Following the AIA G702 line structure
|
Owner
Riverside Health Partners LLC
200 Capitol Mall, Suite 1400, Sacramento, CA 95814
|
Contractor
Northgate Builders
|
Architect
Ferris & Partners Architects
55 Front Street, Sacramento, CA 95814
|
| 1 | Original contract sum | $4,850,000.00 |
| 2 | Net change by change orders | $148,000.00 |
| 3 | Contract sum to date (1 + 2) | $4,998,000.00 |
| 4 | Total completed and stored to date | $2,915,000.00 |
| 5a | Retainage, 5.00% of completed work | $145,750.00 |
| 5b | Retainage, 2.50% of stored material | $0.00 |
| 5 | Total retainage (5a + 5b) | $145,750.00 |
| 6 | Total earned less retainage (4 − 5) | $2,769,250.00 |
| 7 | Less previous certificates for payment | $2,469,475.00 |
| 8 | Current payment due (6 − 7) | $299,775.00 |
| 9 | Balance to finish, including retainage (3 − 6) | $2,228,750.00 |
| Approved in previous months — additions | $148,000.00 |
| Approved in previous months — deductions | $0.00 |
| Approved this month — additions | $0.00 |
| Approved this month — deductions | $0.00 |
| Net change (to line 2) | $148,000.00 |
The undersigned contractor states that the work covered by this application has been completed in accordance with the contract documents; that the amounts shown have been paid by the contractor for work for which previous certificates were issued and payments received; and that the payment shown as currently due is now properly owing.
|
Contractor — authorised signature
|
Printed name and title
|
Date
|
State of ______________________ County of ______________________
Subscribed and sworn to before me this ______ day of ______________, 20____.
Notary public |
My commission expires |
Based on observations at the site and on the data in this application, the architect certifies to the owner that to the best of the architect's knowledge the work has progressed as stated, that its quality is in accordance with the contract documents, and that the contractor is entitled to payment of the amount certified below.
| Amount certified |
Where the amount certified differs from the amount applied for, initial the figures on this application and on the continuation sheet that have been changed to match, and attach an explanation.
|
Architect — authorised signature
|
Date
|
This certificate is not negotiable. It is payable only to the contractor named above. Issuing, receiving or accepting payment does not prejudice any rights of the owner or the contractor under the contract.
2026-014 — Riverside Medical Office Building · Application no. 5 · 2026-06-01 to 2026-06-30
| A Item no. |
B Description of work |
CSI | C Scheduled value |
D From previous application |
E This period |
F Materials presently stored |
G Total completed and stored |
% (G / C) |
H Balance to finish |
I Retainage |
|---|---|---|---|---|---|---|---|---|---|---|
| 001 | General conditions | 01 | $340,000.00 | $168,000.00 | $42,000.00 | $210,000.00 | 61.76% | $130,000.00 | $10,500.00 | |
| 002 | Demolition and site clearing | 02 | $185,000.00 | $185,000.00 | $185,000.00 | 100.00% | $0.00 | $9,250.00 | ||
| 003 | Concrete — foundations and slabs | 03 | $720,000.00 | $720,000.00 | $720,000.00 | 100.00% | $0.00 | $36,000.00 | ||
| 004 | Masonry | 04 | $265,000.00 | $265,000.00 | $265,000.00 | 100.00% | $0.00 | $13,250.00 | ||
| 005 | Structural steel | 05 | $890,000.00 | $890,000.00 | $890,000.00 | 100.00% | $0.00 | $44,500.00 | ||
| 006 | Rough and finish carpentry | 06 | $210,000.00 | $0.00 | 0.00% | $210,000.00 | ||||
| 007 | Roofing and waterproofing | 07 | $305,000.00 | $120,000.00 | $185,000.00 | $305,000.00 | 100.00% | $0.00 | $15,250.00 | |
| 008 | Glazing and curtain wall | 08 | $615,000.00 | $245,000.00 | $245,000.00 | 39.84% | $370,000.00 | $12,250.00 | ||
| 009 | Interior finishes | 09 | $430,000.00 | $0.00 | 0.00% | $430,000.00 | ||||
| 010 | Plumbing | 22 | $275,000.00 | $95,000.00 | $95,000.00 | 34.55% | $180,000.00 | $4,750.00 | ||
| 011 | HVAC | 23 | $395,000.00 | $0.00 | 0.00% | $395,000.00 | ||||
| 012 | Electrical | 26 | $220,000.00 | $0.00 | 0.00% | $220,000.00 | ||||
| 013 | Rooftop mechanical screen | 05 | $148,000.00 | $0.00 | 0.00% | $148,000.00 | ||||
| Totals | $4,998,000.00 | $2,348,000.00 | $567,000.00 | $0.00 | $2,915,000.00 | $2,083,000.00 | $145,750.00 | |||
Every figure on this application, checked against the contract, the schedule of values and the preceding period. This page travels with the document so nothing it reports can be discovered later.
1 warning(s).
| Rule | Severity | Finding | Expected | Actual | Difference | Reference |
|---|---|---|---|---|---|---|
| COMPLIANCE-MISSING | warning | Form W-9: nothing on file. | project compliance requirements | |||
| INFO-RETAINED | info | Retainage held to date: $145,750.00. | $145,750.00 | |||
| INFO-COMPLETE | info | Project is 58.32% complete by value. | $58.32 | |||
| INFO-MOVEMENT | info | Payment due moved -$610,750.00 against the previous application. | -$610,750.00 |
Prepared with Massing Bill. Format follows the AIA G702/G703 line structure. Massing Bill is not affiliated with, endorsed by, or sponsored by The American Institute of Architects. AIA®, G702® and G703® are registered trademarks of the AIA.