2017-02-14_REPORT - M2011033

• Permit No: M2011033
• IBM Index Class Name: REPORT
• Doc Date: 2/14/2017
• Doc Name: Annual Fee/Report/Map
• From: Harry Corkle Const
• To: DRMS
• Annual Report Year: 2017
• Email Name: PSH
• Media Type: D
• Archive: No

G702 APPLICATION and CERTIFICATE for PAYMENT
To: Corkle Construction Project: Corkle Gravel Pit Application No: 7292 Distribution to:
P.O. Box 306
App. Date: September 26,2016 ®OWNER
Walden,Colorado 80480
®CONSTRUCTION MGR.
Period to: September 26,2016 0 ARCHITECT
From: Green Earth Environmental Inc. i ❑CONTRACTOR
P.O. Box 880 green earth Project Nos: 16-1058 ❑OTHER
Greeley,Colorado 80632 // //�'� Contract Date:
Contract For: Corkle Gravel Pit 11MAfcOIt\.E
The undersigned Contractor certifies that to the best of the Contractor's knowledge,
CONTRACTOR'S APPLICATION FOR PAYMENT information and belief the Work covered by this Application for Payment has been completed
Application is made for payment,as shown below, in connection with the Contract. in accordance with the Contract Documents,that all amounts have been paid by the
Continuation Sheet, G703, is attached. Contractor for Work for which previous Certificates for Payment were issued and payments
1. ORIGINAL CONTRACT SUM
I :ceived from the Owner,and that current payment shown herein is now due.
2. Net Change By Change Orders 0-001 CONTRACT . Gre n rth Environmental Inc
3. CONTRACT SUM TO DATE �� ._ __. By: _ Date: September 26,2016
4. TOTAL COMPLETED AND STORED TO DATE 7ate
o
5. RETAINAGE: f: Colorado County of: Weld
a. of Completed Work 0.00 Subscribed and sworn before me this 26th day of September , 2016
Jim Daulton personally appeared before me,the undersigned notary public,and provided
b. of Stored Material 0.00 satisfactory evidence of identification to be the person who signed this document in my
presence and swore or affirmed to me that the contents of this document are truthful and
TOTAL RETAINAGE 0.00 accurate to the best of his/her knowledge and belief.
6. TOTAL EARNED LESS RETAINAGE
-- Notary Public: My Commission expires:
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT ARCHITECT'S CERTIFICATE FOR PAYMENT
8. CURRENT PAYMENT DUE 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
9. BALANCE TO FINISH, INCLUDING RETAINAGE �— O.Od 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.
RANGE ORDER SUMMARY ADDITIONS DEDUCTIONS AMOUNT CERTIFIED
Total changes approved in (Attach explanation if amount certified differs from the amount applied for. Initial all figures
previous months by Owner on this Application and on the Continuation Sheet that are changed to conform to the amount
Total approval this Month certified.)
TOTALS $ 0.00 $ 0.00 ARCHITECT:
NET CHANGES by Change Order $ 0.00 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.
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