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<br />APPLlCArlON AND CERTIFICATE FOR PAYMENr [SUBSrlrUTE AlA DOCUMENT G7021
<br />
<br />PAGE ONE OF 2 PAGES
<br />
<br />TO (OWNERI: City of Arden Hills
<br />4364 West Round lake Rd
<br />Arden Hills, MN 55112-5794
<br />
<br />PROJECT: Arden Hills City Hall
<br />1245 West Highway 96
<br />Arden Hills, MN 55112
<br />
<br />FROM (CONTRACTOR): Rochon Corporation
<br />
<br />APPLICATION NO:
<br />
<br />12 IADJUSTED)
<br />
<br />PERIOD TO:
<br />
<br />31"Aug-Ol
<br />
<br />3650 Annapolis Lane Nonh, Suite 101
<br />Plymouth, MN 55447
<br />
<br />VIA (ARCHITECT): Architectural Alliance
<br />400 Clifton Avenue S.
<br />Minneapolis, MN 55403
<br />
<br />ARCHITECT'S
<br />PROJECT NO:
<br />
<br />CONTRACT FOR: General Construction
<br />
<br />CONTRACT DATE:
<br />
<br />8115/00
<br />
<br />tit
<br />
<br />CONrRACTOR'S APPLICATION FOR PAYMENT
<br />
<br />CHANGE ORDER SUMMARY
<br />Change Orders approved in ADDITIONS DEDUCTIONS
<br />previous months by Owner ll'i,"'a'1''f,3
<br /> TOTAL 13,1:11.90
<br />Approved this Month
<br />Number Date Approved
<br />+ ,-'1- <>1 3,"Ir::;.OO
<br /> TOTALS 0.00
<br />Net change by Change Orders 1<1,(11.aO'" llr <>t.'1.'f3
<br />
<br />The undersigned Contractor certifies that to the best of the Contractor's
<br />knowledge,informationarld belief the Work covered by IhisAppl icatiorl
<br />for Payment has been completed in accordance with the Contract
<br />Documents, that all amounts have beerl paid by the Contractor for Work for
<br />which previous Certificates for Payment were issued and payments received
<br />from the Owner, and that current payment shown herein is now due.
<br />
<br />Application is made for Payment, as shown below, in connection
<br />with the Contract, Continuation Sheet, Substitute AlA Document
<br />G703 is attached.
<br />
<br />1. ORIGINAL CONTRACT SUM......
<br />2. Net Change by Change Orders
<br />
<br />...$
<br />,
<br />
<br />'3 'Clla,S46.!lJ"
<br />
<br />--
<br />
<br />3. CONTRACT SUM TO DATE (Line 1 +/-21 ........... $
<br />4. TOTAL COMPLETED & STORED TO DATE..
<br />(Column G on G703}
<br />5. RETAINAGE:
<br />
<br />'] Qi'" nOA no:>
<br />
<br />2,14S,8.5.IT
<br />
<br />a._% of Completed Work
<br />(Column D + Eon G703l
<br />b. % of Stored Material
<br />(Column F on G703l
<br />Total Retainage (Line 5il +5b or
<br />Totill in Column I of G703).m
<br />
<br />,
<br />
<br />1",,'" ail ":I 1<':
<br />
<br />6. TOTAL EARNED LESS RETAINAGE
<br />
<br />V;8B,L"'1.S"
<br />
<br />(Line 4 less Line 5 Total)
<br />7. LESS PREVIOUS CERTIFICATES FOR
<br />
<br />2,511,441.54
<br />81>,:':;1e.1":'
<br />
<br />PAYMENT (Line 6 from prior Certificatel. .. $
<br />8. CURRENT PAYMENT DUL...
<br />Date: September 1, 2001 9. BALANCE TO FINISH, PLUS RET AINAGE
<br />(Line 3 less Line 6}
<br />
<br />CONTRACTOR: Roch n Corporation
<br />
<br />By:
<br />
<br />JeffW
<br />
<br />resident
<br />
<br />. "^^^^^^"-";"......'.......,,...;"J'._,,/...,.,'/"v'.A_ .....~.
<br />lr'Z?0 .C,C:,': L. cuRGHARDT f
<br />'-<,-~.. ,,; .,;" . r-!_=UC - r,1INNESOTA
<br />~ L':j~ :~:~~~. Ex~ir6S Jan. 31, 2005
<br />.~.....T...".,..,."H.VI.,.A..,.V...
<br />
<br />11:".913.92
<br />
<br />State of: Minnesota
<br />
<br />County of: Hennepin
<br />
<br />2~~"?-jo4G'.t:Jo
<br />liS ,,1.'\.'1;
<br />,
<br />,3. """, ot.'1."'I"
<br />2,1"11, o'\'i .O~
<br />
<br />I ~1 0"5'1.7c
<br />J
<br />;;Z'''.'t'Oe3~
<br />
<br />"12,5'7' "i>
<br />-+'5'10,0::;0.5.
<br />
<br />ARCHITECT' 5 CERTIFICATE FOR PAYMENT
<br />
<br />In accordance with the Contract Documents, based on on-site observations
<br />and thedilta comprising the above application, the Architectcert ifies to the
<br />Owner that to the best of the Architect's knowledge. information and belief the
<br />Work has progressed asindicated,the quality of the Work is in acc ordance
<br />with the Contract Documents. and the Contractor is entitled to payment
<br />of the AMOUNT CERTIFIED.
<br />
<br />Subscribed and sworn to before me this 1st day of September. 2001
<br />
<br />NotaryPubhc /(
<br />
<br />-~/\UC-L -<
<br />
<br />~~~$
<br />
<br />My Commission expires: January 31. 2005
<br />
<br />AMOUNT CERTlFIED..................m............$
<br />
<br />12,9f1.r/
<br />.
<br />
<br />lAttach explanation if amount certified differs from the amount ap pliedfor.l
<br />
<br />::.7fJiJu;tW1!v. t~/ r: /6 !
<br />
<br />This certificate is not negotiable. The AMOUN'T CERYl FlED is payable
<br />only to the Contractor nilmed herein. Issuance, payment and acceptance
<br />of payment are without prejudice to any rights of the Owner or Contractor
<br />under this Contract.
<br />
<br />e
<br />
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