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APPLICATION AND CERTIFICATE FOR PAYMENT <br />A/A D G702 <br />PAGE ONE OF TWO PAGES <br />TO: City Of Ramsey <br />CUSTOMER PROJECT: <br />APPLICATION NO: <br />14 <br />Distribution to: <br />(OWNER) 7550 Sunwood Drive NW <br />Water Tower No.3 <br />CB$rl NO. <br />37147815 <br />OWNER <br />Ramsey, MN 55303 <br />Project No.08 -21 <br />PERIOD TO: <br />08/28/10. <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 / 152' TCL <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 />23,817.00 <br />23,817.00 <br />DEDUCTIONS <br />0.00 <br />Approved <br />this Application <br />Number <br />I Date Approved <br />TOTALS <br />0.00 <br />0.00 <br />Net change by Change Orders <br />23,817.00 <br />The undersigned Contractor certifies that to the best of the Contractor's knowledge, <br />information and belief that the Work covered by this Aplication 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 Sheet, AIA Document G703, is attached. <br />1. ORIGINAL CONTRACT SUM $3,188,400.00 <br />$23,817.00 <br />$3,212,217.00 <br />$3,072,058.00 <br />2. Net change by Change Orders <br />3. CONTRACT SUM TO DATE (Line 1 +/ -2) <br />4. TOTAL COMPLETED & STORED TO DATE (Col G on G703) <br />5. RETAINAGE: <br />a. 3% of Completed Work <br />(Col D+ E on G703) <br />b. 0% of Stored Material <br />Col F on G703) <br />Total Retainage (Line So +Sb or <br />(Total in Col I of G703) <br />6. TOTAL EARNED LESS RETAINAGE <br />(Line 4less Line 5 Total) <br />7. LESS PREVIOUS CERTIFICATES FOR <br />PAYMENT (Line 6 from prior Certificate) <br />8. CURRENT PAYMENT DUE <br />9. BALANCE TO FINISH, PLUS RETAINAGE <br />$92,161.74 <br />$2,979,896.26 <br />$2,861,245.86 <br />$118,650.40 <br />$232,320.74 <br />(Line 3less Line 6) <br />State of: IOWA County of: POLK <br />Subscribed andsWonlito before me this 2nd day of September, 2010. a GAYLA t r <br />L. ZENZ <br />° Commission Number 713888 <br />�.Q <br />September 2, 2010 Notary public X , J) on MY Commission Expires <br />December, 320 <br />My Commission expires: Dec. 03, 2010 <br />CERTIFICATE FOR PAYMENT <br />In accordance with the Contract Documents, based on on -site observations and the <br />data Comprising the above appplication, the Engineer certifies to the Owner that to the <br />best of the Engineers knowledge, information and belief the Work has progressed as <br />indicated, the quality of the Work is in accordance with the Contract Documents, and <br />the Contractor is entitled to payment of the AMOUNT CERTIFIED. <br />AMOUNT CERTIFIED � f18 650 �O <br />(Attach explanation if amount certified differs from the amount applied for.) <br />Consulting Engineers, Inc. <br />This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the <br />Contractor named herein. Issuance, payment and acceptance of payment are without <br />$92,161.74 <br />r rl <br />prejudice to any rights of the Owner or Contractor under this Contract. <br />AIA DDCUMENr G7D2 APPUCATIONANDCERTIFICATE FOR PAYMENT MAY 1983 EDITION AA @ 1932 G70Y1a92 <br />THEAMERICAN INE WTEOFARCHITECTS. 17 35 NEWYORKAVENUE. N.W..WASHINGTON. D.C. 20006 <br />