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F~F~LICATION AND CERTIFICATE FOk PAYMENT PAGE 1 t0 40WNERJ : t4ARIUN CL~INTY ~ 1~~ HIGH 51. NE SALEM, Uft 57310 FR0~1 tCUtJTRACTUR): STAfON CONSTRUCTION, INC c9394-b Airport Road Eugene„ OR 97402-9594 RHDNE #: l541) 461-1~543 RROJECT: MARION CO/SALEM/DEMO 220 HI(~--I 5T. SALEM, OR 97310 UTA (ARCHITECT): CUtdTRACT FOR: APF'LICATION H0: 5 DATE 07/19/97 F'ERIOD T0: 07/19/97 ARCHITECT'S PROJECT N0: t;(]NTRACT DATE: CHANt;E DRDER 5UI~M~iAY I CHHfJGE DRBERS f~PROVEU IN I RKEVIOUS MUNTHS RV OWNER I ADDITIOPIS I DEDL~TIONS i i I ~ I F+~RRDVED THIS MONTH I I I i I I NL~iRER I DATE ANRkOVEU 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 TOTAi.S I I I I I I I~T CF~iGE i I I AY CFI~16E OfiDERS I I I ' I ~ The undersigned Contractor certifies that to the best of the Contractor's knoHledge, inforeation and belief the wnrk covered hy this Application far Pay~ent has been co~pleted in accordance Nith the Contract Docu~ents, that all a~ourts have been paid by the Contractor for work for which previous Certificates for Pay~ent were is5ued and pay~ents rereived fro~ the OHner, and that current pay~ent shown herein is nuw due. CO~JTRACTUR: . ~ ~~-// ~` Date: py _~~~/~~/~ y~~_ ~ ORI6INAL CDNTRACT 5UM tJET CHANGE RY CHAtdGE ORDERS 518, 579. QN~ CONTRACT SUM TO DATE 518,579.~ TuTAL CDMPLETED AND STORED TO DATE :,.`,~,514.`,~ RETAI~JA6E: S.~X of Co~pleted Nork s.`~,514.`~ 5.0X of Stored Material Total Retainage 17,5c5.7s' TDT~ EARNED LE5S RETAIP~6E 3s'2,988.77 ~ LESS PREVIDLIS CERTIFICATES ~ RAYhIENT 207,298.55 ~~ ~~ ~ ° ~ CURRENT 5ALE5 TAX: ~ ~ Q z J m ~a= Z ~ 0. @~-X nf Taxable Aeount o V~ ~ o z `~ Current 5ales Tax ~ ~ ~ CURRENT PAYP4ENT Dl~ 125,b90.~c BALANCE~FINISH, INCLJID~NG RETAINAb~ 1AJ~J9Q~.^c3 1 ~ ~ ., ~ ~._l . ~` ~ y` v State of: ~~C~~'j(~ County of: ~-~~~R, Suhs~r-~ibed and sHOrn to hefore ~e this \~~~~day of~~, 19`~1 My Coroission expires: ~ -`-~-~~ ARt:HITECT'S CERTIFICATE FOR RAYh~NT In accordanee Mith the Cantraet Uoeu~ents, based on on-site ohservations and the data co~prising the ahove application the Architert certifies to the Dwner that to the best of the Architect's knowledge, infor~ation and belief the Nnrk has ressed as indicated, the quality of the Work is in jance with the Contract Docu~ents, and the Contractor i~'f'ntitled to pay~ent of the AMOUNT CERTIFIED. AMOUNT CERTIFIED S ARCHITECT: Ay; Date: This Certification is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor na~ed herein. Issuance, pay~ent and acceptance of pay~ent are Nithout prejudice to any rights of the Owner or Contractor under thi5 Contract.