AIA Document G702 1992

Application and Certificate for Payment

TO OWNER:
Westmere Fire District 1741 Western Avenue Albany, New York 12203

TM

PROJECT:

Westmere Fire District 1741 Western Avenue Albany, New York 12203 $%&% 'ale Associates (0 $entury !il) Drive )at*am, New York 12110

FROM CONTRACTOR:

VIA ARCHITECT:

APPLICATION NO: 001 PERIOD TO: CONTRACT FOR: ! Door "e#lacement CONTRACT DATE: PROJECT NOS: 10%11+(, !D -

Distribution to:
OWNER: ARCHITECT: CONTRACTOR: FIELD: OTHER:

CONTRACTOR'S APPLICATION FOR PAYMENT

A##lication is ma.e 0or #ayment, as s*own below, in connection wit* t*e $ontract% $ontinuation 3*eet, A4A Document 5703, is attac*e.% 6 1 ORI!INAL CONTRACT S"M # N$t %&'n($ b) C&'n($ Or*$rs 6 + CONTRACT S"M TO DATE 7)ine 1 8 29 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 6 , TOTAL COMPLETED - STORED TO DATE 7$olumn 5 on 57039 %%%%%%%%%%%%%%%% 6 . RETAINA!E: ' ( < o0 $om#lete. Work 7$olumn D = > on 57039 b ( < o0 3tore. 'aterial 7$olumn F on 57039 0%00 0%00 0%00 0%00

&*e un.ersi/ne. $ontractor certi0ies t*at to t*e best o0 t*e $ontractor1s knowle./e, in0ormation an. belie0 t*e Work covere. by t*is A##lication 0or 2ayment *as been com#lete. in accor.ance wit* t*e $ontract Documents, t*at all amounts *ave been #ai. by t*e $ontractor 0or Work 0or w*ic* #revious $erti0icates 0or 2ayment were issue. an. #ayments receive. 0rom t*e wner, an. t*at current #ayment s*own *erein is now .ue% CONTRACTOR: :y; 3tate o0; $ounty o0; 3ubscribe. an. sworn to be0ore me t*is .ay o0 Notary 2ublic; 'y $ommission e?#ires; Date;

6 6

0%00 0%00 0%00 0%00 0%00 0%00 0%00

&otal "etaina/e 7)ines (a = (b or &otal in $olumn 4 o0 57039 %%%%%%%%%%%%%%%%% 6 / TOTAL EARNED LESS RETAINA!E %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 6 7)ine 4 )ess )ine ( &otal9 0 LESS PREVIO"S CERTIFICATES FOR PAYMENT %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 6 7)ine B 0rom #rior $erti0icate9 1 C"RRENT PAYMENT D"E 2 3ALANCE TO FINISH4 INCL"DIN! RETAINA!E 7)ine 3 less )ine B9 $!AN5> "D>" 3A''A"Y &otal c*an/es a##rove. in #revious mont*s by wner &otal a##rove. t*is 'ont* & &A)3 N>& $!AN5>3 by $*an/e r.er 6 6

ARCHITECT'S CERTIFICATE FOR PAYMENT

4n accor.ance wit* t*e $ontract Documents, base. on on,site observations an. t*e .ata com#risin/ t*is a##lication, t*e Arc*itect certi0ies to t*e wner t*at to t*e best o0 t*e Arc*itect1s knowle./e, in0ormation an. belie0 t*e Work *as #ro/resse. as in.icate., t*e @uality o0 t*e Work is in accor.ance wit* t*e $ontract Documents, an. t*e $ontractor is entitle. to #ayment o0 t*e A' AN& $>"&4F4>D% AMO"NT CERTIFIED %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 6 (Attach explanation if amount certified differs from the amount applied. Initial all figures on this Application and on the Continuation Sheet that are changed to conform with the amount certified.) ARCHITECT: :y; Date;

6 6 6 6

ADD4&4 N3 D>DA$&4 N3 0%00 6 0%00 0%00 6 0%00 0%00 6 0%00 0%00

&*is $erti0icate is not ne/otiable% &*e A' AN& $>"&4F4>D is #ayable only to t*e $ontractor name. *erein% 4ssuance, #ayment an. acce#tance o0 #ayment are wit*out #reCu.ice to any ri/*ts o0 t*e wner or $ontractor un.er t*is $ontract%

AIA Document G702 1992. Copyright 1953, 1963, 1965, 1971, 1978, 1983 and 1992 by The American Institute of Architects. All rights reserved. WARNING: This AIA Document is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AIA Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. This draft was produced by AIA software at 10:06:42 on 06/24/2008 under Order No.1000358896_1 which expires on 8/30/2009, and is not for resale. User Notes: (3678714135)