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•5" Al.A Document G702 ® - 1992
<br />Application and Certificate for Payment
<br />TO OWNER: Board of Public Works
<br />City of South Bend
<br />227 East Jefferson Blvd.
<br />South Bend, IN 46601
<br />PROJECT: 17848 -SB = WWTP Admin WWTP Administration Building
<br />Masonry Improvements
<br />APPLICATION NO: 009
<br />PERIOD TO: November 30, 2020
<br />Distribution to:
<br />OWNER: [8l
<br />ARCHITECT: [8l
<br />CONTRACTOR: 0
<br />FIELD: 0
<br />OTHER: 0
<br />FROM VIA
<br />CONTRACTOR: Ziolkowski Construction, Inc.
<br />4050 Ralph Jones Dr.
<br />ARCHITECT: Kil Architecture I Planning
<br />CONTRACT FOR: General Construction
<br />CONTRACT DATE: December 20, 2018
<br />PROJECT NOS: 118 / 087 I
<br />South Bend, IN 46628
<br />CONTRACTOR'S APPLICATION FOR PAYMENT
<br />Application is made for payment, as shown below, in connection with the Contract. AIA Document G703®, Continuation Sheet, is attached.
<br />1. ORIGINAL CONTRACT SUM ............................................................................... .
<br />2.NET CHANGE BY CHANGE ORDERS ................................................................ .
<br />3.CONTRACT SUM TO DATE (Line 1 ± 2) ........................................................... .
<br />4. TOTAL COMPLETED & STORED TO DATE (Column G on G703) ................ .
<br />5. RETAINAGE:
<br />a.2.:QQ.__% of Completed Work
<br />(Column D +E on G703)
<br />b.0.00 % of Stored Material
<br />(Column F on G703)
<br />$0.00
<br />$0.00
<br />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 completed in accordance with the Contract Documents, that all amounts have been paid by the Contractor for Work for which previous Certificates for Payment were issued and
<br />$463,380.00 payments received from the Owner, and that current payment shown herein is now due.
<br />-$1_,_889.00 CONTRACTOa,:
<br />$461,491 .00 By: /[f.�'C... �� $461_,_491.00
<br />Subscribed and sworn to bef.ore .,,,0� d :,T ,H ,tJ '"'· ,::,,.
<br />Jennifer Wiest
<br />Date: December 04_,_ 2020
<br />' ,, .... .,,,,,, JENNIFER WIE ST '-''\'-TEO� i' ;.•· · ·•.; i Notary Public. State of Indiana �.:•�•:•i St. Joseph County ; •• SEA� : i Commission # 663344
<br />� ;• •••• ·; $My Commission Expires ,,,,:;r,;�.�,,,,� January 28, 2023
<br />Total Retainage (Lines Sa+ Sb or Total in Column I of G703) ............... .. $0.00 My Commission expires: January 28, 2023 -----�;..;:_:_
<br />6.TOTAL EARNED LESS RETAINAGE ................................................................. ..
<br />(Line 4 Less Line S Total)
<br />7.LESS PREVIOUS CERTIFICATES FOR PAYMENT .......................................... ..
<br />(Line 6 from prior Certificate)
<br />$461,491 .00 ARCHITECT'S CERTIFICATE FOR PAYMENT
<br />In accordance with the Contract Documents, based on on-site observations and the data
<br />$438,416.4 S
<br />8.CURRENT PAYMENT DUE .......................................................................... 1 $23,074.551
<br />comprising this 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, the
<br />quality of the Work is in accordance with the Contract Documents, and the Contractor is entitled to payment of the AMOUNT CERTIFIED.
<br />9. BALANCE TO FINISH, INCLUDING RETAINAGE
<br />(Line 3 less Line 6)
<br />CHANGE ORDER SUMMARY ADDITIONS
<br />Total changes approved in previous months by Owner $0.00
<br />Total approved this Month $0.00
<br />TOTALS $0.00
<br />NET CHANGES by Change Order
<br />$0.00
<br />DEDUCTIONS
<br />$1,889.00
<br />$0.00
<br />$1,889.00
<br />-$1,889.00
<br />AMOUNT CERTIFIED .................................................................................... .. $23_,_074.55
<br />(Attach explanation if amount certified differs from the amount applied. Initial all figures on this
<br />Application and on the Continuation Sheet that are changed to conform with the amount certified.)
<br />ARCHITECT:
<br />By:--------Date:
<br />This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract.
<br />AIA Document G702ll> -1992. Copyright© 1953, 1963, 1965. 1971, 1978, 1983 and 1992 by The American Institute of Architects. All rights reserved. The "American Institute of Arch itec ts," "A IA," the AIA Logo,
<br />"G702," and "AIA Co ntrac t Documents" are registered tr ademarks and may not be used without permission . This document was produced by AIA software at 13:35:17 ET on 12/04/2020 under Order No.6002723076 1 which expires on 07/04/2021, is not for resale, is licensed for one-time use only, and may only be used in accordance with the AIA Contract Documents® Terms of Service. To report copyright violations, e-mail
<br />copyright@aia.org.
<br />User Notes: (3B9ADA48)
<br />December 16, 2020
<br />XX 008 -JMK
<br />03-30-2021
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