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<br />APPLICATION AND CERTIFICArE FOR PAYMENr ISUBSTITurE AlA DOCUI
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<br />2 PAGES
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<br />13-1,045"93
<br />'2' S11' [i-41. Slt
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<br />PROJECT: Arden Hills City Hall
<br />1245 West Highway 96
<br />Arden Hills, MN 551'2
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<br />TO (OWNERI: City of Arden Hills
<br />4364 West Round Lake Rd
<br />Arden Hills, MN 55112-5794
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<br />FROM [CONTRACTOR): Rochon Corporation
<br />3650 Annapolis Lane North, Suite 101
<br />Plymouth, MN 55447
<br />
<br />VIA IARCHITECTl: Architectural Alliance
<br />400 Clifton Avenue S.
<br />Minneapolis, MN 55403
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<br />003
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<br />9~,451'09
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<br />;'i:
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<br />(:ONTRACT DATE:
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<br />8/15100
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<br />CONTRACT FOR: General Construction
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<br />Application is made for Payment, as shown below, in connection
<br />with the Contract, Continuation Sheet, Substitute AlA Document
<br />G 703 is attached.
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<br />CONTRAcrOR'S APPLICATION FOR PAYMENT
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<br />CHANGE ORDER SUMMARY
<br />Change Orders approved in ADDITIONS DEDUCTIONS
<br />previous months by Owner 11"1,0<('1.'13
<br /> TOTAL
<br />Approved this Month
<br />Number Date Approved
<br />-+ 7/'1/0 I ~, '1 ~S'. 00
<br /> TOTALS 0.00
<br />Net change by Change Orders 1:,511.88 ,,<'<.010' .13
<br />
<br />a,613,548.SS 2, ~+2,ooo.Oo
<br />12.'''..' \ \ t, "Ia"l. '\"3-
<br />a.9&S,9B1.98 3,0,,".0, oc..'i..q~
<br />:;!,:le,ala.l:' 2./ 7~1, o,\"".oc;,
<br />
<br />.
<br />..........~...... $
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<br />1. ORIGINAL CONTRACT SUM
<br />2. Net Change by Challge Orders..
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<br />3. CONTRACT SUM TO DATE (line t +/-21........ $
<br />4. TOTAL COMPLETED 8< STORED TO DATEm...
<br />(Column G on G7031
<br />5. RETAJNAGE:
<br />
<br />0/0 of Completed Work
<br />(Column D+ E on G703)
<br />b. % of Stored Material
<br />IColumn F on G703)
<br />Total Retainage (line 5a+5b or
<br />Total in Column I of G7Q3)...
<br />6. TOTAL EARNED LESS RETAINAGE..
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<br />The undersigned Contractor certifies that to the best of the Contractor's
<br />knowledge, information and belief the Work covered by this Application
<br />for Payment has been completed in accordance with the Contract
<br />Documents, that all amounts have been paid by the Contractor for Work. for
<br />
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<br />13E,81:<!.lE
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<br />LSBO,ITI.81
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<br />which previous Certificates tor Payment were Issued and payments received
<br />from the Owner, and that current payment shown herein is now due.
<br />
<br />{Line 4 less line 5 Totall
<br />7. LESS PREVlOUS CERTIFICATES FOR
<br />CONTRACTOR: Rochon Corporation PAYMENT (line 6 trom prior Certificate) ... $
<br />8. CURRENT PAYMENT DUE....... ..... $
<br />By: /G?<L----rrate: September " 2001 9. BALANCE TO FINISH, PLUS RETAINAGE.... $
<br />
<br />2,511,441.54
<br />
<br />(pS7'7'~ I
<br />4si,"'o.:>S'
<br />
<br />96,n$.G
<br />11:,91a.9.a
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<br />
<br />(Une 3 less Une 6)
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<br />JeffWel
<br />
<br />County of: Hennepin
<br />
<br />State of; Minnesota
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<br />Subscribed and sworn to before me this 1st day of September, 2001
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<br />_....AAI'''^"''......''-^-''''--^-''~~
<br />.\~-( ..>').RDT "\
<br />:.{i_-it.\ .'r','" , ;:~ - !filNNESOTA
<br />@ ,;;" ~,,~',". c;,,,,, Jan. 3'. 2005 .
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<br />.
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<br />Notary Public:
<br />
<br />~~~ U- ;;! ~Vv1-N-f
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<br />My Commission expires: Januarv 31. 2005
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<br />12-,711, t:.I
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<br />(Attach explanation it amount certified differs from the amount applied for.)
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<br />AMOUNT CERTIFIED..............._............. .... $.
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<br />ARCHITECT'S CERTIFICATE FOR PAYMENT
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<br />In accordance with the Contract Documents. based on on-site observations
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<br />and the data comprising the above application, theArchitectcer tities 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 acco rdance
<br />with the Contract Documents, and the Contractor is entitled to payment
<br />
<br />:~p~l" 10 /z /0 (
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<br />I .
<br />This certificate is not negotiable. The AMOUNT CERTIFIED is payable
<br />only to the Contractor named herein. Issuance, payment and acceptance
<br />of payment are witl'1out prejudice to any rights of the Owner or Contractor
<br />under this Contract.
<br />
<br />at the AMOUNT CERTIFIED.
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