Sheet 1: COVER SHEET

	
	
	
	
	
	
	
	
	
	
	

		
SUBCONTRACTOR APPLICATION AND CERTIFICATE FOR PAYMENT
		
	

		


		


		


		


		


		


		


		


		
HCS Contract #
		


	
	

		
TO:
		
Hollister Construction Services
		


		
FROM:  
		
Subcontractor Name:
		


		


		


		
Application #
		


	
	

		


		
777 Terrace Avenue
		


		


		
Address:
		


		


		


		


		


	
	

		


		
Hasbrouck Heights, NJ  07604
		


		


		


		


		


		
Application Date:
		


	
	

		


		
Phone:
		
(201) 393-7500
		


		


		


		


		


		


		


	
	

		


		
Fax:
		
(201) 393-8907
		


		
Phone:
		


		


		


		
Period To:
		


	
	

		


		


		


		


		


		


		


		


		


		


	
	

		


		
THIS SECTION FOR HOLLISTER CONSTRUCTION SERVICES USE ONLY
		


		
PROJECT NAME:
		


		


		


		


		
HCS JOB #
		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		
Line 1
		
Subcontract Amount:
		


		


		


		
 $-   
		
	

		


		


		
Line 2
		
Amount of Approved Change Orders to Date:
		


		


		


		
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Line 3
		
Adjusted Contract Amount:  (Line 1 + Line 2)
		


		


		


		
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Line 4
		
Work Completed to Date:
		


		


		


		
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Line 5
		
Less Retainage (10%):
		


		


		


		
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Line 6
		
Amount Earned to Date:  (Line 4 - Line 5)
		


		


		


		
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Line 7
		
Previous Applications for Payment:  (Line 6 from previous Application)
		


		


		


		
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Line 8
		
Net Amount of this Application for Payment:  (Line 6 - Line 7)
		


		


		


		
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CONDITIONAL WAIVER AND RELEASE UPON PROGRESS PAYMENT
		
	

		


		


		
The undersigned represents that neither it Nor any of its subcontractors or materialmen have filed a Construction Lien, Notice of Unpaid Balance, or Right To File Lien
		
	

		


		


		
regarding the Project, or have taken any action to file or perfect a construction lien to the Project for which any labor or materials or both have been furnished.
		
	

		


		


		
In consideration of this payment and all previous payments, the undersigned hereby expressly waives, releases and discharges any and all construction liens and the
		
	

		


		


		
right to file a notice of Unpaid Balance and/or Right to File Lien pertaining to the Project for which the aforesaid labor and material or both have been furnished by the
		
	

		


		


		
undersigned to or for the account of Hollister Construction Services.
		
	

		


		


		
Signed:
		
______________________________________________________      Date:______________________________
		


		


		


		


		


	
	

		


		


		


		
                 (Signature of Officer or Authorized Agent of Subcontractor)
		


		


		


		


		


	
	

		


		


		
By:
		
______________________________________________________      Title:______________________________
		


		


		


		


		


	
	

		


		


		


		
                  (Print Name of Officer or Authorized Agent of Subcontractor)
		


		


		


		


		


	
	

		


		


		
State of _______________________,  County of _______________________, BE IT REMEMBERED, that on this _________day of ______________, 2009,
		


		


		


		


		


		


	
	

		


		


		
in the County and State aforesaid, personally appeared before me, the subscriber, a Notary Public of the State of _____________________,
		


		


		


		


		


		


	
	

		


		


		
___________________________________________________________________(name of Person signing this release) who I am satisfied is the Party Mentioned
		
	

		


		


		
in the within instrument, to whom first made known the contents thereof, and thereupon (he/she) signed, sealed and delivered the same as (his/her) voluntary act
		
	

		


		


		
and deed for the uses and purposes therein expressed.
		
	

		


		


		


		


		


		
                                     _______________________________________________________________
		


		


		


	
	

		


		


		


		


		


		


		
(Signature of Notary Public)
		


		


	
	

		


		


		
NOTE: APPLICATION FOR PAYMENT WILL NOT BE PROCESSED IF NON-APPROVED CHANGE ORDER REQUESTS ARE ADDED TO SUBCONTRACT AMOUNT.  
		
	

		


		


		
IMPROPERLY EXECUTED CERTIFICATIONS WILL BE RETURNED WITHOUT REVIEW.
		



Sheet 2: CONTINUATION SHEET

	
	
	
	
	
	
	
	
	

		
CONTINUATION SHEET
		


		


		


		


		


		


		


		


		
Continuation Sheet Page   1  of   1    
	
	

		
APPLICATION AND CERTIFICATE FOR PAYMENT
		


		


		


		


		


		
Application #
		


		
	

		
Subcontractor's signed Certification is attached.
		


		


		


		


		


		


		
Application Date:
		


		
	

		


		


		


		


		


		


		


		
Period To:
		


		
	

		


		


		


		


		


		


		


		
Project Name:
		


		
	

		


		
SUBCONTRACTOR:
		


		


		


		


		


		
HCS Job Number:
		


		
	

		


		


		


		


		


		


		


		


		


		


	
	

		
A
		
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C
		
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H
		
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WORK COMPLETED
		


		


		


		


		


	
	

		
ITEM NO.
		
DESCRIPTION OF WORK
		
SCHEDULED VALUE
		
FROM PREVIOUS APPLICATION (D+E)
		
THIS PERIOD
		
MATERIALS PRESENTLY STORED (NOT IN D OR E)
		
 TOTAL COMPLETED & STORED TO DATE 
		
% (G/C)
		
BALANCE TO FINISH (C-G)
		
RETAINAGE
	
	

		
	

		
	

		


		


		


		


		


		


		
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Totals
		
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