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po iosay APPLICATION AND CERTIFICATE FOR PAYMENT nin DocuMErrT G~oa c~~s«~~~~o~s o~ ~e~~=Se S~de~ PAGE ONE OF ~~~Es TO OWNER: PROJECT: APPLICATION NO.: 04 Distribution co: MatiOn County RiSk Managemeilt Sal~n Courthouse SqUare PrOjeCt PERIOD TO: 5-21-97 ~OWNER ,~/~ ,~y..,~~ Asbestos Abatement & Demo ~DO /~ il.J J~WL2.~- PROJECT NOS.: None ^ ARCHITEC7' ~~;~y~Q~O C,73 ~/ ^ CONTRACTOR FROM CONTRACTOR: VIA ARCHITECT: CONTRAC'f DATE: 4-21-97 ^ Precision Industrial Constructors, Inc. ^ 1395-D Downriver ffizive, Woodland, 49A 98674 CONTRACT FOR: CONTRACTOR'S APPLICATION FOR PAYMENT Application is made for paymenc, as shown below, in connection with the Con[ract. Concinua[ion Shee[, AIA Documenc G703, is acrached. ORIGINAL CONTRACT SUM . . . .... . ..... . . ...4 Z3Z.175.00 . Net change by Change Orders ...............5 -~- 3. CONTRACT SUM TO DATE (Line 1 t 2) ........ S 232,175.00 4. TOTAL COMPLETED & STORED TO DATE ......8 Z32,175.00 (Column G on G703) 5. RETAINAGE: 71 608.75 a. s~_% of Completed Work S ~ (Columns D + E on G703) The undersigned Contrac[or cercifies [hat ro[he besc of che Concnc[or's knowledgq infoo- macion and belief che Work covered by [his Applicacion for Paymenc has been completed in accordance with the Contrac[ Documencs, tha[ all amoun[5 have been paid by the Conccac~or for Work for which previous Certificaces for Payment were issued and pay- men[s received from the Owner, and that currenc paymen[ shown herein is now due CONTRACTOR: . gy; ~ 09 ~. ~ Da~e: . ~/~ 7 ~~~ / / S~are of: G~~sfS+~/rNETDi/ . Counry of: ~j~/~ fZ Subscribed and swom to ~before ~ me this /~ day of /~ (/ . ~, ~Ct~e=~~(~-~ b. % of Scored Macerial 8 (Column F on G703) Nomry Totu Rerainage (Line Sa + Sb or My Co To[alinColumnlofG703)••.••••••••••••••$ 11,608.75 _ 6.TOTAL EARNED LESS RETAINAGE............8 ZZ0~566.25 (Line 4 less Line 5 To~al) 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT 154 927.07 (Line 6 from prior Cert~cace) . . . . . . . . . . . . . . . . .8 ~ . CURRENT PAYMENT DUE ................. S o5,639.18 9. BALANCE TO FINISH, INCLUDING RETAINAGE (Line 3 less Line 6) 8 11 , 608.75 - Retainage CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS iota] changes approved in previous months by Owner , Toral approved this Monch TOTALS NET CHANGES by Change Order - ARCHITECT'S CERTIFICATE FOR PAYMENT In accordance wich [he Concract Documen[s, based on on-site observacions and the data comprising [his applica[ion, [he Architect cer[ifies to [he Owner cha[ to che besc of ehe Archi[ec['s knowledge, information and belief [he Work has progressed as indicaced; [he quality of the Work is in accordance wi[h the Contract Documents, and che Concractor is en[icled ~o paymen[ of che AMOUNT CERTIFIED. AMOUNT CERTIFIED ...............................5 (Attach explanation ij amount certijied differs jrom !he amount applied for. /nitia! a[l jigures on tbis App/ication and on !he Continuation Sheet that are changed to conform to tfie amount~certijied.). ARCHITEGT: By: Da[e: This Cer[ificace is noc nego[iable T~ie AIvIOUNT CERTIFIED 'u payable only co [he Conc [ractor named herein. IssuancG paymen[ and acceprance of payment are wichoue prejudice to any righes of the Owner or Contracror under [his Contract. ° AIA DOCUMENT G702 • APPLIGTTON AND CER77FIGTE FOR PAYMENT • 199Z EDITION • AlAm •~07992 • THE AMERICAN IN517TUTE OF ARCHITECIS, 1735 NeW YORK ~ AvENUE, N.W., WASHINGCON, D.G 2000Cs5292 • WARNING: Unllcer~setl photocopying vlolates U.S. copgrlah[ laws and wlll subJect the vlolator to legal proseeutlon. G7OL-'I99L .? ~.... ~ . ~ CAUTION: You should use an origlnal AIA document whlch has thls caution prlnted in red. An orlginal assures that changes will not be obscured as may oecur when documents are reproduced