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<br /> APPLICATION AND CERTIFICATE FOR PAYMENT
<br /> CONSTRUCTION
<br /> SUBMITTED TO: City of Elk River PROJECT: Elk River Public Works INVOICE NO: 1109039613
<br /> Attn:Tim Simon 19000 Proctor Road APPLICATION DATE: 9130/2012
<br /> 13065 Orono Parkway Elk River,MN 55330
<br /> Elk River,MN 55330 PERIOD END DATE: 9/30/2012
<br /> PROJECT NO: 2011-09-0396
<br /> REMIT TO: RJM CONSTRUCTION LLC ARCHITECT: CONTRACT DATE: 0
<br /> SDS 12-2903, PO Box 86
<br /> Minneapolis,MN 55486-2903 CONTRACT NO: 11090396
<br /> The undersigned Contractor certifies that to the best of the Contractor's knowledge,information and belief the ORIGINAL CONTRACT SUM $ 8,730,705.00
<br /> Work coved by this Application for Payment has been completed in accordance with the Contract Documents,
<br /> that all amounts have been paid by the Contractor for Work for which previous Certificates for payment were NET CHANGE BY CHANGE ORDERS TO DATE . ... ., $ 0.00
<br /> issued and payments received from Owner,and that current payment shown herein is now due. CONTRACT SUM TO DATE
<br /> $ 8,730,705.00
<br /> WAIVER&RELEASE OF LIEN TOTAL COMPLETED AND STORED TO DATE $ 6,465,564.98
<br /> Where the undersigned Contractor has provided labor,services,materials,or equipment for the above project, q%OF COMPLETED WORK $ 285,960.14
<br /> under an agreement with the owner.
<br /> 0%OF STORED MATERIAL $ 0.00
<br /> The undersigned does hereby waive and release all bond claims,liens,claims or right to claim,or right of lien,
<br /> statutory or otherwise,against the property,project Owner,or any other person or entity who is or may be TOTAL RETAINAGE $ 285,960.14
<br /> claimed to be liable,or any sureties,for labor,services,materials,or equipment,as provided by the TOTAL EARNED LESS RETAINAGE $ 6,179,604.84
<br /> undersigned,to the extent of payment received,as indicated herein,together with any previous payment(s)
<br /> already received but excluding any retainage or any labor,services,materials,or equipment provided after the LESS PREVIOUS CERTIFICATES FOR PAYMENT $ 5,538,281.03
<br /> application period stated above. The undersigned agrees upon receipt of the above amount for labor,services,
<br /> materials,or equipment as described herein,he does herby grant this release unconditionally. CURRENT PAYMENT DUE $ 641,323.81
<br /> BALANCE TO FINISH INCLUDING RETAINAGE $ 2,551,100.16
<br /> The person signing below does hereby certify that he/she is fully authorized and empowered to execute this
<br /> instrument and to bind the undersigned hereto,and does in fact so execute this instrument
<br /> RAI CONSTRUCTION, LLC
<br /> 700 3 W.LAKE ST.,SUITE 400 ARCHITECTS CERTIFICATE FOR PAYMENT
<br /> 7003
<br /> ST. LOUIS PARK,MN 55426 In accordance with the Contract Documents,based on on-site observations and the data composing this
<br /> P 952-837-8601.. '14,2-832-96M application.the Architect certify to the Owner that to the best of their knowledge,information and belief the Work
<br /> has progressed as indicated,the quality of the Work is in accordance with the Construction Documents,and the
<br /> SIGNED 1 DATED: 2
<br /> ' Contractor is entitled to payment of the AMOUNT CERTIFIED. 8/„ ,,,4. /° } AMOUNT CERTIFIED $ i / 3 3. �a
<br /> PRINTED TITLE: a t f , r, Attach explanation if amount certified differs from the amount applied for,initial all figures on this
<br /> application and on the Continuation Sheets that changed to conform to the amount certified.
<br /> State of Minnesota
<br /> County Architect:
<br /> Coun of ,
<br /> .. 2 1 y= .
<br /> Subscribed and sworn to before me this day of B I t ificate is negotiable. The AMOUNT CERTIFIED payable only to the Contractor named
<br /> Notary Public Issuance,payment and acceptance of payment are without prejudice to any rights of the
<br /> '3 I:.;
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