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<br />PAGE ONE OF 2 PAGES
<br />
<br />APPLICATION ANO CERTIFICATE FOR PAYMENT (SUBSTITUTE AlA DOCUMENT G7021
<br />
<br />TO (OWNER): City of Arden Hill5
<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 />APPLICATION NO:
<br />
<br />'4
<br />
<br />PERIOD TO:
<br />
<br />31.0ct.Ol
<br />
<br />FROM ICONTRACTOR): Rochon Corporation
<br />3650 Annapolis Lane North, 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 />CONTRAcrOR'S APPLICATION FOR PAYMENT
<br />
<br />CONTRACT DATE:
<br />
<br />8/15/00
<br />
<br />CONTRACT FOR: General Construction
<br />
<br />CHANGE ORDER SUMMARY
<br />Change Orders approved in ADDITIONS DEDUCTIONS
<br />previous monthS by Owner
<br />TOTAL 139,528.93
<br />Approved this Month
<br />Number OateApproved
<br />TOTALS 0.00
<br />Net change by Change Orders 139.528.93
<br />
<br />The undersigned Contractor certifies that to the best of the Contractor's
<br />knowledge, information and belief the Work covered by this Appllcation
<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 />
<br />which previous Certificates fot Payment were issued and payments received
<br />from the Owner, and that current payment shown herein is now due.
<br />
<br />
<br />Date: November 1, 2001
<br />
<br />By:
<br />
<br />.~~~.
<br />\ cc'c I "I '~GHARDT l
<br />~ l.' - : L. G'-Jn
<br />:~,:,::,.-. ' . "'?:C - MINNESOTA
<br />"',,_ -, ._.;:.:r:5 Jan. 31. 2005
<br />..Vv'V'o.f.......c~.,;...-...-"..,'VV~.
<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 />
<br />.....$
<br />
<br />2,942,000.00
<br />139,528.93
<br />3,081,528.93
<br />
<br />.
<br />
<br />,"0,51<'\ .:31
<br />1."f~l, I......
<br />
<br />"2.,1<;,,!>.1'50.03
<br />I 0", fYi.O<>
<br />
<br />2......., 3'3<> .~"
<br />
<br />ARCHITECT'S CERTIFICATE FOR PAYMENT
<br />
<br />In accordance with the Contract Documents, based on on-site observations
<br />and the data comprising the above application, the Architect certifies 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 acco rdance
<br />with the Contract Documents, and the Contractor is entitled to payment
<br />of the AMOUNT CERTIFIED.
<br />
<br />2. Net Change by Change Orders..........................
<br />3. CONTRACT SUM TO DATE lLine 1 +/.2)............ $
<br />4. TOTAL COMPLETED & STORED TO DATE.........
<br />,Column G on G703)
<br />5. RETA1NAGE:
<br />
<br />a,81u,:-e:-.1e
<br />3,OIi,1Sl'-I'''
<br />
<br />i'I__,*, of Completed Work
<br />(Column D+E on G7031
<br />b._% of Stored Material
<br />(Column F on G703)
<br />Total Retainage lLine Sa + 5b or
<br />Total in Column I of G7031..,.,..
<br />6. TOTAL EARNED LESS RETAINAGE.
<br />
<br />15:8.B39.a7'
<br />
<br />1,nO:i.348.S!
<br />
<br />(Line 4 less Line 5 Totall
<br />
<br />7. LESS PREVIOUS CERTIFICATES fOR
<br />PAYMENT (Une 6 from prior Certificatel ... $
<br />8. CURRENT PAYMENT DUE................................. $
<br />9. BALANCE TO FINISH, PLUS RETAINAGE............ $
<br />lLine 3 less Line 6)
<br />
<br />t,i6\,.tS3.14
<br />16\, lBB.:ZS
<br />i!.15:,SeB.91
<br />
<br />State of: Minnesota
<br />
<br />County of: Hennepin
<br />
<br />Subscribed and sworn to before me this 1st day of November, 2001
<br />
<br />N""~~<'-L;;! 13,"~Hff
<br />
<br />My Commission expires: January 31, 2005
<br />
<br />AMOUNT CERTIFIED."....,...""".""""..".... / 0 7 I ~ 18 . 00
<br />I
<br />(Attach explanation if amount certified differs from the amount applied for.I
<br />
<br />::.7~~ZJ/;iciuL t( /~ r /0 (
<br />
<br />This certificate is not negotiable. The AMOUNT tERTIFIEri is paY~ble
<br />only to the Contral:tor named 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 />,
<br />
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