09.03A Maintenance Facility Project - Greystone Construction Payment Certificates #3 & #4

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APPLICATION AND CERTIFICATION FOR PAYMENT �Docul►tElv7'G�o2 PAGEONEOF 2 PAGES TO OWNER: PROJECT: APPLICATION NO 4 Distdbution to: City of Pequot Lakes Pequot Lakes Maint. APP.DATE 10/I 1/18 -�X OWNER 4638 Main Street Department Garage �X ARCHITECT Pequot Lakes,MN 56472 Project#0130B0063.000 PERIOD TO: 10/11/18 �X CONTRACTOR FROM CONTRACTOR: VIA ARCffiTECT: � Greystone Construction Comparry Architect Name � S00 S.Marschal!Road,Suite#300 Architect Address PROJECT NOS: FS 18-8170 Siurlcopee,MN 55379 Architect Address Retainage CONTRACT FOR CONTRACT DATE 03/O1/18 — CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, Application is made for paymeat,as shown below,in connection with the Conhact information and lulief the Work covered by this Application for Payment has been Continuation Sheet,AIA Document G703,is attached. completed in accordance with the Conhact Documents,that all amounts have been paid by the Contcactor for Work for which previous Certificates for Payment were issued and payments received&om the Owner,and that current payment shown herein is now due. 1. ORI(3INAL CONTRACT SiJM $ 78,872.00 Z. Net cha.nge by Change Ordets $ 0.00 CONTRACT . Greystone Construction Company 3. CONTRACT SiJM TO DATE(Line 1 t 2) $ 78,872.00 4. TOTAL COMPI,ETED&STORED TO $ 78,872.00 �� DATE (Column G on G703) By: Date: October 11,2018 5. RETAINAGE: a. 5 °/a of Completed Work $ 0.00 State of: NIN County oF Scott (Column D+E on G703) Subscnbed and swor �es � is 11 er 2 1 b. %of Stored Material $ Notary Public: ��'"�� KAREN M.BAUMANN (Column F on G703) My Com*�+.�aion expues: January 31,2020 ��.�� Notary PubllC Total Retainage(Lines Sa+Sb or TotalinColumnIofG703) $ o.00 ARCHITECT'S CERTIFICATE FOR �� ' '�o��o»trzozo 6. TOTAL EARNED LESS RETAINAGE $ 78,872.00 In accordance with the Contract Documents,based on on-site observations and the data (Line 4 Less Line 5 Total) comprising the application,the Architect certifies to the Owner that to the best of the 7. LESS PREVIOUS CERTIFICATES FOR Architect's l�owledge,information and belief the Work has progressed as indicated, PAYMIIVT(Line 6 from prior Certificate) $ 74,928.40 the quality of the Work is in accordance with the Contract Docaments,and the Contractor 8. CLJRRENT PAYIVIENT DUE $ 3,943.60 is entided to payment of the AMOUNT CERTIFFIED. 9. BALANCE TO FINISH,INCLUDING RETAINAGE $ 0.00 (Line 31ess Line 6) AMOiJNT CERTIFIED...........$ 3,943.60 HANGE ORDER S Y ADD ONS DED Cl'ION (Attach explanation if amount certified d ffers from the amount applied.Irsitial all figures on this Total changes approved Application and on the Continuation Sheet that are changed to conform with the amount certified.) in previous months by Owner ARCHITEGT: Total a oved this Month By; Date; TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOiJNT CERTIFIED is payable only to the (.:ontractor named herem.lssuance,payment and acceptance oi payment are v�nthout NET CHANGES by Change Order $0.00 prejudice to any rights of the Owner or Contractor under this Conhact AIA DOCUMENT(3702•ApP�IG►TION AND CEqTIFICATION FOR PAYMENT•1882 EDITION•AIA•01992 THE AMERICAN INSTITUTE OF ARCHITECT3,1735 NEW YORK AVE,N.W.,WASHINGTON,DC 2000�5?�2 Users may obtain validatlon of this document by requesting a completed AIA Document D401 -Certiflcation of DocumenYs Authenticity from the Licensee.