3 less Line 6) 'S 22,450 CHANGE ORDER SUMMARY I ADDITIONS DEDUCTIONS /5- I a 7)13 Total ehingea approved in By: fg-1 Dam' d previous months by Owner Total approved this Month This Certificate is not negotable.The AMOUNT CERTIFIED is payable only to the Contractor named herein TOTAL Issuance,payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor NET CHANGES by Change Ordr under this Contract. G Cry/ ,,.,r 7�Z 21l/3 —