APPLICATION AND CERTIFICATE FOR PAYMENT
TO (OWNER):
Ely Sakhai
PROJECT:
99 Powerhouse
AIA DOCUMENT G702
APPLICATION NO: 4
PAGE ONE OF
PAGES
Distribution to:
x OWNER
ARCHITECT
CONTRACTOR
PERIOD TO:
FROM (CONTRACTOR):
VIA (ARCHITECT):
ARCHITECT'S
PROJECT NO:
The Lombardo Group
CONTRACT FOR:
CONTRACT DATE:
CONTRACTOR'S APPLICATION FOR PAYMENT
CHANGE ORDER SUMMARY
Change Orders approved in
AIA Document G703, is attached.
ADDITIONS
DEDUCTIONS
previous months by Owner
TOTAL
Approved this Month
Number
Date Approved
4
2/2/23
TOTALS
Net change by Change Orders
Application is made for Payment, as shown below, in connection with the Contract, Continuation Sheet,
20,000
The undersigned Contractor certifies that to the best of the Contractor's knowledge,
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 which previous Certificates for Payment were issued and payments received from the
Owner, and that current payment shown herein is now due.
CONTRACTOR:
1. ORIGINAL CONTRACT SUM
2. Net change by Change Orders
$
$
3. CONTRACT SUM TO DATE
4. TOTAL COMPLETED & STORED TO DATE
(Column G on G703)
5. RETAINAGE
a. _5____% of Completed Work
(Column D + E on G703)
% of Stored Material
b.
(Column F on G703)
Total Retainage (Line 5A + 5b or
Total in Column I of G703)
6. TOTAL EARNED LESS RETAINAGE
(Line 4 less Line 5 Total)
7. LESS PREVIOUS CERTIFICATES FOR
PAYMENT (Line 6 from prior Certificates)
8. CURRENT PAYMENT DUE
9. BALANCE TO FINISH, PLUS RETAINAGE
$
$
24,000
$
$
$
$
$
$
147,000
40,000.00
368,000
(Line 3 less Line 6)
State of:
By:
$
480,00
35,000
515,000
147,000
Date:
2/2/23
ARCHITECT'S CERTIFICATE FOR PAYMENT
In accordance with the Contract Documents, based on on-site observations and the data
comprising the above application, the Architect certifies to the Owner that to the best of the
Architect's knowledge, information and belief the Work has progressed as indicated, the quality
of the Work is in accordance with the Contract Documents, and the Contractor is entitled to
payment of the AMOUNT CERTIFIED.
Subscribed and sworn to before me this
Notary Public:
My Commission expires:
County of:
day of
AMOUNT CERTIFIED
$
(Attach explanation if amount certified differs from the amount applied for.)
ARCHITECT:
2/2/23
By:
Date:
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.
CONTINUATION SHEET
AIA DOCUMENT G703
PAGE
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, containing
Contractor's signed Certification is attached.
In tabulation below, amounts are stated to the nearest dollar.
Use Column I on Contracts where variable retainage for the line items may apply
A
B
C
ITEM
NO.
DESCRIPTION OF WORK
SCHEDULED
VALUE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Concrete on metal deck replacement
Concrete on metal deck w/asphalt
Underside Concrete slab Repair
Concrete slab crack repair
Steel Beam Replacement
Steel Beam Flange Repair
Asphalt topping slab replacement
Asphalt Replacement
Asphalt bump and slab replacement
Waterproofing
Concrete exterior stair underside Storm
Drain replacement
Storm Trench Grate
Remove 4'0" Pipe
Masonry Column Enclosure removal
New Perimeter Angle ledge
New sidewalk flags and curbs
New concrete curb
Exterior beam repair
310,000
25,000
2,500
2,500
10,000
20,000
15,000
10,000
3,500
40,000
1,500
8,000
4,500
2,500
2,500
6,500
7,000
7,000
7,500
D
PAGES
APPLICATION DATE:
PERIOD TO:
ARCHITECT'S PROJECT NO:
E
WORK COMPLETED
FROM PREVIOUS
THIS PERIOD
APPLICATION
(D + E)
147,000
OF
APPLICATION NUMBER:
40,000
F
G
MATERIALS
PRESENTLY
STORED
(NOT IN
TOTAL
COMPLETED
AND STORED
TO DATE
D OR E)
(D+E+F)
%
(G+C)
H
I
BALANCE
TO FINISH
(C-G)
RETAINAGE
123,000