APPLICATION AND CERTIFICATION FOR PAYMENT
To:
From:
City of Pacifica, Public Works
Attn: Matt Kelly
170 Santa Maria Ave
Pacifica, CA 94044
Michael Roberts Construction Inc
1660 Dell Avenue
Campbell, CA 95008-6901
Contract For: Mechanical
Project:
Architect:
168-02-23
San Jose Beach Sdwlk Undermine
Pacifica, CA
Invoice: 16802001
Application No: 16802001
App. date: 1/31/2024
Period ending date: 1/31/2024
Project: 168-02-23
Contract date:
DISTRIBUTE TO:
□ OWNER
□ ARCHITECT
□ CONTRACTOR
a
a
A�Ja����l�a:.�. ��J!kiEeJj2.i�efS>_a, ��YMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, Information and belief the WOii< 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 Is now due.
Contract. Continuation Sheet attached.
1. ORIGINAL CONTRACT SUM
2. Net Change By Change Orders
3. CONTRACT SUM TO DATE (Line 1 t 2)
4. TOTAL COMPLETED & STORED TO DATE
5. RETAINAGE:
s11,900.001
$0.001
$71,990.001
$71,990.001
a. O % of Completed Wor1<
TOTAL RETAINAGE:
�----·
so.001
1 ....--------so.ool
:=, _ =======; 6. TOTAL EARNED LESS RETAINAGE $71,990.00!
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT
(Line 6 From Prbr CERTIFICATE)
8. CURRENT PAYMENT DUE (Line 6 Less Line 7)
9. BALANCE TO FINISH INCLUDING RETAINAGE
(Line 3 Less Line 6)
Changes approved in previous months by
Owner
Total approved this Month
NET CHANGES by Change Order
so.001
$71,990.00!
$0.001
Contractor:
By:
Date:
State Of County Of
January 31, 2024
Subscribed and sv.orn to before me this ___ day of _________ _ The above personally appeared before me, the undersigned notary republic and provided satisfactory evidence of identification as to the person who signed this document in my presence and swore or affirmed to me that the contents of this document are truthful and accurate to the best of his/her knowledge and belief.
Notary Public: My commissbn expires:
ARCHITECT'S CERTIFICATE FOR PAYMENT
In accordance with the Contract Documents, based on on-site observations and the data comprising the 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 entitied to payment of the AMOUNT CERTIFIED.
AMOUNT CERTIFIED: .......................... $-----
(Attach explanation if amount certified c/jffers from the amount applied for. lnllial all figures o,; this Application and on the ConUnuatlon Sheet thet ere changed to conform to the amount certified.)
ARCHITECT:
By: ----------------- Date:
This Ceraficate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contracto, named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract.
ATTACHMENT 1
APPLICATION AND CERTIFICATION FOR PAYMENT
To: Project: 168-04-24
Sharp Park
Pacifica, CA
From:
Architect:
City of Pacifica, Public Works
Attn: Matt Kelly
170 Santa Maria Ave
Pacifica, CA 94044
Michael Roberts Construction Inc
1660 Dell Avenue
Campbell, CA 95008-6901
Contract For: Mechanical
CONTRACTOR'S APPLICATION FOR PAYMENT
Application is made for payment, as shown above, in connection with the Contract. Continuation Sheet attached.
1. ORIGINAL CONTRACT SUM $74,254.601
2. Net Change By Change Orders $0.001
3. CONTRACT SUM TO DATE {Line 1 ± 2) $74,254.601
4. TOTAL COMPLETED & STORED TO DATE $74,254.601
5. RETAINAGE:
a. 0 % of Completed Work
TOTAL RETAINAGE :
$0.001----- ---------'· 1
=========
$o
=
o.
=
ol
1 6. TOTAL EARNED LESS RETAINAGE $74,254.aoi
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT
(Line 6 From Prior CERTIFICATE)
8. CURRENT PAYMENT DUE (Line 6 Less Line 7)
9. BALANCE TO FINISH INCLUDING RETAINAGE
(Line 3 Less Line 6)
CHANGE ORDER SUMMARY ADDITIONS
Changes approved in previous months by
Owner
Total approved this Month
TOTALS
NET CHANGES by Change Order
$0.001
$74,254.601
$0.00J
DEDUCTIONS
DISTRIBUTE TO:
Invoice: 16804001
Application No: 168-04-001 □
App. date: 4/12/2024 □
Period ending date: 4/12/2024 □
Project: 168-04-24 □
Contract date: □
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 is now due.
Contractor:
By:
Date: April 12, 2024
State Of County Of
OWNER
ARCHITECT
CONTRACTOR
Subscribed and sworn to before me this ___ day of __________ _ The above personally appeared before me, the undersigned notary republic and provided satisfactory evidence of identification as to the person who signed this document in my presence and swore or affirmed to me that the contents of this document are truthful and accurate to the best of his/her knowledge and belief.
Notary Public: My commission expires:
ARCHITECT'S CERTIFICATE FOR PAYMENT
In accordance with the Contract Documents, based on on-site observations and the data comprising the 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: .......................... $-----
(Attach explanation if amount certified differs from the amount applied for. Initial all figures or, this Application and on the Continuation Sheet that are changed to conform to the amount certified.)
ARCHITECT:
By: ------------------ Date:
This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contracto1 named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract.
