CONTRACTOR'S APPLICATION FOR PAYMENT

1 APPLICATION AND CERTIFICATION FOR PAYMENTAIA DOCUMENT G702 PAGE ONE OFPAGESTO OWNER:PROJECT: APPLICATION NO:Distribution to:OWNERARCHITECTPERIOD TO:CONTRACTORFROM CONTRACTOR:VIA ARCHITECT: PROJECT NO'S:COMMITMENT NO'SCONTRACTS tellar surfacesCONTRACT DATE: CONTRACTOR'S APPLICATION FOR PAYMENTThe undersigned Contractor certifies that to the best of the CONTRACTOR'S knowledge, APPLICATION is made for PAYMENT , as shown below, in connection with the and belief the Work covered by this APPLICATION for PAYMENT has beenContinuation Sheet, AIA Document G703, is 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 ORIGINAL CONTRACT SUM $2.

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. of Completed Work $State of:County of:(Column D + E on G703)Subscribed and sworn to before me this day of of Stored Material $Notary Public:(Column F on G703)My Commission expires: Total Retainage (Lines 5a + 5b orTotal in Column I of G703) ARCHITECT'S CERTIFICATE FOR PAYMENT6. 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 Architect certifies to the Owner that to the best of the7. 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 Contractor8.

3 CURRENT PAYMENT DUE $is entitled to PAYMENT of the AMOUNT BALANCE TO FINISH, INCLUDING RETAINAGE $( line 3 less line 6)AMOUNT CERTIFIED .. $CHANGE ORDER SUMMARYADDITIONSDEDUCTIONS(Attach explanation if amount certified differs from the amount applied. Initial all figures on this Total changes approvedApplication and onthe Continuation Sheet that are changed to conform with the amount certified.) in previous months by OwnerARCHITECT: Total approved this MonthBy: Date: TOTALSThis 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 Orderprejudice to any rights of the Owner or Contractor under this SHEETAIA DOCUMENT G703 PAGE OF PAGESAPPLICATION NO: APPLICATION DATE:PERIOD TO:NNI's PROJECT NO:AB CDEFGHIJITEMDESCRIPTION OF WORKSCHEDULEDWORK COMPLETEDMATERIALSTOTAL%BALANCE PREVIOUS THIS PERIODPRESENTLY COMPLETED(G C)TO FINISH(IF VARIABLEAPPLICATIONSTOREDAND STORED(C - G)RATE)(D + E)(NOT INTO DATED OR E)(D+E+F)GRAND TOTALSW avier of Lien 2016 CONDITIONAL waiver AND release OF LIEN UPON FINAL PAYMENT To All Whom It May Concern.

4 The undersigned is to be paid a final PAYMENT in the sum of $ (Amount) for labor, services, equipment, or material furnished . Upon receipt and when the check has been properly endorsed and has been paid by the bank upon which it is drawn, this document shall become effective to release any mechanic s lien, stop notice or bond right the undersigned has on the job of: Job Name: Address: City: County: State: This release covers the final PAYMENT to the undersigned for all labor, services, equipment, or material furnished on the job, except for disputed claims for additional work in the amount of $.

5 Before any recipient of this document relies on it, the party should verify evidence of PAYMENT to the undersigned By: _____ Company Name: Print Name: Company Trade: Print Title: Dated: SWORN TO BEFORE ME AND SUBSCRIBED IN MY PRESENCE, at , this day of A. D., 20 AFFIDAVIT OF (SUB ORIGINAL) CONTRACTOR DATE: STATE OF , COUNTY, ss: being first duly sworn, says that he/she is the of (Sub) contractor having a contract with the for situated on or around or in front of the following described property: where of was the owner, part owner or lessee.

6 Affiant further says that the following shows the names of every sub-contractor in the employ of said giving the amount, if any, which is due, or to become due, to them, or any of them, for work done or machinery, material or fuel furnished to date hereof, under said contracts. NOTE: This statement must be accompanied by a similar sworn statement signed by each of the Sub-contractors listed below. SUB-CONTRACTORS Names Trade Contract PriceAmount Previously PaidThis PAYMENT Balance Due Said affiant further says that the following shows the names of every person furnishing machinery, Material or fuel, to giving the amount, if any, which is due, or to become due, to them or any of them, for machinery, material, or fuel furnished to date hereof, under said contracts.

7 MATERIAL MEN Names Trade Contract PriceAmount Previously PaidThis PAYMENT Balance Due Said affiant further says that the following shows the names of every unpaid laborer in the employ of due for labor done to date hereof: NOTE: If the fact that every laborer has been paid in full, then recite: Every laborer has been paid in full. If not, then give each unpaid laborer s name and the amount due or to become due. LABOR NAME HOURS Amount due or to become due for labor Furnished to date hereof. That the amount due or to become due to said sub-contractor, material men and laborers, for work done, or machinery, material or fuel furnished to the date hereof, to is fully and correctly set forth opposite their names, respectively, in the aforesaid statements, and further evidenced by certificates of every person furnishing machinery, material or fuel, hereto attached, and made a part.

8 Affiant further says that has not employed or purchased or procured machinery, material or fuel from, or sub-contractor with any person, firm or corporation, other than those above mentioned, and owes for no labor performed, or machinery, material or fuel furnished under said contracts than above set forth. Signature X SWORN TO BEFORE ME AND SUBSCRIBED IN MY PRESENCE, at This day of 201_. _____ Notary Public