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f~PLICATItI~I AND CERTIFICATE FOA PAYh~NT TO {~R) : I~RI[l~l C~INTY 1@0 HI6H ST. NE S(~EP4, OR 9731@ FRL~4 !C(kITRACTOR) : STATDN C(~1STRl~TION, INC. 29394-B Airport Road Eugene„ OR 9748c-9594 pF~E #: f 541) 4b 1-054's PROJECT: MARION CO/Sf~EM/DEh~] 22@ HIGH ST. SALEM, OR 97310 VIA (ARCHITECT): (X1~ITRACT FOR: PAGE 1 f~ICATIDhI I~: 3 DATE 0b/~7/97 ~RIDD T0: 06/27/97 ARCHITECT'S PROJECT N0: CONTRf~T DATE: (~ DRDER 5l~RY I ADDITIO~IS i DEDUCTIONS I (~NGE ORDERS f~ROVED IN I I I PREVIOUS MO~ITHS BY ~R I I I I I I ARPROVED THIS h~NTH I I I I I I t~ER I tiATE RPPRDUED I I I I I I ~ I I I I I I I I I I I I I I I I I I I I I I I I I I I I TOTALS I I 1 I I I ~ ~ ~ ~ ~ BY (~ ORDERS I I I ~ ~ ~ The underaigned Contractor certifies that to the best of the Contractor's knoNledge, infor~atian and belief the Mork covered by this Application for Pay~ent has been co~pleted in accordance Nith the Contract Docu~ent5, that all a~ounts have been paid by the Contractor for Nork for r~hi~h previous Certificates for Pay~ent Nere issued and pay~ents received fro~ the (~ner, and that current pay~ent shoHn herein is noN due. CO~ITRACTDR: ~ ~ By ~ ~~~ ,~/~~"~ ~~ Dat e : ~ ~ / ~. ~ ~iG~~~ ORI6I1~. CONTRACT 5'LA4 518, 579. @0 NET (~ BY (~E ORDERS L'~JTRf~T Sl~i TO DATE 518, 579. ~1 TOT~ CQt~ETED A~ID STDf~D TO ~TE 186, SbO. 0@ RETAII~E: 5.0% of Co~pleted Nark 186,560.00 5.@% of Stored Material Total Retainage 9,~8•~ TOT~ EAf~D L.E5S i~TAINf~ 177, 232. @~ LESS PREVIOUS CERTIFICATES ~ PRYl~NT 128,5b9.20 CURf~NT SAL.E5 TAX: O.~X of Taxable A~ount Current Sales Tax CURf~NT RAYI~NT DUE 48,662.80 Q ; ~ ~' =o~` i ~ c~ Q c^- 2~~' ' ~QQ w ~ ~Za ~ ~~~~¢ I ~p;~o~ ~ ~ a~nz ~ oU~~~; LL }~ (n~ { Z ~ I F-~`~~ ; ~~ _ I . ~. I I5'FI, It~L It~6E 1, 347. ~ 5tate of: ~.~i~~-j"~!L County of: L-Cl/Z2. Subscrihed and sNOrn to before ~e this a(o~ day ov~,..L,199~ My Conission expires: Co-~ 99 ~LINT CERTIFIED ARCNITECT'S CERTIFICATE FOR PAYM~NT In accordance -+ith the Contra~t Do~u~ents, based on on-site observations and the data co~prising the above application the Arrhitect certifies to the Owner that to the best of the Architect's knaHledge, infor~ation and belief the Nork has progressed as indicated, the quality of the WorN is in rdance aith the Contract Docu~ents, and the Contractor :~°entitled to pay~ent of the f~1T CEATIFIED. f RRCHITECT• ~~~ BY.~- -- - Date: 3j~ 7"7 This Certification is not negotiable. The F~UNT CERTIFIED is payable only to the Contractor na~ed herein. Issuance, pay~ent and acceptance af pay~ent are Nithaut prejudice to any rights of the Owner or Contractor under this Contract.