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aen~ uy. Ji~+i~n ~VivJinU~ilVlv <br />~PRLICATIflN AND CERTIFICAFE FOR PAYMENT <br />IU t0~llEfll: 11~RI1~1 C~ITY <br />180 Hi6N Sl. f~ <br />SAtf~4, DR 4Tf0 <br />FRar~ ~C~Tf~cTURt: STAT~s1 [~rtSfRUCrFE~, ThC. <br />29394-$ Ajrport Raad <br />fugene„ t1R 97~+02-9594 <br />GHOt~ ~: (~4l) 451-4543 <br />CHRHG~ URDER ~HfARY <br />! ADDITI(s~tS 1 DEDuC7IE]f~S i <br />a~k16E OROERS ARPRUVED IN ~ i 1 <br />PRtVI WS MdVTHS BY O~ER I 81, 816. 88 i I <br />I I f <br />ANF'RtlVED THIS I~NTH I f ~ <br />I ~ ~ <br />l~k I DATE ANPfd~VED I ~ ~ <br />i I I t <br />2 1 10/2~/97 I <br />I ~ <br />1 y <br />~ ~ 2,b9~.0$ t ~ <br />~ ~ <br />~ ~ <br />~ I <br />I I <br />~ I <br />I - I ~ <br />1 E <br />I 1 <br />tOTA~S I <br />t ~f 645. @B ! ~ <br />_ F ~ <br />~ NE3 CHWi6E 1 I I <br />B Y C. ~ l A f$ Q i i~ R S t <br />i 8 3~ 711. 8B I I <br />,i~i <br />t~ul unt u545; 1U/11/y! Z:aSNM;,j~ #242;Naye 4i5 <br />PREI.3ECT: MRRt~I fA/SRf.Elf/DEMO <br />228 NIEF! ST. <br />SAI~hl, ttR 97318 <br />~ 1 <br />~~~~I~1 ~0: !8 DATE 10/C3/97 <br />REAIOD i0: I0/23197 <br />ARt~i1TECT' S <br />PRflJEC7 ME1: <br />CQlTRACT DATE: <br />u1A tARCNiTECT>: <br />COKTF~CT FOR; <br />fhe undersi g ned Contrxtor certifies that to t Ae C es t o f t he <br />Contractor's knowledge, infor~ation and 6elief the work <br />covered by this Application for Pay~er~ has been co~pDeted <br />in atcordance Mith the Contract Docaaents, that all a~ounts <br />have beert paid Dp the Contractor for work for -Rrith prtvlous <br />Lertiticates far Pay~eri# were issued and pay~ents rereived <br />fro~ the Ownerf ~nd that current pay~ent shown herein ~s naN <br />dee. <br />CDFtI RACTEIfi: <br />Sy: ~ <br />,~ °~°: 1v-aa ~t7 <br />ORI6I~L CiR~RRCT 5!!P! 518, 579. QO <br />-~r ct~ ar c~ os~~s 83, 711.Os <br />CQMTRACT SUM TO DATE bB2,298.88 <br />FUTAL C~MRLETEO F~ STDRED TQ DATE b~,29A.88 <br />HETAIt~GE; <br />Z of Co~Pleted V~ark <br />5.0% of Storrd Materiat <br />Total Retainage <br />TDTAL EAft~ED LESS RE1RIt~ 582,P98.88 ~ <br /> <br />kJ. <br />LESS PREUlEk1S C~RTFFICATES E!F PAYI~NT 572, }75.58 ~~ ~ a <br /> <br />W <br />~~ <br /> <br />QIRf~ENT 5ALE5 TAX: ~ <br />~~ <br />7?~~ g z <br /> ZS !1 j i5 ~ <br />8. B~c of Taxa6le Aiaunt ~~` r~~o <br />o(~~~~~ <br /> <br />Current Sales Tax Qi-~y <br />N g`~~ <br /> <br />CURRfNT PAYl~EM lKJE <br />30, 314.50 ~ <br />H~ANCE S~~SH, INCLIlDIN~.,gET~Att~E , L_J ~"~~~ <br />v v <br />Statr af: ~/~,Q_~~~/] Gaunty of: ~.Qi"C.Q._ <br />Subscribed and 3MOrn ta before ~e this~~~day af(' ~'~ ;f99 7 <br />MY ~~~15410n lxpSrES: (~-fj~ sJ~ <br />AKCHIIEGI'S C~R7IFICATF FUR PAY1~Eti7 <br />in accordance Kith the Cont~act Oacwents, based oa on-site <br />obserwations ar~f t~e data ra~prising the atrove application <br />the Arc~iteci ~ertifies ta the Owner that ta thr best of the <br />Ar~ititect's knowlydgr, snfor~ation araf delief the liork Ras <br />proqressed is indicated, the qwlity oP the ~brA is in <br />aecor0ance ~ith the Cnntrart Dacwents, and the Cantractor <br />i~ ~tled to pty~ent af the A!~!T CFATiFIED. <br />A440tlNT GERTIfIED 1 <br />AF~Et1ITECT: ~~~K~t"~-E2~ ~1~~ <br />U <br />8y' Date: <br />_--~~-~~~~ l~n- z z- y ~ <br />Fh~s Crrtifiratian IS not negotiaDle. ?hr A~90UN7 CFATIFFED is <br />payaCle aniY to the Contract~ na~rd hrrein. Issvance~ pay~ent <br />and acceptance of pay~ent are wltt-out pre,judice to any rights <br />of the EA~mer or Gontractor under this Contr~Ct. <br />