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<br />F'Jl.GE ONE OF ;2. FACiES
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<br />APPLICATION AND CERTIFICATE FOR PAYMENT ISUBSTITUTE AlA DOCUMENT G7021
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<br />TO IOWNet); Ciry 01 jl,rd~n Hilla
<br />4364 WltSr Rgund uklll Rd
<br />Artl1!In HIIII. MN S 5112-5794
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<br />PROJECT: Ar~ ~ Cil'J' H"
<br />1245 WIISl Highw;"" 96
<br />.A.rd~" HiII&. MM 551 12
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<br />APPl.JC:ATlO/'ll NO:
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<br />PERioD TO:
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<br />31.M;rrO'
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<br />F"OM [CONTRACTORI; Flo.::hon Corporation
<br />365Q AnnoltpoflJ Lane North. Suite 101
<br />PIVmouth, MN S~447
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<br />VIA lAfl:CHlTEC11: .6rc:hiLt~I...,.1 AllaM.
<br />400 C1if'l.on "\Ienue S.
<br />M;nnUpQrl$. MN 55.03
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<br />ARCHITECT'S
<br />PROJE:CT IlIQ:
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<br />CCNTfUl.CT FOR; Ge~ CGn~ltt.1C,jQn
<br />CONTRACTOR'S APPLICATION FOR PAYMENT
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<br />CHANGE OReER SUMMARY
<br />Ch..mgll o"'~r~ I!lllprov8d '" ADDITIONS DEOUCTIONS
<br />pI"~US months by Own8t
<br />TOTAL. 1l,S44.00
<br />ApprQ...ed tnla Month
<br />Numbar O;llle Apprcyl!l'll
<br />TOTALS 0.00
<br />Noll' ctlanDIt Dy ChOlnglll Or<1l!u 12.5+4.00
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<br />The u'"'t19rsillfled ConU'llelar <o:~fies lhflll to tl'lll best 0' I"'. Conuaato"$
<br />\.nowled!l9, Inr~l'!Y\atWn ilnd belief th.., Wo,k cllverl!Ml Ill", lhlll ..."pllud.....
<br />for Plillymel'lt Ila, been .::gmplel~ in eC:C:Dtda/'ttl'l Witl'l the Cornfllct
<br />Do<:um~nt5_ thel ell ,lI110UntB nit". bao:n pOlid by tbl!! Conltactot Illr Work for
<br />which prl!'o'lo\,lS Ccrtilil:m8 lef Pa,:m8I'1t WllfB Iss\,lsd itnd p;rym~ r$:ei...~
<br />rrcm Lhl! Owner. Il",d that cu~nt payml!nt shown tl.llleil'l Ie now (lue.
<br />
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<br />Datll.~ June 1. 2001
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<br />By;
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<br />. . ~~... ......
<br />10' JULIE K. ANDERSON I
<br />. ::~ NOTARY PUBUC - MINNESOTA
<br />'-'~ My COml1'l, uplfes. Jan. 31, 2OD5
<br />.~ ~ .
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<br />CONTRACT PATE:
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<br />BIlSJOO
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<br />Application Is made fot Payment. ilIll sho'Nn below_ in c:..mnel:tion
<br />will'l d'le (:o1"lUlct. Continuatiorl. Sheet. Substitute AlA DDcument:
<br />G70'3 is l!Ini!lc:h~.
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<br />1. O~IGIN"L CONTRACT SUMd._.....____n........._._
<br />2_ Net Chall''lgll by Chilnglll Qrdll"...nn_............_.___ $
<br />3. CONTRACT SUM TO DAn iU,..e 1 +/.%1..."...."... $
<br />4. TOTAL COMPLf.TEC & STORED TO DATE_.___n.... s
<br />ICglumn G on C0703)
<br />S. JU~TA.INlIoGE:
<br />1._--' of Co",p~cd w.......
<br />leg""'''''' D + IE" gn G7031
<br />D._ ~ or Storll'Cl MilIterlal
<br />ICol""''' F on G70:;!J
<br />ToOl Fletalni!]8 tUne 5a+6b CI'
<br />TCUlI i"l Column lot G7031.........".,-....-..... :;
<br />e. TOT.A.1. E.b.RN'eO U:SS RETAINAGE..n ................., a
<br />{Line 4 leas U1I6 5 ToQn
<br />7 _ \$SS PREVIOUS CERTlflCA TES FOJ:l
<br />PA.YMENT 11.inc 6 from Dtior CIll.rtJ1icittel..",
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<br />2.,9&2,000,00
<br />, 2, S4&.DO
<br />~,95.4_544.00
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<br />L,U.J,':'.~.~....
<br />2 ,'Z.o'5,001- "10
<br />
<br />11D11I~-~\
<br />
<br />, ,....~j~.ICl
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<br />., roc,," ~,:~"'tI
<br />Z.Oq,4Iir-;.ZIj
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<br />d 1.901,51.9JJ4 ~
<br />J -.3 ""71/';l..~
<br />.$ ~8li_,x.n
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<br />.I!_ CURf'lENT PA"I'MENT OUE.._........_m...._......_mn
<br />9. BAlANCE TO FINISH. P\.US RETAII'l.A.GL____._. :;
<br />
<br />8~ . ~v..L4
<br />~'$" 11..(.,0-,1
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<br />tUn~ 3 1O!ti UnQ G)
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<br />Stolte <If: MinndOa'!.
<br />
<br />County of; Hr:f1nepln
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<br />SIlb:5crib~ "nd swgm to karore me this 1st dn of J\,lno. ::l.001
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<br />_o'_(}~<---
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<br />to.4y C::ommL~'" expir~: January 31, 2005
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<br />AFlCj.lITE"t;T'S cmnAcATE FOR PAyMENT
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<br />In olIccordanc;:ol: with the ComraC:f Do~menu. tiMed on on-5if'e obs~"llioft'!l
<br />$nLl tt-e dUB CQfIlpri~l'1<i1 fh<; ablJ"'" ,.p~klltion, the Archttect c~"ifi~ 1IJ \h~
<br />O"'-n<lir f!'lll \0 me bGrt of tho Architect',", ..n"'....ledge, ;,..IOf",Btlon 20M brief the
<br />Worlo:. has ~r'O;,,,"ed _s IrJdlcilltc"lll. the qu~tv of Lhl! WrlflL is In 9(:"COrr;f;Inc,e
<br />...ith the C(lnUllct Ooc"",,nU. otnd the Conu.toetOf is &ntirllJO to plIyrr'lellt
<br />
<br />0' tr,e AMOUNT C~IFlED_
<br />
<br />1'1; 31J.Z1-
<br />AMOI.JNT CERTTFlfD............J....-n-..-......:lI
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<br />i,A.1t.-.ch ~Ianlltion it 811'l(llJrot c~fiod djtters fn;Im the. lImCunlllpolialllor.1
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<br />ARCHITECT:
<br />8Y'~
<br />
<br />
<br />08t.:
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<br />Thi5 etn.lriCf!lte ls: not: nl!JQti;:ll:lIo".
<br />ontv to thl!! CQnlnlc::tOr named !\erein. I:ssll.laonce., payml!!ftt mKI accep11lnCII
<br />of P'lyltlent are wtthalolt pre;udic:l!! to l!lny r1ahla of the OWMllr or Contr.lI:tOf
<br />Ul'ldllr;tUs:Ce>ntr.lCl_
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<br />roo I'D1
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<br />SiiIH N::I<IlIV ~
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<br />::I~NVliiV iVlll1L~aLIH~lIV
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<br />XV.:! IO:n
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