APPLICATION AND CERTIFICATION FOR PAYMENT
3/20/2024
App. date:
Period ending date:
16803001
To:
From:
3/21/2024
168-03-001
City of Pacifica, Public Works
Attn: Matt Kelly
170 Santa Maria Ave
Pacifica, CA 94044
Michael Roberts Construction Inc
1660 Dell Avenue
Campbell, CA 95008-6901
Invoice:
Project: 168-03-23
Contract date:
OWNER
CONTRACTOR
ARCHITECT
DISTRIBUTE TO: Architect:
Contract For: Mechanical
Application No:
Project:
Milagra Outfall
168-01-23
Pacifica, CA
$0.00
$0.00
$13,630.00
$0.00
$13,630.00
$13,630.00
$0.00
$13,630.00
Notary Public: My commission expires:
Subscribed and sworn to before me this ______ day of _______________________ $13,630.00
NET CHANGES by Change Order
TOTALS
Total approved this Month
Changes approved in previous months by
Owner
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS
State Of County Of
CONTRACTOR'S APPLICATION FOR PAYMENT
1. ORIGINAL CONTRACT SUM
2. Net Change By Change Orders
4. TOTAL COMPLETED & STORED TO DATE
3. CONTRACT SUM TO DATE (Line 1 ± 2)
Application is made for payment, as shown above, in connection with the Contract. Continuation Sheet attached.
5. RETAINAGE:
a. 0 % of Completed Work
6. TOTAL EARNED LESS RETAINAGE
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT
(Line 6 From Prior CERTIFICATE)
8. CURRENT PAYMENT DUE (Line 6 Less Line 7)
9. BALANCE TO FINISH INCLUDING RETAINAGE
(Line 3 Less Line 6)
The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and belief the Work covered by this Application for Payment has been completed in accordance with the Contract Documents, that all amounts have been paid by the Contractor for Work for which previous Certificates for Payment were issued and payments received from the Owner, and that current payment shown herein is now due.
Date: March 21, 2024 By:
This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract.
By: Date:
ARCHITECT: (Attach explanation if amount certified differs from the amount applied for. Initial all figures on this Application and on the Continuation Sheet that are changed to conform to the amount certified.)
AMOUNT CERTIFIED: ..........................$
In accordance with the Contract Documents, based on on-site observations and the data comprising the 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.
ARCHITECT'S CERTIFICATE FOR PAYMENT
Contractor:
The above personally appeared before me, the undersigned notary republic and provided satisfactory evidence of identification as to the person who signed this document in my presence and swore or affirmed to me that the contents of this document are truthful and accurate to the best of his/her knowledge and belief.
$0.00
TOTAL RETAINAGE :
Invoice: 168-03-001 Draw: Detail Page 2 of 3 Pages
Retainage
Balance
Balance
To
Finish
%
Comp
Total Completed
And Stored
To Date
Materials
Stored & Used
Prior + Current
This
Period
From Previous
Application(s)
Schedule
of
Values
Item ID Description of Work
Project: 168-03-23 / Milagra Outfall 16803001 3/20/2024 Period Ending Date:
CONTINUATION SHEET (REQUEST FOR PAYMENT DETAIL )
Work Completed
01-000 Sand & Rock Work 13,630.00 13,630.00 13,630.00 100.00 GRAND TOTAL: 13,630.00 13,630.00 13,630.00 100.00
APPLICATION AND CERTIFICATION FOR PAYMENT
To:
From:
City of Pacifica, Public Works
Attn: Matt Kelly
170 Santa Maria Ave
Pacifica, CA 94044
Michael Roberts Construction Inc
1660 Dell Avenue
Campbell, CA 95008-6901
Contract For: Mechanical
Project:
Architect:
168-05-24
Sharp Park Beach Sand
Pacifica, CA
CONTRACTOR'S APPLICATION FOR PAYMENT
Application is made for payment, as shown above, in connection with the Contract. Continuation Sheet attached.
1. ORIGINAL CONTRACT SUM $109,980.321
2. Net Change By Change Orders $0.001
3. CONTRACT SUM TO DATE (Line 1 ± 2) $109,980.321
4. TOTAL COMPLETED & STORED TO DATE $109,980.321
5. RETAINAGE:
a. 0 % of Completed Work
TOTAL RETAINAGE:
$0.00 -------
1 ----
:::
I
========
$0
=
.o
:::::
ol
1 $109,980.32 6. TOTAL EARNED LESS RETAINAGE 1
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT
(Line 6 From Prior CERTIFICATE}
8. CURRENT PAYMENT DUE (Line 6 Less Line 7)
9. BALANCE TO FINISH INCLUDING RETAINAGE
(Line 3 Less Line 6)
CHANGE ORDER SUMMARY ADDITIONS
Changes approved in previous months by
Owner
Total approved this Month
TOTALSNET CHANGES by Change Order
$0.001
$109,980.32!
$0.001
DEDUCTIONS
Invoice: 16805001
Application No: 168-05-001
App. date: 5/29/2024
Period ending date: 5/31/2024
Project: 168-05-24
Contract date:
DISTRIBUTE TO:
□ OWNER
□ ARCHITECT
□ CONTRACTOR
□
□
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 is now due.
Contractor:
By: Date: May 29, 2024
State Of County Of
Subscribed and sworn to before me this ___ day of _________ _ The above personally appeared before me, the undersigned notary republic and provided satisfactory evidence of identification as to the person who signed this document in my presence and swore or affirmed to me that the contents of this document are truthful and accurate to the best of his/her knowledge and belief.
Notary Public: My commission expires:
ARCHITECT'S CERTIFICATE FOR PAYMENT
In accordance with the Contract Documents, based on on-site observations and the data comprising the 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 CERTI FIE□.
AMOUNT CERTIFIED: .......................... $ -----
(Attach explanation if amount certified differs from the amount applied for. Initial all figures or, this Application and on the Continuation Sheet that are changed to conform to the amount certified.)
ARCHITECT:
By: ------------------ Date:
This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contracto1 named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract.