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APPLICATION AND CERTIFICATE FOR PAYMENT <br />ALA DOCUMENT G702 <br />PAGE ONE Of TWO PAGES <br />TO: City of Ramsey <br />CUSTOMER PROJECT: <br />APPLICATION NO: <br />3 <br />Distribution to: <br />(OWNER) 7550 Sunwood Drive NW <br />Water Tower No-3 <br />CB&I NO. <br />37147815 <br />08/31109 <br />TOTALS I <br />OWNER <br />Ramsey, MN. 55303 <br />Project No-08-21 <br />PERIOD TO: <br />09125/09 <br />ENGINEER <br />CONTRACTOR <br />FROM (CONTRACTOR); <br />VIA (ENGINEER): <br />ENGINEER'S <br />OTHER <br />CB&I Inc. - Steel Plate Structures <br />Progressive Consulting Engineers, <br />PROJECT NO: <br />Project No. 08015 <br />9550 Hickman Road Clive, IA 50325-5316 <br />Inc. <br />CONTRACT FOR: <br />6120 Earle Brown Drive, Suite 629 <br />CONTRACT DATE: <br />07/09/09 <br />2MMG HP/ 152TCL <br />Minneapolis, MN 55430 <br />16600 St- Francis Blvd-, Unit #2 <br />CONTRACTOR'S APPLICATION FOR PAYMENT <br />CHANGE ORDER SUMMARY <br />Change Orders approved in <br />previous months by Owner <br />TOTAL <br />ADDITIONS <br />0.00 <br />DEDUCTIONS <br />0.00 <br />Approve this Application <br />22,977-00 <br />Number <br />I Date Approved <br />#1 <br />08/31109 <br />TOTALS I <br />22,877.001 <br />0-00 <br />Net change by C 6 Orders <br />22.877.00 <br />The undersigned Contractor certifies that to the best of the Contractors knowledge, <br />information and belief that the Work covered by this Apfication for Payment has been <br />completed in accordance with Contract Documents, that all amounts have been <br />paid by the Contractor for Work for which previous Certificates for Payment were <br />issued and payments received from the Owner, and that current payment shown <br />herein is now due_ <br />CONTRACTOR: CB&I Inc. - Steel Plate Structures <br />Application is made for Payment, as shown below, in connection with the Contract. <br />Continuation Shpt, AIA Document G703, is attached. <br />t ORIGINAL CONTRACT SUM <br />2. Net change by Change Orders <br />3. CONTRACT SUM TO DATE (Line 1*1- 2) <br />4. TOTAL COMPLETED & STORED TO DATE (Col G on G703) <br />S. RETAINAGE: <br />iL 5% of Completed Work <br />(Col D * E on G703) <br />IL 0% of Stared Material <br />Col F an 6703) <br />TOW Retabutge (Line Sa * fib or <br />(Total in " I of G703) <br />S. TOTAL EARNED LESS RETAINAGE <br />tLine4le" Line SToW) <br />7. LESS PREVIOUS CERTIFICATES FOR <br />PAYMENT (L!m 6 from prior Certificate) <br />CURRENT PAYMENT DUE <br />188,400.00 <br />$22,877-00 <br />$3,211,277.00 <br />$1.140,878-00 <br />$57,043-90 <br />$1,1383,834.10 _ <br />$284.40625 <br />$79%427.85 <br />9. BALANCE TO FINISH, PLUS RETAINAGE $2,127,442,90, <br />(Una 3 less Line 6) <br />Sta te of' IOWA County of. POLIO <br />Subscribed and swam to before me this 28th day of September. 2003. GAVIA L. ZENZ <br />Corranission Number 713U8 <br />September 28, 2009 Notary Public EVk9s,—_ <br />December. 3 20 <br />My Commission expires. Dec. 03, 2010 <br />ENGINEER'S CERTIFICATE FOR PAYMENT <br />In accordance with the Contact Documents, based on or site observations and the <br />data comprising the above alopplication. the Engineerzeddies to the Own" that to the <br />best of the Engineers kTowAadge, iinformation and belief the Work has progressed as <br />indicated, the quality of the W" is in accordance vifth the Contact Documents, and <br />the Contractor is entitled to payment of the AMOUNT CERTIFIED. <br />AMOUNT CERTIFIED <br />(Attach explanation if amount certified differs from the amount applied for.) <br />$57.043.90 <br />57 - 671 <br />Date: 1) 2 <br />Contractor named be— Issuance, payment and acceptance of payment are vAttuxit <br />preAutim to any tights of the Owner or Contractor wider this Contract <br />AIA DOCUMENT G7D2 APPLICATM AND CERTIFICATE FOR PAYMENT MAY ISM EDITION AIA a 1952 <br />THE AMERICAN IN STI TUTE Of ARC19TECTS, 1735 WX YORK AVENUE– Nw, WASHMGTON, D.C_ 2NN <br />This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the <br />