Packet: Tiffin Regular City Council Meeting (09/01/2026)

APPLICATION AND CERTIFICATE FOR PAYMENT Page: 1 of 4 TO OWNER: City of Tiffin PROJECT: City of Tiffin Community Recreation Center 300 Railroad St 105 S Park Road APPLICATION NO.: 16 Distribution to: nite. IA 52340 HA 1A 52340 PERIOD TO : 08/31/2026 (owner PROJECT NOS.: 250120 (J ARcHiTEcT FROM Miron Construction Co., Inc. ARCHITECT: Atura Architecture INVOICE NO.: 250120-0016 [contractor CONTRACTOR: po Box 1372 912 North 13th Street Green Bay, WI 54305-1372 Clear Lake, IA 50428 CONTRACT DATE : 11/49/2024 Oo CONTRACT FOR: City of Néfin Community Recreation Center APPLICATION Al ERTI FICATE FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and belief the work . 5 ; 3 covered by this Application for Payment has been completed in accordance wi ie Contract Documents, that all amounts jppaleation is made for payment, as sho’ elow, in connection with the Contract. Continuation sheet have been paid by the Contractor for Work for which previous Certificates for payment were issued and payments received is attached. from the Owner, and that current payment shown herein is now : 1. ORIGINAL CONTRACT SUM......> 12,435,142.00 waRrnING: DO NOT CHANGE ESTABLISHED PAYMENT INSTRUCTIONS FOR PAYMENTS TO MIRON 2. Net change by change orders......... . -1,042,001.88 CONSTRUCTION CO., INC.: Miron Construction Ce-'inc. does not change Its bank routing or account numbers. Do not 3. CONTRACT SUM TO DATE( Line’ +/- 2 ) oe accept or rely upon:emails.or corresponden 11 ,393, 140.12 instructions. Any change to Miron Cons} questing changes to Miron Construction Co., Inc.'s established payment ion Co., Inc.'s payment instructions can only be made bya fully executed 4. TOTAL COMPLETED & STORED TO DATE.... 9,426,01 0.65 Change Order to the Agreement between Owner and Miron Construction Co., Inc... PAAH E eNAGE, cunttactone-ARER.O5p ction Co., Inc, en ton, 5. : GE: By: b 4 Date: August 26,2026 as“. SOMy,.an, (Total retainage Column | of G703)..........02..0.0.0 0.22 e eee $ 471,300.54 Se pou 55%, 6. TOTAL EARNED LESS RETAINAGE.......... $ Wisconsin Ey eae WO (Line 4 less Line 5 Total ) Winnebago FS! geting POR 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT Stiisndbed’and anorn io befor Per S_.- 3 F (Line 6 from prior Certificate)... 2.2... 2. eee eee ei " BON Sf Pup © As 253 8. CURRENT PAYMENT DUE...... day of _ August 2026 zo," % Os as “GF 3 9, BALANCE TO FINISH, INCLUDING RETAINAGE MICNLULL A SOMME) (7 a Lseee ORs os i “> OF wis » (Line 3 less Line 6 ) $ 2,438,430.01 My Commission e} : 07-10.20 20 tetas yO" CHANGE ORDER SUMMARY ADDITIONS} DEDUCTION: Fi a Change Order approved in 990 -4,042,001.88 ARCHITECT S CERTIFICATE FOR PAYMENT previous months by Owner In accordance, prop ae oben allots and the data comprising the above application, APPROVED THiS MONTH ct certifies to the Owner that to the best of the Archité ledge, information and belief the Work has progressed as indicated, the quality of Workis in accordance with the Contract ents, and the Contractor is entitled to Number Date Approved the payment of the AMOUNT CERTIFIED. (Attach explanation If amount certified differs from the arpount applied for. Initial figures on this Applicatiorand on the Continuation Sheet that are changed to conform to the amount certified.) \ 4 By: 7 City of Tiffin Current Total: 0.00 [ 0.00] ARCHITECT: Atura Architecture iNet Change by Change Orders Xx -1,042,001.88| By: Date: WARNING: This AIAD Doptmnentis protested by U.S. Copyright ‘Law and In TrealiesoL r is AAD This Certificate is not negotiable. The AMOUNT CERTIFIED is payabie only to the Contractor_n: herein. issuance, AIA Document G702 ~1892.Copyight © 1953, 1963, 1865, 1971, 1978, 1983 and 1992by The American Intute af Architects,All afi reserved. . 3 - . 5 Document, or any portion af', may result n severe civ and criminal wri wil be salutes extentpossi Ungar: This document was produced at 14:44:11 on 08/26/2026 under Order No 20240046063 which expires on 07/24/2027, and is not for resale. User Nates: payment and acceptance of payment are without prejudice to any rights of the Own factor under this Contract.