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------- _- _ APPLICATION AND CERTIFICATE FOR PAYMENT Ain DocuMErrT G~oz «~s~tU~~,o„5 0~ ~e~~~sp~e~o~ay P~~e, TO OWNER: PROJECT: APPLICATION NO.: 04 Distribu[ion [o: MariOR. C1o~unty RiS,~~~~t ,~l~n Cou~hOUSe Square prOject PERIOD TO: 5-21-97 ~O~wtvER ,~OD~ ~/~~~-~c~J~ f2/ ~SbeStos Abatement & DemO PROJECT NOS.: NORE ^ ARCHITECT vC~"~'r~ ~ O~ ~~`~ ~l ^ CONTRACTOR FROM CONTRACTOR: VIA ARCHITECT: CONTRACT DATE: 4-27-97 ^ Precision Indiystrial CoryStructors, Inc, ~ 1395-D Downriver ]~rive, Woodland, yTA gg(7q CONTRACT FOR: ~ CONTRACTOR'S APPLICATION FOR PAYMENT Appiication is made For paymenc, as shown below, in connec[ion with che Con[ract. Continua~ion Sheet, AIA Documen[ G703, is a[tached. ORIGINAL CONTRACT SUM . . . . . . . . . . . . . . . . . . E_ 232,175.00 . Net change by Change Orders ...............5 -0- 3. CONTRACT SUM TO DATE (Line 1 t 2) ........ S 232 ~ 175.00 4. TOTAL COMPLETED & STORED TO DATE ...... E-_ z32 • 175.00 (Column G on G703) 5. RETqINAGE: a. s,r_/o of Comple[ed Work g ~ ~~608.75 (COlumns D + E on G703) b. % of S[ored Material g (Column F on G703) No~ary Torai Retainage (Line Sa + Sb or My Co To[al in Column I of G703) . . . . . . . . . . . . . . . . . S_ 71 , 608.75 G.TOTAL EARNED LESS RETqINAGE............E z20,566.25 (Line 4 less Line 5 Total) 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT (Line 6 from priot Certificate) . . . . . . . . . . . . . . . . . S 154, 927.07 _ . CURRENT PAYMENT DUE ................. $ ~5~639.18 9. BALANCE TO FINISH, INCLUDING RETAINAGE (Line 3 less Line 6) g 11 , 608.75 - Retainaqe CHANGE ORDER SUMMARY ADDI'TIONS .DEDUCTIONS Total changes approved in previ0u5 mOn[hs by Owner ' Total approved this Month TOTALS NET CHANGES by Change Order ~ The undersigned Con[rac[or mr[iFies cha[ [o [he bac of [he Concrac[or's knowledgq infor- ma[ion and belief the Work covered by this Appticacion for Payment has been compl~[ed in accordance wi~h the Concrac[ Documents, tha[ all amounts have been paid by che Con[rac[or for Work for which previous Cer[ificaces for Paymen[ were issued and pay- mencs received from~ che Owner, and [hat wrren[ payment shown herein is now due. CONTRACTOR: . By: ~ ~ ~~. Da~e: ~~ ~ ~ Stare of: G~iA3,~fiNE7ai1/ . Counry of: ~j~~~ fl ~ Subscribed and sworn [o ~before ~ me this /~ day of /~~j~ ' / ~ i/. 9 9 % ARCHITECT'S CERTIFICATE FOR PAYMENT In aecordance wieh the Concract Documen[s, based on on-site observa[ions and ~he dara comprising this application, che Architect certifies to the Owner chat to the best of the Architecc's knowledge, information and belief the Work has progressed u indicated; [he quality of the Work is in accordance wieh the Concrac[ Documents, and ~he Contrac~or is enti~led to p9ymenc of the AMOUNT CERTIFIED. AMOUNT CERTIFIED ............................... (Attach exp[arzation ijamount certijied difjersJrom tbe amount app[ied for. Initia[ a[1 jigures on tbis App/ication and on the Continuation Sheet that are changed ro conjorm fo the amount~certified.), ARCHITECT: IIY~ Date: This Ceruficace is no[ negociabte. T~ie AI~IOUNT CERTIFIED is payable only [o che Con- cractor named herein. Issuance, payment and acceptance of payment are withou[ prejudice [o any rights of the Owner or Con[racror under ~h;s Con[rac[. ~``mm, AIA DOCUMENT G70y • eppLIU170N AND CERTIFIG7E FOR PAYMENl' • I992 EDITION • AlAm •~01992 • THE AMERICAN iN51'3TUTE OF ARCHITECfS, 1735 NEW YORK $ly/~ AVENUE, N.W., WnSHINGI'ON, D.C. 2000Ca5292 • WARNING: Unllcensed photocopying violates U.S. copyright Iaws and wlll wbJeM the Wolator to 1¢gal prosetutlon. G702-1992 ~.~~~~ CAUTION: You should use an orlglnal AIA doeument whlch has thls cautlon prlnted In red. An origlnal assures that changes will not be obscured as may occur when documents are reproduced