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APPUCAT"~~ AND CERTIFICATION FOR PAYMENT_ DoCUMENTC7o2 PAGE ONE OF PAGES <br />APPLICATION NO: 3 Distribution to: <br />TO OWNER City of Eugene PROJECT: City of EugeneOWNER <br />Facility Management Division Amazon Ball Field Restroom ARCHITECT <br />210 Cheshire Ave. and Lighting Replacement CONTRACTOR <br />Or 97401 PERIOD TO: 11/24/03 Q <br />Eugene, <br />FROM CONTRACTOR VIA ARCHITECT: WBGS Architecture <br />Colberg Commercial, Inc 72 West Broadway <br />1310 Coburg Road, Suite 10 Eugene, Or 97401 PROJECT NOS: 11/24/03 <br />Eugene, Or 97401 CONTRACT DATE: <br />CONTRACT FOR ` <br />CONTRACTOR'S APPLlCATlON FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, <br />information and belief the Work covered by this Application for Payment has been <br />Application is made for payment, as shown below, in connection with the Contract. completed in accordance with the Contract Documents, that all amounts have been paid by <br />Continuation Sheet, AIA Document G703, is attached. the Contractor for Work for which previous Certificates for Payment were issued and <br />payments received from the Owner, and that current payment shown herein is now due. <br />1. ORIGINAL CONTRACT SUM <br />2. Net change by Change Orders <br />3. CONTRACT SUM TO DATE (Line 1 f 2) <br />4. TOTAL COMPLETED & STORED TO <br />DATE (Column G on G703) <br />5. RETAINAGE: <br />a, 5 % of Completed Work <br />(Column D + E on G703) <br />b, % of Stored Material <br />(Column F on G703) <br />Total Retainage (Lines Sa+ Sb or <br />$ 358,731.00 <br />$ 358,731.00 <br />$ 206,220.00 <br />$ 10,311 <br /> <br />Total in Column I of G703) <br />6. TOTAL EARNED LESS RETAINAGE <br />(Line 4 Less Line 5 Totai) <br />7. LESS PREVIOUS CERTIFICATES FOR <br />PAYMENT (Line 6 from prior Certificate) <br />8. CURRENT PAYMENT DUE <br />9. BALANCE TO FINISH, INCLUDING RETAINAGE <br />(Line 31ess Line b) <br />in previous months by Owner <br />Total approved this Month <br />$ 10,311.00 <br />$ " 195,909.00 <br />$ 159,146 <br />$ ~ 162,822.00~~~ <br />$0.00 f __ $0.00 <br />FFICIAL SEAL <br />of: 13y ~ County W A REINIiARD <br />Su ands to me thi .- of $ ~ -OREGON <br />COM I SION NO. 348371 <br />Notary Public: - Mr CpMMISSION EXPIRES AU6. t0. T005 <br />My Commission expires: ~_/ fl .v~ <br />In accordance with the Contract Documents, based on on-site observations and the data <br />comprising the application, the Architect certifies to the Owner that to the best of the <br />Architect's knowledge, information and belief the Work has progressed as indicated, <br />the quality of the Work is in accordance with the Contract Documents, and the Contractor <br />is entitled to payment of the AMOUNT' CERTIFIED] <br />AMOUNT CERTIFIED ........... $ _ (~ <br />(Attach explanario if mount certified di,~ers from the amount applied. Initial all figures on this <br />Application and o h Continuation Sheet that are changed to conform with the amount certified.) <br />ARC T: <br />By: Date: Z O?i <br />This 'cafe not negotiable. The AMOUNT CERTIFIED is payable only to the <br />Con r named herein. Issuance, payment and acceptance of payment are without <br />' di to rights of the Owner or Contractor under this Contract. <br />I NET CHANGES by Change Order ~ $0.00 ~ pre~u ce any <br />THE AMERICAN INSTITUTE OF ARCHITECTS, 1733 NEW YORK AVE.. N.W., WASHINGTON, DC 200065292 <br />AfA DOCUMENT G702 • -ARAI.ICAT~ AND CERTIFICATfON FOR PAYAlIENT • 1982 EDITION • AIA®• O 1992 <br />Users may obtain validation of this document by requesting a completed AIA Document D401 -Certification of Documents Authenticity from the Licensee. <br />