Sheet 1: G702B

	
	
	
	
	
	
	
	
	
	
	
	
	
	
	

		
APPLICATION AND CERTIFICATION FOR PAYMENT
		


		


		


		


		


		
USE W/AIA G703
		


		


		
PAGE ONE OF
		
1 
		


		


		
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TO: SENATE BUILDERS & CONSTRUCTION MANAGERS, INC.
		


		


		


		


		


		


		
APPLICATION NO:
		


		


		
Distribution to:
		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		
2232 DEKALB PIKE
		


		


		


		


		


		


		


		


		


		
ACCOUNTING
		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		
EAST NORRITON, PA 19401
		


		


		


		


		


		


		


		


		


		
PROJ. MGR.
		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		
PERIOD TO: 
		


		


		


		
PROJECT FILES
		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
FROM SUBCONTRACTOR:
		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		
 
		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		
PROJECT NO:
		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
CONTRACT FOR: 
		


		


		


		


		


		


		
CONTRACT DATE:
		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
SUBCONTRACTOR'S APPLICATION FOR PAYMENT
		


		


		


		


		


		
SUBCONTRACTOR CERTIFICATION AND LIEN WAIVER
		


		


		


		


		


		


		


	
	

		
Application is made for payment, as shown below, in connection with the Contract.
		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
Continuation Sheet, AIA Document G703, is attached.
		


		


		


		


		


		
I herby certify that the work performed and the materials supplied to date, as shown herein,
		


		


		


		


		


		


		


	
	

		
 
		


		


		


		


		


		
represent the actual value of completed work under the terms of the contract between the
		


		


		


		


		


		


		


	
	

		
 
		


		


		


		


		


		
undersigned and Senate Builders relating to the referenced project.
		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
1.  ORIGINAL CONTRACT SUM 
		


		


		
 $
		
0.00 
		


		
I also certify that all payments have been made through the period covered by previous 
		


		


		


		


		


		


		


	
	

		
2.  Net change by Change Orders 
		


		


		
 $
		
0.00 
		


		
payments received from the contractor, to all my subcontractors, and for all materials and
		


		


		


		


		


		


		


	
	

		
3.  CONTRACT SUM TO DATE (Line 1 ± 2)                                        $
		


		


		
$
		
0.00 
		


		
labor used in connection with the performance of this contract. I further certify that I have 
		


		


		


		


		


		


		


	
	

		
4.  TOTAL COMPLETED & STORED TO
		


		


		
$
		
0.00 
		


		
complied with federal, state and local tax laws, including social security laws, unemployment
		


		


		


		


		


		


		


	
	

		
         DATE       (Column G on G703)
		


		


		


		


		


		
tax laws, and workmens compensation laws insofar as applicable to the performance
		


		


		


		


		


		


		


	
	

		
5.  RETAINAGE:
		


		


		


		


		


		
of this contract.
		


		


		


		


		


		


		


	
	

		
a.
		
10%
		
of Completed Work                 
		
$0.00 
		


		


		


		


		


		


		


		


		


		


	
	

		


		
(Column D + E on G703)
		


		


		


		


		
I certify that contingent upon release of said payment, the undersigned does hereby waive,
		


		


		


		


		


		


		


	
	

		
b.
		
10%
		
of Stored Material                   
		
$0.00 
		


		


		
release, remiss and relinquish any and all rights to claim any lien or liens for work done or
		


		


		


		


		


		


		


	
	

		


		
(Column F on G703)
		


		


		


		


		
material furnished, prior to the date thereof, for the building and premises referenced on said
		


		


		


		


		


		


		


	
	

		
           Total Retainage (Lines 5a + 5b or
		


		


		


		


		


		
invoice.
		


		


		


		


		


		


		


	
	

		


		
Total in Column I of G703) 
		


		
             
		
0.00 
		


		
SUBCONTRACTOR
		


		


		


		


		


		


		


	
	

		
6.  TOTAL EARNED LESS RETAINAGE 
		


		


		


		
$0.00 
		


		
By:
		


		


		


		
 Date:
		


		


		


	
	

		


		
(Line 4 Less Line 5 Total)
		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
7.  LESS PREVIOUS CERTIFICATES FOR
		


		


		
$0.00 
		


		


		
State of: 
		


		


		
County of: 
		


		


		


		


	
	

		
     PAYMENT (Line 6 from prior Certificate) 
		


		


		


		


		


		
Subscribed and sworn to before me this 
		


		


		
_____ day of ____________
		


		


		


		
 
	
	

		
8.  CURRENT PAYMENT DUE 
		


		


		


		
$0.00 
		


		
Notary Public:
		


		


		


		


		


		


		


	
	

		
9.  BALANCE TO FINISH, INCLUDING RETAINAGE                     
		


		


		


		
$0.00 
		


		
My Commission expires:
		


		


		


		


		


		


		


	
	

		


		
(Line 3 less Line 6)
		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		
By:
		


		


		


		
 Date:
		


		


		


	
	

		
CHANGE ORDER SUMMARY
		
ADDITIONS
		
DEDUCTIONS
		


		


		


		


		


		


		


		


		


	
	

		
     Total changes approved
		


		


		
$0.00 
		


		


		
APPLICATION APPROVAL BY SENATE BUILDERS PROJECT MANAGER
		


		


		


		


		


		


		


	
	

		
     in previous months by Owner
		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		
$0.00 
		


		


		


		


		


		


		


		


		


		


	
	

		
     Total approved this Month
		


		


		


		
BY:
		


		


		


		
DATE:
		


		


		


	
	

		


		


		


		
$0.00 
		
$0.00 
		


		


		


		


		


		


		


		


		


	
	

		
     TOTALS
		


		


		


		
This Certificate is not negotiable.  The AMOUNT CERTIFIED is payable only to the 
		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		
Subcontractor named herein. Issuance, payment and acceptance of payment are 
		


		


		


		


		


		


		


	
	

		
     NET CHANGES by Change Order
		


		


		
$0.00 
		


		
without prejudice to any rights of Senate Builders under this Contract.
		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
SENATE BUILDERS APPLICATION AND CERTIFICATION FOR PAYMENT