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Application and Certification for Payment To(Owner): City of Everett Contract No.: N/A Application No.: 01 3200 Cedar Street Work Order No.: 36 Application Date: 10/31/2016 Everett,WA Contract PO No.: JC16056 Yost House Demo Payment Period: 10/1/16-10/31/16 WO PO No.: N/A From(Contractor): Forma Construction Company 1736 4th Avenue South Seattle,WA 98134 CONTRACTOR'S APPLICATION FOR PAYMENT CONTRACTOR'S CERTIFICATION Application is made for Payment as shown below: The undersigned Contractor certifies that to the best of Contractor's knowledge, information and belief,the Work covered by his Application for Payment has been 1. Original Work Order Sum $ 76,791.53 completed in accordance with the Contract Documents and in a good and 2. Net Change(s)by Change Order(s) ($2,343.85) workmanlike manner by appropriate means;that all amounts,including applicable sales tax,have been paid by Contractor for Work for which previous Certificates of 3. Total Work Order Sum(Line 1 +Line 2) $ 74,447.68 Payment were issued and payment received from the Owner;that the prevailing 4. TOTAL EARNED(Completed Work) $ 74,447.68 wages have been paid In accordance with the pre-filed statement or statements of 5. Balance to Complete(Line 3-Line 4) $ _ Intent to pay prevailing wages;and that payment as shown herein is now due. 6. RETAINAGE on TOTAL EARNED $ - 7. Total Earned Less Retainage(Line 4-Line 6) $ 74,447.B8 8. Previously Approved(Line 7 from Previous Application) $ - CONTRACTOR 9. Current Amount Due(Line 7-Line 8) _ $ 74,447.68 By: Ail Date: 10/26/2016 10. WA State Sales Tax,if applicable(Total Applied to Date) $ 6,849.19 CITY OF EVER TT CERTIFICATE FOR PAYMENT 11. Less WSST Previously Paid $ _ 12. WSST Due this Period(Line 10-Line 11) $ 6,849.19_ In accordance with the Contract Documents and based on observations at the site, review of Contractor's record drawings as of the date of this Application,the 13. Total Payment Due with WSST(Line 9+Line 12) $ 81,296.87 Resident Engineer certifies to the Owner that to the best of his/her knowledge, information and belief,the Work has progressed as indicated and in accordance with the Contract Documents,that all required inspections have been performed, Retainage Rate 0% and the Contractor is entitled to payment in the Amount Certified below. AMOUNT CERTIFIED I e41 Y(o i 7-7 I (attach explanation 1f amount certified diff from the amount Epplied for) Cl F EVERE r \�i r By: -LAJ , Date: I\ 1 L - -- Proje anager 1 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.