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.. ~ . . . '. APPLICATION AND CERTIFICATE FOR PAYMENT (SUBSTITUTE AlA DOCUMENT G7021 PAGE ONt: OF 2 PAGES TO (OWNER): City of Arden Hills 4364 West Round Lake Rd Arden Hills, MN 55112-5794 PROJECT: Arden Hills City Hall 1245 West Highway 96 Arden Hills, MN 55112 FROM (CONTRACTORl: Rochon Corpor~t;on APPLICATION NO: PERIOD TO; 3D-Sep-OO 3650 Annapolis Lane North, Suite 120 Plymouth, MN !J5447 VIA [ARCHITECT): Architectural Alliance 400 Clifton AvenueJ S. Minneapolis. MN 55403 ARCHITECT'S PROJECT NO: CONTRACT FOR: General Construction CONTRACT DATE: 08/15/2000 CONTRACTOR'S APPLICATION FOR PAYMENT CHANGE ORDER SUMMARY Change Orders approved in ADDiTIONS DEDUCTIONS previous months by Owner TOTAL 0.00 Approved this Month Number Date Approved TOTALS 0.00 Net change by Change Orders 0.00 The undersigned Contr(lctor certifies that to tile best of the Contractor's knowledge, information and belief the Work covered by this Application lor Payment has been completed in accordance with the Contract Documents, that ;;11 amounts have belJrl paid by the Contractor for Work far which previous Certificates for Payment were issued and payments received from the Owner, and tha: current payment shown herein is now due. CONTRACTOR: Rochon Corporation /"/ //'7C--- - U/ By: / ~_ 7;7// ,~- Jeflvrre an - Vice President Date: October 1, 2000 Subscribed and sworn to before me this 1 st day of October, 2000 .~~. i GRIC I 8URGHARDT , g!l T'''- 'r:~ Pile - MINNESOTA ~2:;), s Ex<=, res Jan. 31, 2005 .....,.,..,..rN~. Application is made for Payment, as shown below, in connection with the Contract, Continuation Sheet, Substitute AlA Document G703 is attached. 1. ORIGINAL CONTRACT SUM.. 2. Net Change by Change Orders 3. CONTRACT SUM TO DATE ILine 1 +/-2).. , 4. TOTAL COMPLETED & STORED TO DATE.. (Column G on G703) 5 RETAINAGE: % of Completed Work iColumn D + E on G7031 b. % of Stored Material IColumn F on G703J Total Retainage (Line 5a+5b or Total in Column I of G703).. . 6. TOTAL EARNED LESS RET AINAGE." ILine41ess Line 5 Total) 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT ILine 6 from prior Certificate} ...$ 2,942,000,00 0.00 2,942,000.00 55,498.67 2,774.93 52,723.74 8, CURRENT PAYMENT DUE.. . 9. BALANCE TO FINISH, PLUS RETAINAGE.. .$ $ 0.00 52,723.74 2,889,276.26 (Line 3 less Line 6) State of: Minnesota County of: Hennepin Notary Public: Z~~ ~d/"0.4. C-L. My Commission expires: January 31, 2005 ARCHITECT'S CERTIFICATE FOR PAYMENT AMOUNT CERTIFIED.... t, .............$ '52., 72-~. 7~ in accordance with the Contrar;tDocuments, based on on-site observations and the data comprising the above application, the Architect certifies to the OWller 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 acco rdance with the Contract Documents, and the Con:ractor is entitled tD payment 0; the AMOUNT CERTIFIED (Attach explanation if amount cHrtified differs from the amount applled for.I ARCHITECT: By,.c::/ -~ D,t" lo-ll-oO This certificate 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 rigllts of the Owner or Contractor under this Contract.