SW0001-EM040204APPLICATION AND CERTIFICATION FOR PAYMEN I
TO: CiB'ofCoppell
PO Box 9478
Coppel, TX 75019
FROM: Green Sc, aping
8o17 Card(no Lane
N Richlm~d Hills. TX 76180
AIA DOCU^.tENT G702
APPLICATION NO: 5 Final
Application Date: 2/4/04
PERIOD TO: 1/31/04
PAGE ONE OF 1 of 2
Distribution to
1~'-} OWNER
[-'~ ARCHITECT
~ CONTRACTOR
CONTRACT FOR: Ri,,erchase Sidewalk
CONTRACTOR'S APPLICATION FOR PAYMENT
Application is madc for payment, as shown belmv, m connection with lite Contract.
Continuation Sheet. AIA Document G703, is attached.
1. ORIGINAL CONTRACT SUM
2. Net clkange by Change Orders
3. CON3IL~CT SUM TO DATE (Line I ± 2)
4. TOTAL CON'FPLETED & STORED TO
DATE (Column G on G703)
5. RETAFNAGE:
a. 0 % of Completed Work
(Column D + E on G703)
b~ % of Stored Material
~ (Colmnn F on G703)
Z: Total Retainagc (Lines 5a + 5b or
0. Total in Column I of G703)
· 6, TOTAL EARNED LESS RETAiNAGE
t~ (Linc 4 Less Line 5 Total)
7. LESS pREVIOUS CERTUFICATES FOR
Z: PAYMENT (Line 6 from prior Certificate)
~ CURRENT pAYMENT DUE
8.
$
$
$ 135,737.00
$ 6,906,00
$ 142,643.00
$ 142,343.00
0.00
0.00
$ 0.00
$ 142,343.00
9. BALANCE TO FINISH. INCLUDING RETAINAGE
(Line 3 less Line 6)
128,108.70
14,234.30
300.00
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS
Total changes approved
in previous months by Owner
Total approved this Month 6,906,00
TOTALS 6,906 00
NET CHANGES by Change Order $6,90600
The tmdersigned Contractor certifies that to tho best of(be Conlractor's kno/~ledge,
infonnafion and belief the Work covered by this Application for Pa3'menl has been
completed in accordance with the Contract Documents, that all amounts have boon paid by
the Contractor for Work for wkich previous Ccrtitlcates for Payment x~ere issued and
payments received front the Owner, and that current payment shown herein is now due.
CONTRACIOR: Green Scaping
State of: Texas
Sobscribed and sworn Io before me fids
Notary Public:
My Commission expires:
County of: Tm'rant
day of
ARCHITECT'S CERTIFICATE FOR PAYMENT
In accordance with the Contract Documents, based on on-silo observalions and the data
comprising the application, the Amhitect certifies to the Owner thai to the besl of the
Arci-fitect's knowledge, information }md belief the Work has progressed as indicated,
file quality of rite Work is in accordance w/th tho Contract Docmnems, and the Contractor
is enlilled to payment of the AIVlOUNT CERTIFIED,
AMOUNT CERTIFIED ....... $
fl It(ach explanation if amount certified differs from the amount applied lnithd all figurex on this
Application end on(he Contimtation ,Sheet that are changed to conform **ith lite amount certified)
ARCHITECT:
By: Date: , ,,
This Cer6ficate is not negot ab e Thc Pd,,IOUNT CERTPFIED is payable onh' to the
prejud cc to any fights of the O~* nor or Contractor under lhis Contract.
CONTINUATION SHEET
Subcontractor Green Scaping
8917 Cardinal Lane
N. RichJand Hills, TX 76180
AM DOCUMENT (7703
APPLICATION NO:
APPLICATION DATE:
PEI/JOD TO:
5 Final
2/4/2004
1/31/2004
CONTRACT FOR: Riverchase Sidewalk
A B C D ] E F O H I
TEM I)ESCRIPHON OF WORK SCHEDULED WORK COMPLETED MA I'ERIAI,S fOTAL 5',; BALANCE REiAINAGF
NO. VALUE FROM PREVIOI IS THIS PERIOD PRESENTLY COMPI,ETED (G + C'~ it) FINISH 10%
APPLICATION S [ORED AND STORFD (C - O) RATE)
(D + E) (NOT IN TO DATE
D DR E) (I)+E+F)
[-1 Earth&Borrow 20,310.0C $20,31000 $20,31000 100.00% $0.00 $2,03100
I-2 Silt Fence 294.0( $29400 $294.00 100.00% $0.00 $2940
I-3 H%' Bale Check Dam 300.0( $0.00 0.00% $300.0C $0.00
I4 Concrete Sew Cut 36000 $360.00 $360.00 10000% $00C $36.00
I-5 4" Concrete Sidewalk $10,188.00 $10,188.00 $10,188.00 I00.00~ $00C $1.018 80
I-6 Barrier Free Ramp $2,400.00 $2,400.00 $2,400.00 lO0.O0°A $0.0~ $240.00
I-7 g' Elevated Sidewalk $101,885.00 $I01,885.00 $101,885.00 100,00% $0.0( $10,188.50
CHANGE ORDERS
I Earth & Bonow $1,560.00 $1,560.00 $1,560.0C 100.00~ $0.00 $156.00
Concrete Saw Cut $150.00 $150.00 $150.0C 100.00°g $0.00 $15.00
4" Concrete Sidewalk $3,996.00 $3,996.00 $3,996.0( 100.00%' $0.00 $399.6~
lamer Free Ramp $1,200.00 $1,200.00 $1,200.0( 100.00% $0.00 $120.00
GRAND TOTALS $142,643.0( $142,343.0( $0.00 $0.00 $142,343.00 9939% $300.00 $14,23430