Packet: Tiffin Regular City Council Meeting (07/07/2026)

APPLICATION AND CERTIFICATE FOR PAYMENT CONTRACTOR: Cornerstone Excavating, Inc. PO Box 928 Washington, IA 52353 SUBCONTRACTOR: PROJECT: EARTH STOCKPILE SPREAD JOH067 TIFFIN, IA CONTRACT FOR: City of Tiffin APPLICATION NUMBER: 4 APPLICATION DATE: 06/26/26 PERIOD TO: 06/26/26 PROJECT NOS.: CONTRACT DATE: VIA CONSTRUCTION MANAGER: BJ Miller VIA ARCHITECT: CONTRACTOR'S APPLICATION FOR PAYMENT Application is made for payment, as shown below, in accordance with the Contract. Continuation Sheet, AIA Document G703, is attached. 1. ORIGINAL CONTRACT SUM $138,050.00 2. Net Change By Change Orders $46,645.00 3. CONTRACT SUM TO DATE (Line 1 +2) $184,695.00 4. TOTAL COMPLETED & STORED TO DATE (Column G on G703) $170,451.50 5. RETAINAGE: a. 3% % of Completed Work (Columns D & E on G703) $5,113.55 b. 3% % of Stored Material (Column F on G703) $0.00 Total Retainage (Line 5a + 5b or Total in Column 1 of G703) $5,113.55 6. TOTAL EARNED LESS RETAINAGE (Line 4 less Line 5 Total) $165,337.95 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT (Line 6 from prior Certificate) $150,333.27 8. CURRENT PAYMENT DUE $15,004.68 9. BALANCE TO FINISH, INCLUDING RETAINAGE (Line 3 less Line 6) $19,357.05 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: [signature] BY: [signature] DATE 6/26/26 State of: [blank] County of: [blank] Subscribed and sworn before me this day of [blank], 2026 Notary Public: My Commission Expires: CERTIFICATE FOR PAYMENT In accordance with the Contract Documents, based on on-site observations and the data comprising the above application, the Construction Manager certifies that to the best of his 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 $15,004.68 (Attach explanation if amount certified differs from the amount applied for. Initial all figures on this Application and on the Continuation Sheet that changed to conform to the amount certified.) CONSTRUCTION MGR: By: [blank] Date: [blank] ARCHITECT: By: [signature] Date: 07/01/2026 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.