Copy of Copy of Pay request.xls

XLS spreadsheet 96 KB Posted May 22, 2020

Attached to: Add to the Building Automations HVAC System which is Automated Logic In accordance with the Statement of work.
Solicitation number: 246-20-Q-0060
Issued by: Department of Health and Human Services Indian Health Service

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G702

APPLICATION AND CERTIFICATION FOR PAYMENT					AIA DOCUMENT G702		PAGE 1 OF			PAGES
TO OWNER:			PROJECT:			APPLICATION NO:		Distribution to:
						PERIOD TO:			OWNER
									ARCHITECT
								X
									CONTRACTOR
FROM CONTRACTOR:			VIA COTR:			Contractor #:
						CONTRACT #:
						PROJECT #:
						DELIVERY ORDER #:
CONTRACT FOR:						CONTRACT DATE:
CONTRACTOR'S APPLICATION FOR PAYMENT					The undersigned Contractor certifies that to the best of the Contractor's knowledge,
Application is made for payment, as shown below, in connection with the Contract.					information and belief the Work covered by this Application for Payment has been
Continuation Sheet, AIA Document G703, is attached.					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.
1. ORIGINAL CONTRACT SUM			$
2. Net change by Change Orders			$		CONTRACTOR:
3. CONTRACT SUM TO DATE (Line 1 ± 2) $			$
4. TOTAL COMPLETED & STORED TO			$
DATE (Column G on G703)					By:			Date:
5. RETAINAGE:
a.	0%	of Completed Work $			State of:		County of:
	(Column D + E on G703)				Subscribed and sworn to before me this		day of
b.		% of Stored Material $			Notary Public:
	(Column F on G703)				My Commission expires:
Total Retainage (Lines 5a + 5b or
	Total in Column I of G703)		$		CONTRACTOR'S CERTIFICATE FOR PAYMENT
6. TOTAL EARNED LESS RETAINAGE			$		In accordance with the Contract Documents, based on on-site observations and the data
	(Line 4 Less Line 5 Total)				comprising the application, the COTR certifies to the Owner that to the best of the
7. LESS PREVIOUS CERTIFICATES FOR					COTR's knowledge, information and belief the Work has progressed as indicated,
PAYMENT (Line 6 from prior Certificate)			$		the quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE			$		is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE $
	(Line 3 less Line 6)				AMOUNT CERTIFIED . . . . . . . . . . . $
CHANGE ORDER SUMMARY			ADDITIONS	DEDUCTIONS	(Attach explanation if amount certified differs from the amount applied. Initial all figures on this
Total changes approved					Application and onthe Continuation Sheet that are changed to conform with the amount certified.)
in previous months by Owner					COTR:
Total approved this Month					By:			Date:
TOTALS				$0.00	This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
					Contractor named herein. Issuance, payment and acceptance of payment are without
NET CHANGES by Change Order					prejudice to any rights of the Owner or Contractor under this Contract.
AIA DOCUMENT G702 · APPLICATION AND CERTIFICATION FOR PAYMENT · 1992 EDITION · AIA · ©1992
Users may obtain validation of this document by requesting a completed AIA Document D401 - Certification of Document's Authenticity from the Licensee.

