SW0001-EM040131APPLICATION ANO C[:.1'~1 II-ICA I ION PUN ffP,¥MbN I
TO CiD' of Coppell
~- PO Box 9478
o Coppcl, TX 75019
FROM: Green Scapmg
8917 Cardinal Lune
N. Richland Hills, TX 76180
Alii I)( )(/UM'P,'N?' (i 702
APPLICATION NO: 4
Application Date: 2/4/04
PERIOD TO: 1/31/04
Dismbution to:
~--]OWNER
~'~]ARCH1TECT
~--1CONI RACTOR
CONTRACT FOR: Riverchase Sidewalk
CONTRACTOR'S APPLICATION FOR PAYMENT
Application is made for paymem, as shovm bclov,., in com~ectio~_ with the Cuntract.
Continuation Sheet, AIA Documeul G703, is attached.
The undersigned Contractor cer:ifies that to tile best of the Contractor's knowledge,
information and belief the Work covered by this Application for Pay'taunt has been
completed in aecotdunce v;ith the Contract Documems, that all amounts have been Prod by
the Conlractor for Work for ,ahich previous Certificates for Paymem were issued and
payments reccwcd from Ihe Ovmer, and that current pa~menl sbown herein is now due
I ORIGINAL CONTRACT SUM
2. Net change by Change Orders
3. CONTRACT SUM TO DATE (Line 1 ± 2)
4. TOTAL COMPLETED & STORED TO
DATE (Colmnn G on G703)
5 RETAtNAGE:
a 10 % of Completed Work
(Cohinm D + E on O703)
b. % of Stored Material
(Colmnn F on Ca703)
Total Retainage (Lines 5a + 5b or
Total in Colunm I of G703)
6. TOTAL EARNED LESS RETAINAGE
(Line 4 Less Line 5 Total)
7. LESS PREVIOUS CERT1FICATESFOR
PAYMENT (Linc 6 from prior Certificate)
~ CI2~RENT PAYMENT DUE
9. BALANCE TO FINISH, INCLUDING RETAINAOE
(Line 3 less Line 6)
$ 135,737.00
$ 6,906.00
$ 142,643.00
$ 142,343.00
$ 14,234,30
$ 0,00
$ 14,234.30
$ 128,108.70
$ 110,711.25
$ 17~97.45
$ 300.00
CONTRACTOR: Green Sg.a~
State of: Texas (%'h
Subscribed and sworn to before mc this
Notasy Public:
My Cormnissiun expires:
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS
Total changes approved
in prev/ous months by Owner
Total approved this Month 6,906.0(
TOTALS 6,906,0t $0
NET CHANGES b>r Change Order $6,906.00
Count), of: Tan'ant
day of
.RCHITECT'S CERTIFICATE FOR PAYMENT
In accordance with the Contract Doctwaents, based on on-sitc obscv,,ations and the dala
comprising the application, the Architect certifies to the Owner that to the best of thc
Architect's knowledge, information and belief thc Work has progressed as indicaled,
file quality of the Work is in accordmrce with the Contract Documents, and thc Contractor
is entitled Io payment of the AMOUNT CEEI
AMOUNT CERTIIeIED ........... $
(Attach explanation tf amount certified dtfferx from the amount applied Initial all figures on this
Application and onthe Continuation Sheet that are changed to conform with the amount certified )
ARCHITECT:
By: Date:
This Certifimte is not negotiable. The AMOUNT CERTIFIED is pa)able only to the
prejudice to ,-my rights of thc Owner or Contractor under this Contract
CONTINUATION SHEET
Subcontractor Green Scaping
8917 Cardinal Lane
N Richland Hills, TX 76180
AIA DOCUMlhYT (3 703
PAGE 20F2 PAGES
APPLICAT[ON NO: 4
APPLICATION DATE: 2/4/2004
PERIOD TO: 113112004
CONTKA. CT FOR: Rivercl~ase bt~lewanc
A B C D I E F G II I
I[~M DFSCRIPTION OF WOP, XK SC[[EDU1,ED WORK cOMPLF'IED lv~\Tl~ RIALS I'OTA1, % BALANCF IGETAI3NAGE
NO VAI,UF: FROM PREVIOUS THiS PERIOF~" PRESENVLY COMPI.ETED (O; CI TO FINISH 10%
APPLICATION S'rORED AND STORED (C - O) R Al ii)
(D + E [NOT IN TO DATE,
D OR E) ('D+E+F)
1-1 Earth&Borrow 20,310.0( $20,310.00' $20,310.00 10000% $0.01 $2.031.1.11)
1-2 Silt Fence 294.00 $294.00 $294~ 100.00% $00( $29.40
I-3 Hay Bale Check Dam 300.00 $0.0C 0 00% $300.00 $000
[-4 Concrete Saw Cut 360.00 $360.00 $360.012 100.00~ $0.00 $36.0(i
I-5 4" Concretc Sidexvalk $10,188.00 $10,188.00 $10,[88.0( 100 00~ $0 00 $1,018.8£
I-6 Barrier Free Ramp $2,400.00 $2,400.00 $2,400.0( 100.00%! $000 $2400£
I-7 8' Elevated Sidewalk $[01,88500 $83,62850 $18,2565(: $101,885.00 100.00% $0.00 $10,1885(
CHANGE ORDERS
I Earth&Borrow $1,560.00 $780.0C $780.0( $1,560.00 100.00% $0.00 $15600
Concrete Saw Cut $150.0( $150.0( $15000 100.00% $0.0(1 $15.00
4" Concrete Sidc~x'alk $3,996.0( $3,996.0( $3,996.00 10000% $0.0C $399.60
Bamer Frce Ramp $1,200.00 $1,200.0( $1,200.00 100.00% $0.0(: $120.00
GRAND IOI'ALS $142,643.00 $123,012.50 $19,330.5C $0.0( $142,343.00 99.790/o: $300.00 $14,2343(: