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<br />APPLICATION AND CERTIFICATE FOR PAYMENT ISUBSTITurE AlA DOCUMENr G702)
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<br />PAGE ONE OF 2 PAGES
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<br />TO !OWNER}: City of Arden Hills
<br />4364 West Round Lake Ad
<br />Arden Hills, MN 551'2-5794
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<br />PROJECT: Arden Hills City Hell
<br />1245 West Highway 96
<br />Arden Hills,MN 55112
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<br />fROM (CONTRACTOR]; Rochon Corporation
<br />3650 Annapolis Lane North, Suite 101
<br />Plymouth, MN 55447
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<br />APPLICATION NO: 13
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<br />PERIOD TO:
<br />
<br />30-Sep"Ol
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<br />VIA (ARCHITECT]: Architectural Alliance
<br />400 Clifton Avenue S.
<br />Minneapolis, MN 55403
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<br />ARCHITECT'S
<br />PROJECT NO:
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<br />CONTRACT FOR; General Construction
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<br />CONTRACT DATE:
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<br />CONTRACTOR'S APPLICATION FOR PAYMENT
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<br />8/15/00
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<br />CHANGE ORDER SUMMARY
<br />Change Orders approved in ADDITIONS DEDUCTIONS
<br />previous months by Owner
<br /> TOTAL 118,069.93
<br />Approved this Month
<br />Number Date Approved
<br />5 10/9/2001 21,459.00
<br /> TOTALS 21,459.00
<br />Net change by Change Orders 139,528.93
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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
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<br />which previous Certificates for Payment were issued and payments received
<br />from the Owner, and that current payment shown herein is now due.
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<br />By:
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<br />
<br />Date: October 1,2001
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<br />Jof
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<br />"
<br />"\ ,. GRACE L. BURGHARDT \
<br />~ NO'-' -:,'J r~i311C - MINNESOTA
<br />~ r>i ~:~'":,::.:,, l>.>:rC$ Jan.. 31,2005 .
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<br />"
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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 />G703 is attached.
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<br />1. ORIGINAL CONTRACT SUM..... ........................ $
<br />2. Net Chi'mge by Change Orders.. ....................... $
<br />3. CONTRACT SUM TO DATE (Line 1 +/-2)...
<br />4. TOTAL COMPLETED & STORED TO DATE.........
<br />[Column G on G703)
<br />5. RETAINAGE:
<br />a. % of Completed Work
<br />(Column D + Eon G703)
<br />b._% of Stored Material
<br />(Column FonG703)
<br />Total Retainage [Line 5a+Sb or
<br />Total in Column I of G703)..
<br />
<br />2,942.000.00
<br />139.528.93
<br />3,081.528.93
<br />i,e8e,95I.ti 2,g'\~,tC.).1'
<br />
<br />11E,i31:'.:"!1
<br />2,:'S1,S8S.!:5
<br />
<br />11-('1,''11",.1\,0
<br />2,15"t 3'>0_
<br />
<br />2,"01,'6"12. ~3
<br />14'1,'/<;7.<;0
<br />~zt I n~'''1 0
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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
<br />and the data comprisIng the above application, the Architectcertlfles to the
<br />Owner that to the best of the Architect's knowledge, information and belief the
<br />Work has progressed as indicated, the quality of the Work is in accordance
<br />with the Contratt Documents, and the Contractor is entitled to payment
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<br />of the AMOUNT CERTIFIED.
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<br />6. TOTAL EARNED LESS RETAINAGE_
<br />(Line 4 less Line 5 Totall
<br />7. LESS PREVIOUS CERTIFICATES FOR
<br />PAYMENT (line 6 from prior Certificate!.... $
<br />8. CURRENT PAYMENT DUE............................. ... $
<br />9. BALANCE TO FINISH, PLUS RETAINAGE.....
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<br />:l,SQ1,03G'.1:2!
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<br />"i:' i€: 14
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<br />919,91'.::.98
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<br />[Line 3 less line 6)
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<br />State 01: Minnesota
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<br />County of; Hennepin
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<br />Subscribed and sworn to before me this 1st day of October, 2001
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<br />NOl"Y:d~ce-;t dS~~
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<br />My Commission expires: January 31, 2005
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<br />{ifCf, Vr7.VD
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<br />lAttach explanation it amount certified differs from the amount applied tor.!
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<br />AMOUNT CERTIFIED................_... .............$
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<br />ARCHI~
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<br />B,,1t "
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<br />This certificate is not negotIable. The AMOUNT CERTIFIED is payable
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<br />(6ft)! /r; (
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<br />only to the Contractor named herein. Issuance, payment and acceptance
<br />of payment are without prejudice to any rights of the Owner or Contractor
<br />under this Contract.
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