G703

CONTINUATION SHEET				AIA DOCUMENT G703				PAGE 2 OF 4 PAGES		/WGPD
AIA Document G702, APPLICATION AND CERTIFICATION FOR PAYMENT, containing							APPLICATION NO:	0		/wir.{d 25}~{r 6}/cf~~{L 6}~
Contractor's signed certification is attached.							APPLICATION DATE:	12/31/99		/wgpe
In tabulations below, amounts are stated to the nearest dollar.							PERIOD TO:	12/31/99		/ru.{d 26}
Use Column I on Contracts where variable retainage for line items may apply.							DELIVERY ORDER #	0		{L 5}
										{L 9}
A	B	C	D	E	F	G		H	I	/ru.{d 26}~
ITEM	DESCRIPTION OF WORK	SCHEDULED	WORK COMPLETED		MATERIALS	TOTAL	%	BALANCE	RETAINAGE
NO.		VALUE	FROM PREVIOUS	THIS PERIOD	PRESENTLY	COMPLETED	(G ÷ C)	TO FINISH	(IF VARIABLE
			APPLICATION		STORED	AND STORED		(C - G)	RATE)
			(D + E)		(NOT IN	TO DATE
					D OR E)	(D+E+F)
1	Section 01.57.33 tempory controls	$5,000.00		$0.00		$0.00		$5,000.00
	EPA SWWPPP Permit			$0.00		$0.00		$0.00
2	Section 01.57.33 tempory controls	$8,000.00		$0.00		$0.00		$8,000.00
	Safety barrier fencing to protect			$0.00		$0.00		$0.00
	The wetlanda			$0.00		$0.00		$0.00
3	Section 03.30.00 CAST in place	$3,000.00		$0.00		$0.00		$3,000.00
	Concrete Thrust Blocks, restrained			$0.00		$0.00		$0.00
	joints are ok. Seven for 4" lines and			$0.00		$0.00		$0.00
	two for 12" lines			$0.00		$0.00		$0.00
4	SECTION 01.30.00 CAST IN PLACE			$0.00		$0.00		$0.00
	CONCRETE Concrete Pads (Cell#1)	$18,000.00		$0.00		$0.00		$18,000.00
	4" AB-3AS-1 Aggregate base coarse, concrete to be 7" thick, 4,000 psi, 5-8%

air, 4-6" slump, with Fibermesh 300 (or approved equal) additive. Appurtenances is to be included in this

Lump Sum.		$0.00		$0.00		$0.00
	5	SECTION 03.30.00 CAST-IN-PLACE CONCRETE	$2,752.00		$0.00		$0.00		$2,752.00
		Concrete Pad (Cell #2). Concrete pad in Cell #2 to			$0.00		$0.00		$0.00
		meet all material requirements of the Concrete Pad in			$0.00		$0.00		$0.00
		Cell #1. Appurtenances is to be included in this Lump			$0.00		$0.00		$0.00
		Sum.			$0.00		$0.00		$0.00
					$0.00		$0.00		$0.00
	6	SECTION 26.20.00 LOW VOLTAGE ELECTRICAL TRANSMISSION	$1,000.00		$0.00		$0.00		$1,000.00
	7	SECTION 26.20.00 LOW VOLTAGE ELECTRICAL TRANSMISSION	$18,779.34		$0.00		$0.00		$18,779.34
					$0.00		$0.00		$0.00
					$0.00		$0.00		$0.00
					$0.00		$0.00		$0.00
					$0.00		$0.00		$0.00
					$0.00		$0.00		$0.00
							$0.00	$0.00	$0.00
		PAGE TOTALS	$56,531.34	$0.00	$0.00	$0.00	$0.00		$56,531.34
	Users may obtain validation of this document by requesting of the license a completed AIA Document D401 - Certification of Document's Authenticity

&L&"Arial"&6AIA DOCUMENT G703 · CONTINUATION SHEET FOR G702 · 1992 EDITION · AIA · ©1992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVENUE, N.W. WASHINGTON, D.C. 20006-5232&R&"Arial"&8&BG703-1992

G703 contd.

