Discussion and Consideration of Pay Application #5 – Miron Construction, Recreation Center - Motion to Approve

APPLICATION AND CERTIFICATE FOR PAYMENT Page: of 4 TO OWNER: City of Tiffin PROJECT: City of Tiffin Community Recreation Center 300 Railroad St 105 S Park Road APPLICATION NO.: 5 Distribution to: Tiffin, IA 52340 Tiffin, IA 52340 PERIOD TO : 09/30/2025 [] owNER USA USA □ PROJECT NOS.: 250120 [] AcHtreor FROM Miron Construction Co., Inc. ARCHITECT: Atura Architecture INVOICE NO.: 250120-0005 CONTRACTOR CONTRACTOR: PO Box 1372 912 North 13th Street □ Green Bay, WI 54305-1372 Clear Lake, IA 50428 CONTRACT DATE : 11/19/2024 □ CONTRACT FOR: City of Tiffin Community Recreation Center APPLICATION AND CERTIFICATE FOR PAYMENT 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 Application is made for payment, as shown below, 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 due. 1. ORIGINAL CONTRACT SUM . $ 12,435, 142.00 WARNING: 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 Co., Inc. does not change its bank routing or account numbers. Do not accept or rely upon emails or correspondence requesting changes to Miron Construction Co., Inc.'s established payment 3. CONTRACT SUM TO DATE ( Line1 +/-2)..... $ 11,393,140.12 instructions. Any change to Miron Construction Co., Inc.'s payment instructions can only be made by a fully executed 4. TOTAL COMPLETED & STORED TO DATE .... $ 749,806.93 Change Order to the Agreement between Owner and Miron Construction Co., Inc.. (Column G on G703) Contractor~truction Co., Inc. 5. RETAINAGE: By: /4..,_~~ Date: September vv, ,..,-_.r ~'t't: ·Uf.t:J ..._ (Total retainage Column I of G703) $ 37,490.35 #= 6. TOTAL EARNED LESS RETAINAGE.......... $ 712,316.58 State of: Wisconsin (Line 4 less Line 5 Total ) County of: Winnebago oT4,"" 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT '· ii j{ Subscribed and sworn to before - • • (Line 6 from prior Certificate) 8. CURRENT PAYMENT DUE................ $ $[ 519,083.09 193,233.49 me this 30 u°•Gs is5 9. BALANCE TO FINISH, INCLUDING RETAINAGE (Line 3 less Line 6 ) $ . . 10 680 823 54 My Commission Notary Public: . P 11 r" I f'-.1 'h rs.e;;5$ • . · OJ:' \IJ\SV .... r' 's ' expires: CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS Change Order approved in 0.00 0.00 ARCHITECT'S CERTIFICATE FOR PAYMENT previous months by Owner In accordance with the Contract Documents, based on on-site observations and the data comprising the above application, APPROVED THIS MONTH 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 Work is in accordance with the Contract Documents, and the Contractor is entitled to Number Date Approved the payment of the AMOUNT CERTIFIED. CO001 09/25/2025 -1,042,001.88 AMOUNT CERTIFIED $ (Attach explanation If amount certified differs from the amount applied for. Initial figures on this Application and on the Continuation Sheet that are changed to conform to the amount certified.) By: City of Tiffin Current Total 0.00 -1,042,001.88 ARCHITECT: Atura Architecture Net Change by Change Orders -1.042.001.88 By: Date: 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 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, 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. payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract. This document was produced at 08:21:17 on 09/30/2025 under Order No 20240046063 which expires on 07/24/2026, and Is not for resale. User Notes: