Packet: Tiffin Regular City Council Meeting (02/17/2026)

AIA Document G702™ – 1992 Application and Certificate for Payment TO OWNER: Miron Construction 1471 McMahon Drive Neenah, WI 54956 PROJECT: City Of Tiffin Comm Rec Cntr 105 S. Park Road Tiffin, IA 52340 APPLICATION NO.: #1 PERIOD TO: 1/30/26 CONTRACT FOR: CONTRACT DATE: 11/19/24 PROJECT NOS: 250120 000026 FROM CONTRACTOR: Phillips' floors Inc. 1605 N 9th Street Indianola, IA 50125 VIA ARCHITECT: Autura Distribution to: OWNER [ ] ARCHITECT [ ] CONTRACTOR [ ] FIELD [ ] OTHER [ ] 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. <table> <tr> <th></th> <th></th> <th></th> </tr> <tr> <td>1. ORIGINAL CONTRACT SUM</td> <td>$ 266,500.00</td> <td></td> </tr> <tr> <td>2. Net change by Change Orders</td> <td>$ 0.00</td> <td></td> </tr> <tr> <td>3. CONTRACT SUM TO DATE (Line 1 ± 2)</td> <td>$ 266,500.00</td> <td></td> </tr> <tr> <td>4. TOTAL COMPLETED & STORED TO DATE (Column G on G703)</td> <td>$ 818.00</td> <td></td> </tr> <tr> <td colspan="3">5. RETAINAGE:</td> </tr> <tr> <td>a. 5% of Completed Work<br>(Column D + E on G703)</td> <td>$ 0.00</td> <td></td> </tr> <tr> <td>b. 5% of Stored Material<br>(Column F on G703)</td> <td>$ 40.90</td> <td></td> </tr> <tr> <td>Total Retainage (Lines 5a + 5b or Total in Column I of G703)</td> <td>$ 40.90</td> <td></td> </tr> <tr> <td>6. TOTAL EARNED LESS RETAINAGE<br>(Line 4 Less Line 5 Total)</td> <td>$ 777.10</td> <td></td> </tr> <tr> <td>7. LESS PREVIOUS CERTIFICATES FOR PAYMENT<br>(Line 6 from prior Certificate)</td> <td>$ 0.00</td> <td></td> </tr> <tr> <td>8. CURRENT PAYMENT DUE</td> <td>$ 777.10</td> <td></td> </tr> <tr> <td>9. BALANCE TO FINISH, INCLUDING RETAINAGE<br>(Line 3 less Line 6)</td> <td>$ 265,722.90</td> <td></td> </tr> </table> CHANGE ORDER SUMMARY <table> <tr> <th></th> <th>ADDITIONS</th> <th>DEDUCTIONS</th> </tr> <tr> <td>Total changes approved in previous months by Owner</td> <td>$ 0.00</td> <td>$ 0.00</td> </tr> <tr> <td>Total approved this Month</td> <td>$ 0.00</td> <td>$</td> </tr> <tr> <td>TOTALS</td> <td>$</td> <td>$</td> </tr> <tr> <td>NET CHANGES by Change Order</td> <td>$ 0.00</td> <td></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 above due. CONTRACTOR: By: Matt Phillips State of: Iowa County of: Warren Subscribed and sworn to before me this 19th day of January Notary Public: Mark A. Bjork My Commission expires: 3/1/28 ARCHITECT'S CERTIFICATE FOR PAYMENT In accordance with the Contract Documents, based on on-site observations and the data comprising this 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: $ 777.10 (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: ____________________________ Date: ________________ 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. CAUTION: You should sign an original AIA Contract Document, on which this text appears in RED. An original assures that changes will not be obscured. AIA Document G702™ – 1992. Copyright © 1953, 1963, 1965, 1971, 1978, 1983 and 1992 by The American Institute of Architects. All rights reserved. WARNING: This AIA® Document is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AIA® Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. Purchasers are permitted to reproduce ten (10) copies of this document when completed. To report copyright violations of AIA Contract Documents, e-mail The American Institute of Architects’ legal counsel, [email protected].