Attachment_4_-_AIA_Document_G702_Template.pdf

APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 PAGE ONE OF PAGES

TO OWNER: PROJECT: APPLICATION NO 0 Distribution to:

OWNER

ARCHITECT

PERIOD TO: CONTRACTOR

FROM CONTRACTOR: VIA ARCHITECT:

PROJECT NOS:

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 $ 0.00 CONTRACTOR:

3. CONTRACT SUM TO DATE (Line 1 ± 2) $ 0.00

4. TOTAL COMPLETED & STORED TO $ 0.00

DATE (Column G on G703) By: Date:

5. RETAINAGE:

a. % of Completed Work $ $0.00 State of: County of:

(Column D + E on G703) Subscribed and sworn to before me this day of

b. % of Stored Material $ Included in above Notary Public:

(Column F on G703) My Commission expires:

Total Retainage (Lines 5a + 5b or

Total in Column I of G703) $ 0.00 ARCHITECT'S CERTIFICATE FOR PAYMENT

6. TOTAL EARNED LESS RETAINAGE $ 0.00 In accordance with the Contract Documents, based on on-site observations and the data

(Line 4 Less Line 5 Total) comprising the application, the Architect certifies to the Owner that to the best of the

7. LESS PREVIOUS CERTIFICATES FOR Architect'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 $ 0.00 is entitled to payment of the AMOUNT CERTIFIED.

9. BALANCE TO FINISH, INCLUDING RETAINAGE $ 0.00

(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 ARCHITECT:

Total approved this Month By: Date:

TOTALS $0.00 $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 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE., N.W., WASHINGTON, DC 20006-5292

Users may obtain validation of this document by requesting a completed AIA Document D401 - Certification of Document's Authenticity from the Licensee.

$0.00

W911S2-16-B-8000 Asphalt Requirements

Fort Drum, NY