APPLICATION AND CERTIFICATE FOR PAYMENT

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1 AND CERTIFICATE FOR PAYMENT TO OWNER: MASTER TEMPLATE - SAVE PROJECT FILE 1 DATE: 10/5/2012 PERIOD TO: ARCHITECT: PROJECT NO: CONTRACTOR'S FOR PAYMENT Application is made for payment, as shown below, in connection with the Contract. Continuation Sheet is attached 1. ORIGINAL CONTRACT SUM CONTRACT DATE: COMPLETION DATE: Change Order Days Added = 0 NEW CONTRACT COMPLETION DATE: 1/0/1900 $895, 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 for which previous Certificates for Payment were issued and payments received from the Owner, and that current payment shown herein is now due. 2.Net Change by Change Orders $25, CONTRACTOR: 3. CONTRACT SUM TO DATE $920, Overall % Complete 49.32% By: Date: WORK TO DATE : $453, $ TOTAL & TO DATE $454, State of: County of: 5. RETAINAGE Subscribed and sworn to before a. 5 % of completed work $22, me this day of b. 5 % of stored material $13.00 Total Retainage $22, Notary Public: 6.TOTAL EARNED LESS RETAINAGE $431, My Commission expires: ARCHITECT'S CERTIFICATE FOR PAYMENT 7.LESS PREVIOUS PAYMENTS 8. CURRENT PAYMENT DUE $431, , INCLUDING RETAINAGE $488, In accordance with the Contract Documents, based on on-site observations and the data comprising this 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. Distribution : AMOUNT CERTIFIED $ OWNER ( Attach explanation if amount certified differs from the amount applied for. Initial all figures on this Application and on ARCHITECT Copies the Continuation Sheet that are changed to conform to the amount certified. ) ARCHITECT: PROJECT MANAGER By: Date: ACCOUNTING 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. Page 1 of 1

2 TOTAL D Division 1 - GENERAL CONDITIONS 895, , , % 447, Engineering & Design Support % - Submittal & Approval Activities % - Job Site Safety % - Alternates & Options % - Project Coordination & Administration % - Permits, Inspections & Compliance % - Quality Control & Testing % - Temporary Facilities % - Misc Tools & Equipment % - Project Closeout % - Division 2 - SITE WORK % - Site Clearing, Demolition & Removals % - Allowances for Unknown Conditions % - Termite Control % - Concrete Paving, Curbs, Etc % - Water and Gas Distribution System % - Sanitary Sewer System % - Storm Drainage System % - Finish Grading & Grassing % - Division 3 - CONCRETE % - Concrete Formwork % - Concrete Reinforcement % - Cast-in-place Concrete % - Special Concrete Work % - Division 4 - MASONRY % - Mortar % - Masonry Accessories & Bonding % - CMU Units % - Brick Units % - Masonry Pointing and Cleaning % - Brick Pointing and Cleaning % - Cast Stone % - Division 5 - METALS % - Structural Metal % - Open Web Steel Joists % - Metal Roof Deck % - Light Gauge Partition Framing (Welded) % - Pre-Engineered Steel Truss % - Page 1 of 4

3 TOTAL D Miscellaneous Metals % - Metal Stairs & Handrails % - Pipe Bollards % - Division 6 - WOODS & PLASTICS % - Rough Carpentry % - Finish Carpentry % - Millwork % - Cabinetry % - Countertops % - Exterior Wall Sheathing % - FRP Columns & Trim % - Division 7 - BUILDING PROTECTION % - Damp proofing & Waterproofing % - Metal Roof Systems % - Shingle Roof Systems % - Cavity Damp proofing System % - Water Repellant Coating % - Under slab Vapor Barrier % - Building Insulation % - Exterior Insulation & Finish % - Firestopping % - Flashing & Sheet Metal % - Thru-wall Flashing % - Sealants & Caulking % - Division 8 - DOORS & WINDOWS % - Hollow Metal Doors % - Wood Doors % - Special Doors % - Entrances & Storefronts % - Wood Windows % - Aluminum Windows % - Door, Finish & Exit Hardware % - Glass & Glazing % - Skylights % - Division 9 - ES % - Gypsum Walls % - Other Wall Systems % - Hard Tile Work % - Acoustical Ceilings & Surfaces % - Resilient Flooring % - Page 2 of 4

4 TOTAL D Carpeting % - Painting % - Lettering & Room Identifications % - Sheet Wall Covering % - Division 10 - SPECIALTIES % - Building Specialties % - Toilet Partitions % - Louvers & Vents % - Identifying Devices % - Toilet & Bath Accessories % - Fireplaces % - Flagpoles % - Mailboxes, Chalkboards, etc % - Division 11 - EQUIPMENT % - Appliances, Stoves, Dishwashers, Refrigerators, etc % - Parking Control % - Library Equipment % - Vending % - Loading Dock Equipment % - Food Service Equipment % - Division 12 - FURNISHINGS & CASEWORK % - Furniture % - Laboratory Equipment % - Special Construction Casework % - Modular Casework, etc % - Division 13 - SPECIAL CONSTRUCTION % - Swimming Pools % - Aquariums % - Pre-Engineered Stand-a-Lone Structures % - Lightning Protection % - Fire Suppression Systems % - Division 14 - CONVEYING SYSTEMS % - Elevators % - Escalators % - Dumbwaiters, Trash Collectors, Etc % - Division 15 - MECHANICAL % - HVAC Systems % - Plumbing % - Page 3 of 4

5 TOTAL D Sprinkler & Fire Suppression Piping % - Ductwork & Venting % - Automatic Temperature and Humidity Controls % - Division 16 - ELECTRICAL % - Main Supply Lines % - Distribution Panels & Systems % - Communications % - Sound Systems % - Video Systems % - TOTAL CONTRACT SUMMARY: 895, , , , CHANGE ORDER SUMMARY Change Order Item # C.O. Description Approved Amount Completed Work Status Days Added 1 Examples 25, , In Progress 25% 2 Examples % 3 Examples % 4 Examples % 5 Examples % 6 Examples % 7 Examples % 8 Examples % 9 Examples % TOTAL CHANGE ORDERS: 25, , Page 4 of 4

6 DETAILED INVENTORY OF CLIENT: MASTER TEMPLATE - SAVE P CONTRACTOR: MASTER - CONTRACTOR NAM A B C D E F DESCRIPTION PURCHASED TOTAL THIS COLUMNS USED LAST PERIOD PERIOD B + C EXAMPLES OF : ALUMINUM WINDOWS VENTED NAIL BASE INSULATION FIRE PROTECTION BOOSTER PUMP STRUCTURAL STEEL BAR JOIST & DECKING PRE-ENGINEERED METAL BLDG. FRAMING REINFORCING STEEL HOLLOW METAL DOORS & FRAMES HVAC CONTRACTOR Sheetmetal Materials Grills, Louvers & Dampers Equipment Piping TOTALS FOR THIS SHEET To be used as document to support "Stored Materials as of date of accounting" Reported on AND CERTIFICATE FOR PAYMENT Page 1 of 1

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