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AP~LICATIDN AND CERTIFICATE FDR RAYMENT PA6E i TO (DWNER): t~RION C~lNTY PROJECT: MARION CO/SALEM/DEMD APPLICRTIDN N0: 2 DATE ~d6/~d/91 100 HIGH S1. NE ~20 HIGH 5T. PERIDD T0: @6/20/97 SALEh9, OR 97310 SALEM, OR 9731@ ~ ARCHITECT'S FROM tCONTRf~TOR): STATON CONSTRLtCTIDN, INC. VIA (ARCHITECT): RROJECT N0: 29394-B Rirport Road C~ITRACT DATE: Eugene„ DR 9741~2-9594 pHONE #: f541) 461-@54s CONTRACT FOR: CH~E DkDER SUt~RY I ADDITI~]NS I DEINJCTI~ I CHANGE ORDERS APPRDVED IN I I I PREVI(RJS MIDNTHS BY ~IER I I I I I I G~PROVED THIS l40NTH I I I 1 I I P~IMBER I 1}ATE APPROVED I I I I I I I I I I I I 1 I I I I I I I I I I 1 I I I I i I I I I I I TOT~S 1 I I ,~. I I I MET C~VGE 1 1 I BY CFIf~E DKDERS I I I ~ 1 I The undersigned Contrartor certifies that to the best of the Contractar's knowledge, infor~ation and belief the work covered by this Application for Payrent has been co~pleted in accordance with the Contract Docu~ents, that all a~ounts have been paid by the Contractor for work for which previous Certificates for Pay~ent were issued and pay~ents received fro~ the Owner, and that current pay~ent shown herein is now due. CONTRACTOR: „ _ ;,/ ''' Date: ~ By:_~11~ ~ ~ ~° ~1D /~ ~ G = ' -`"LG -x- - - ----- ------------- ARCHITECP S CERTIFICATE FOR PA`fMENT In arcordance r-ith the Contrart Docu~er~ts, based on on-site observations and the data coeprising the above application the Architect certifies to the Dwner that to the best of the Architect's knowledge, infor~ation and belief the Work ha5 ^~^ogressed as indicated, the quality of the Work is ir~ ordance with the Contract Docu~ent5, and the Contr•actor ~1"s entitled to pay~ent of the AMDUNT CERTIFIED. DRI6INf~ CONTRF~T 5UM 518, 579. 08 t~T CHANGE BY CF~NfiE ORDERS C~ITRACT SUM TO DATE 518,579.N0 TOT~ C~ETED A~1D STOi~D TD DATE ls'S, s3b. 0~d RETAINA6E: 5.0X of Co~pleted Work 13i,336.~ 5.0X of Stored P9ateriai Total Retainage 6,766.88 TDTAL EAf~IED LESS RETAII~6E ic8,569.20 LE55 PREVI~IS CERTIFICATES ~ PAYMENT 58,695.75 CURRENT SF~ES TAX: @.OQ~% of Taxable A~ount Current Sales Tax i CURRENT PAYMENT DUE 69,873.45 I U~ n i--z^~ ~ o „- € ~z ~~ ~ ~ `.' x ~ "~, ~' a -; ` ; ;~~-~z~: ; CL `; o` [,i ~ ~ ~ ~,, ~=, i ~f?.' _ - = , ., ~j ~ ~ ~ !` - 'V 1 ~~ ~. BALA~ICE TD ISH, I~~UDI RET IN E 39 ,@~9.80 ~ s'~;~:',~;; C ~'''~` :%i% State of: y,~~~~QIC/ County of: GL~/Z~- ~ 5ubscribed and swo n to before ae thi5a~ day of~~u,19`1~ My Lo~~ission expires: (~-y-J~ Ah~IUNT CERTIFIED ; ------------------ ARCHITECT: py; Date: -------------------------------- ------------ This Certification is not negotiable. The AMOUNT CERTIFIED is payable only to the Cor~tractor r~a~ed herein. Issuance, payrent and acceptanre of payeent are Nithout prejudice to any right~ of the Dwner ur Car~tractor under thi5 Contract.