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AP~'I.ICATION AND CERTIFTCATE FOR PA'fMENT ~~ i ~_ TO {OWNER): MARION COUNTY PROJECT: MARIOtd COISALEMIDE~O RPPLICATION N0: ~ URTE 05/~ib/y7 1~0 HIGH Sl. NE c24~ HIGH ST. PERIDD TQ: 06l20/97 SALEM, OR 9731i~ SALE~i, OR 9731~ ARCHITECT'S FROhI {CONTRACTOR): STflT~N CDNSTRl~TIOAi, INC. VIA {ARCHITECTi: GRfl,IECT N0: ~9394-8 Airpart Raad C~ITRACT DATE: Eugene„ OR 97402-9594 PHONE #: i541) 461-0543 CONTRACT FOR: CHt~V6E QHBER 5UMh1ARY ORI6INF~ COhITR~T S1~9 518, 579. 00 I ADDITIONS ( . DEDIICTI~+IS I CHANGE ORDERS AGPROUEU IN I I 1 GREVIOUS MDNTHS 6Y OWNER I I I ~ ~ ~ RPPROUED THIS M~NTH i I I I f I NU~iBER I 6ATE APPROVED I I I I 1 I I I I I I I I I 1 i I I I I I I I ~ f I I 1 f 1 I I i I { TOTALS I 1 I I I I NET CHANGE i I I RY CHpN6E OkDERS 1 I i I I 1 The undersigned Cantr•actor certifies that to the best of the Cantractar's knowledge, ir~far~ation and belief the work covered by this Application for Payrent has 6een cu~pleted in accordance with the Contract Docu~ent~, that all a~ounts have been paid by the Contractor for work for -~ich previous Certificates for Pay~ent were i55ued and pay~ents received froe the Owner, and that current pay~ent shown herein is now due. CONTRACTOR: ~ _ . a ~~ ~~~/ ~,_ "t~t~C~~~///~.~.~ ~-G'G"7~- Date. ~ v1 7 --------------- -------- D /~ NET CHA~`iE BY CF#~E OADERS C~NTRACT St~l TO DATE JIB! J7~. Q~0 TDTflL COMPI.ETED AI~ID STDi~ll TO DATE ls'5, s's'~. 0~ RETAIt~6E: 5. &% af Ca~pleted Work is,;, 336.00 5.@X of Stored Material Tatal Retainage ~,7E~,g@ T[ITAL EARNED LESS RETflINAGE 1c8,569.20 ..__,......_.. _ LESS PREVIDI~i CERTIFICATE5 ~ RAYMENT ~8, 695. 75 ,~ ~Y. ~, (,=, ~ CURREhIT SflLES TAX: ~ ~ a ~ 3 ` ' ~ ' 0.0Q~x of Taxahle fliount ~ :: ' t - s :, .' , ~ ~-, 4 Current Sales Tax ~ _-----~. - x CURRENT PAYMENT ~ 69, 873. 45 ''~, r .;==:: ; ~ BALANCE TO ISH, It~LUDI I~T I 39 , 009. 80 ~ ', ; % ~::~ 3 State nf: ~(,,~~ ~OaJ County of: ~L~C/Z~- ~._. . _ _. . Subscribed and sNn n tn befare ee this a~ day of~~2e~,19 9~ My Goeeission expires: (o--~/-~ ARCNITECT'S CERTIFICATE FOR PAYMElVT In accnrdance with the Contrart Dacu~ents, based on on-site ohservations and the data co~pri5ing the abuve application the Rrchiteet certifies to the Owner that to the best af the Architect's knowledge, infor~ation and belief the Work has progressed as indicated, the quality of the Work is in accordance aith the Gontract Oocu~ents, and the Contractor is entitled to pay~ent of the At4~JNT CERTIFIED. Ah~UNT CERTIFIED ~ ~~ W~~~ ------------------ ay` - -- -- ----- Date: __ /_ ~.~/~ Y This Certification is not negotiable. The AM~itJNT RTIFIED is payable only to the Gontractur na~ed herein. Issuance, pay~ant and acceptance of pay~ent are aithaut prejudice ta any rights of the Owner or Contractar under this Contract. ~~~ ~~~s-~7