Minutes-9/1/2016

APPLICATION AND CERTIFICATION FOR PAYMENT TO OWNER: City of Tiffin 300 Railroad St Tiffin, IA, 52340 FROM CONTRACTOR: Woodruff Construction, LLC 501 Greenfield Drive Tiffin, IA 52340 PROJECT: #A15-0773 Tiffin Parks and Rec Phase I Improvement ENGINEER: HBK Engineering, LLC 509 S Gilbert Street Iowa City, IA 52240 APPLICATION NO: Four (4) PERIOD TO: 09/30/16 HBK #: A15-0773 WOODRUFF #: 16-022 Distribution to: OWNER ARCHITECT CONTRACTOR CONTRACTOR'S APPLICATION FOR PAYMENT Application is made for payment, as shown below, in connection with the Contract. Continuation Sheet, AIA Document G703, is attached. 1. ORIGINAL CONTRACT SUM $ 1,013,315.20 2. Net change by Change Orders $ 0.00 3. CONTRACT SUM TO DATE (Line 1 ± 2) $ 1,013,315.20 4. TOTAL COMPLETED & STORED TO DATE (Column G on G703) $ 810,885.80 5. RETAINAGE: a. 5% of Completed Work (Column D + E on G703) $ 40,544.29 b. % of Stored Material (Column F on G703) $ 0.00 Total Retainage (Lines 5a + 5b or Total in Column 1 of G703) $ 40,544.29 6. TOTAL EARNED LESS RETAINAGE (Line 4 Less Line 5 Total) $ 770,341.51 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT (Line 6 from prior Certificate) $ 545,213.84 8. CURRENT PAYMENT DUE $ 225,127.67 9. BALANCE TO FINISH, INCL RETAINAGE (Line 3 less Line 6) $ 242,973.69 <table> <tr> <th>CHANGE ORDER SUMMARY</th> <th>ADDITIONS</th> <th>DEDUCTIONS</th> </tr> <tr> <td>Total changes approved in previous months by Owner</td> <td>$0.00</td> <td></td> </tr> <tr> <td>Total approved this Month</td> <td>$0.00</td> <td></td> </tr> <tr> <td>TOTALS</td> <td>$0.00</td> <td>$0.00</td> </tr> <tr> <td>NET CHANGES by Change Order</td> <td colspan="2">$0.00</td> </tr> </table> The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and belief the Work covered by this Application for Payment has been completed 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 due. CONTRACTOR: By: [signature] Date: 10/7/2016 State of: Iowa County of: Johnson Subscribed and sworn to before me this day of October 2016 Notary Public: [signature] My Commission expires: 8/27/2019 ARCHITECT'S CERTIFICATE FOR PAYMENT In accordance with the Contract Documents, based on on-site observations and the data comprising the application, the Architect certifies to the Owner that to the best of the Architect's knowledge, information and belief the Work has progressed as indicated, the quality of the Work is in accordance with the Contract Documents, and the Contractor is entitled to payment of the AMOUNT CERTIFIED. AMOUNT CERTIFIED ............ $ __________ (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: By: [signature] Date: 10.27.2016 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract.