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APPLICA )N AND CERTIFICATION FOR PAYMENT A DOCU~I~IF~VT G702 PAGE ONE OF PA(3ES , <br />TO OWNER: <br />PROJECT: <br />APPLICATION NO: <br />PERIOD TO: <br />FROM CONTRACTOR: <br />VIA ARCHI'fECT: <br />PROJECT NOS: <br />Distribution to: <br />~OWNER <br />QARCHITECT <br />QCONTRACTOR <br />0 <br />0 <br />CONTRACT FOR: CONTRACT DATE: <br />CONTRACTOR'S APPLICATION FOR PAYMENT ~ . n~~ ~a~m~a con~~= ~~~ ~at ~'~~ ~~c ofw~ coo~~~~s x~owi~ag~, :~. <br />AppGcation is mado for peym~nt, as shown below, in com~-ection with the Co~ract information and belief the Work covercd by this Application for Paymeat has been <br />Contiauation Sheet, AIA Document (~903, is attached. completed in accordance with the C~h~act Docume~, that all amounts have been paid by <br />the Contractor for Work for which provious Cerbficaus for Payment wore issued ead <br />~ paymeirts received from the Owner, aad that current payment shown herein is ~w due. <br />1. ORI(~INAL CONTRACT SUM <br />2. Net c6sage by Change Orders <br />3. CONTRACT SUM TO DATE (Lane 1 f 2) <br />4. TOTAL COMPLETED & STORED TO <br />DATE (Columa C~ on C3703) <br />S. RETAINA(3E: <br />a °/. of Completed Work <br />(Col~mn D + E on (3703) <br />b. °/. of Stored Material <br />(Column F ~ Q703) <br />Total Retainage (I.incs Sa + Sb or <br />S <br />S <br />S <br />S <br />S <br />Tota! in Column I of 0903) <br />6. TOTAL EARNED LESS RETAIIdAGE <br />(Iaae 4 Lesa L.ine S Totan <br />7. LESS PREVIOUS CERTIFICATES FOR <br />ppYMENf (Line 6 from prior Certificate) <br />8. CURRENT PAYMENT DUE <br />9. BALANCE TO FIIJISH, WCLUDINC} RETAIIdAGE <br />(Line 3 leaa L'me 6) , . ., . , <br />s o.oo <br />a o.oo <br />S <br />5::....`..'~'_.~.~'<~....~~.~.~_'~'~'':: . ••:.t <br />. ~ .. . ~:~.~~:,~ <br />~ 0.00 <br />CHAN(~E ORDER SUMMARY ADDTTIONS DEDUCTIONS <br />Totel changes approved <br />ia 'ous maaths Owaer • <br />Total a ved this Month <br />TpTpl,g 50.00 50.00 <br />NET CHANOES Change Order a0.~ <br />CONTRACTOR: <br />gy,; Date: <br />State of: Coimty of: <br />Subscribed and sworn to before me this day of <br />Notary Public: <br />My Commission axpires: <br />AR HITE T' ERTIF CATE OR PAYMENT <br />In accordance with the Camact Docnme~s, based ai on-site obse~vationa sad the data <br />comprising the application, the Arc6itect certif es to the Owner that to the best of the <br />Architect's knowledge, information end belief the Work has progressed as indicated, <br />the quality of the Work is in accordance with the Contract Documeats, and the Coimactor <br />is entitled to payment of the AMOUNT CERTff IED. <br />AMOUNT CERTffIED . . . . . . . . . . . S <br />(A11aeh explanation tf amowrt cerlt, Jied di„~''ers from the amount applted Initia! all frgures on thGs <br />Applicat[on arrd onthe Contbruatton She~t that are changed to conform wtth the anrmart cerlift~d) <br />ARCHITECT: <br />By. <br />Date: <br />This CeRificate is not negodable. The AMOUNT CERTIFIED is payable only to the <br />Coatractor named herein. Issusace, PaYment and acceptance of paymctrt are anthout <br />prejudice to aay rights of the Owner or Contractor under this Comract. <br />/UA DOCUAAEHi ~3~02 • APPLIGTION AND CERTIFICATION FOR PAYMENT • 7992 EDITION • AU1 • 01992 THE AMERIGW INSTiME OF ARCHRECTS. 1T33 NEW YORK AVE. N.W.~ WASHINOTON. DC 2000b6?92 <br />Users may obtaln valldation oi thls document by requesting a completed AIA Document D401 - CerdflcaUon of DocumenYs Authentlclty from the Ucensee. <br />