CONTINUATION SHEET				AIA DOCUMENT G703				PAGE 3 OF 4 PAGES		/WGPD
AIA Document G702, APPLICATION AND CERTIFICATION FOR PAYMENT, containing							APPLICATION NO:	0		/wir.{d 25}~{r 6}/cf~~{L 6}~
Contractor's signed certification is attached.							APPLICATION DATE:	12/31/99		/wgpe
In tabulations below, amounts are stated to the nearest dollar.							PERIOD TO:	12/31/99		/ru.{d 26}
Use Column I on Contracts where variable retainage for line items may apply.							DELIVERY ORDER #	0		{L 5}
										{L 9}
A	B	C	D	E	F	G		H	I	/ru.{d 26}~
ITEM	DESCRIPTION OF WORK	SCHEDULED	WORK COMPLETED		MATERIALS	TOTAL	%	BALANCE	RETAINAGE
NO.		VALUE	FROM PREVIOUS	THIS PERIOD	PRESENTLY	COMPLETED	(G ÷ C)	TO FINISH	(IF VARIABLE
			APPLICATION		STORED	AND STORED		(C - G)	RATE)
			(D + E)		(NOT IN	TO DATE
					D OR E)	(D+E+F)
				$0.00		$0.00		$0.00
				$0.00		$0.00		$0.00
				$0.00		$0.00		$0.00
				$0.00		$0.00		$0.00
				$0.00		$0.00		$0.00
				$0.00		$0.00		$0.00
				$0.00		$0.00		$0.00
						$0.00		$0.00
						$0.00		$0.00
						$0.00		$0.00
						$0.00		$0.00
						$0.00		$0.00
						$0.00		$0.00
						$0.00		$0.00
						$0.00		$0.00
						$0.00		$0.00
				$0.00		$0.00		$0.00
						$0.00		$0.00
								$0.00
								$0.00
								$0.00
								$0.00
						$0.00		$0.00
						$0.00		$0.00
						$0.00	$0.00	$0.00
	GRAND TOTALS	$56,531.34	$0.00	$0.00	$0.00	$0.00	0%	$56,531.34
Users may obtain validation of this document by requesting of the license a completed AIA Document D401 - Certification of Document's Authenticity

Mod #1

CONTINUATION SHEET				AIA DOCUMENT G703				PAGE 4 OF 4 PAGES		/WGPD
AIA Document G702, APPLICATION AND CERTIFICATION FOR PAYMENT, containing							APPLICATION NO:	0		/wir.{d 25}~{r 6}/cf~~{L 6}~
Contractor's signed certification is attached.							APPLICATION DATE:	12/31/99		/wgpe
In tabulations below, amounts are stated to the nearest dollar.							PERIOD TO:	12/31/99		/ru.{d 26}
Use Column I on Contracts where variable retainage for line items may apply.							DELIVERY ORDER #	0		{L 5}
										{L 9}
A	B	C	D	E	F	G		H	I	/ru.{d 26}~
ITEM	DESCRIPTION OF WORK	SCHEDULED	WORK COMPLETED		MATERIALS	TOTAL	%	BALANCE	RETAINAGE
NO.		VALUE	FROM PREVIOUS	THIS PERIOD	PRESENTLY	COMPLETED	(G ÷ C)	TO FINISH	(IF VARIABLE
			APPLICATION		STORED	AND STORED		(C - G)	RATE)
			(D + E)		(NOT IN	TO DATE
					D OR E)	(D+E+F)
						$0.00		$0.00
						$0.00		$0.00
				$0.00		$0.00		$0.00
						$0.00		$0.00
						$0.00		$0.00
								$0.00
						$0.00		$0.00
						$0.00		$0.00
						$0.00	0%	$0.00
						$0.00	0%	$0.00
						$0.00	0%	$0.00
						$0.00	0%	$0.00
						$0.00	0%	$0.00
						$0.00	0%	$0.00
						$0.00	0%	$0.00
						$0.00	0%	$0.00
				$0.00		$0.00		$0.00
						$0.00	0.00%	$0.00
						$0.00		$0.00
						$0.00	0.00%	$0.00
						$0.00	0.00%	$0.00
						$0.00	0.00%	$0.00
						$0.00	$0.00	$0.00
	GRAND TOTALS	$0.00	$0.00	$0.00	$0.00	$0.00	0%	$0.00
Users may obtain validation of this document by requesting of the license a completed AIA Document D401 - Certification of Document's Authenticity

File details come from the government source that posted it. Updated May 22, 2020.