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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: 3109039615
<br /> Attn:Tim Simon 19000 Proctor Road APPLICATION DATE: 12/12/2012
<br /> 13065 Orono Parkway Elk River,MN 55330 PERIOD END DATE: 11/30/2012
<br /> Elk River,MN 55330
<br /> PROJECT NO: 2011-09-0396
<br /> REMIT TO: RJM CONSTRUCTION LLC ARCHITECT: CONTRACT DATE:
<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, NET CHANGE BY CHANGE ORDERS TO DATE $ 0.00
<br /> that all amounts have been paid by the Contractor for Work for which previous Certificates for payment were
<br /> issued and payments received from Owner,and that current payment shown herein is now due. CONTRACT SUM TO DATE $ 8,730,705.00
<br /> WAIVER&RELEASE OF LIEN TOTAL COMPLETED AND STORED TO DATE $ 8,000,064.99
<br /> Where the undersigned Contractor has provide labor,services.materials,or equipment for the above project, 6%OF COMPLETED WORK $ 362,685.17
<br /> under an agreement with the owner.
<br /> 0%OF STORED MATERIAL $ 0.00
<br /> -
<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 $ 362,685.17
<br /> claimed to be liable,or any sureties,for labor,services,materials,or equipment,as provided by the TOTAL EARNED LESS RETAINAGE $ 7,637,379.82
<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 $ 6,855,537.45
<br /> application period stated above.The undersigned agrees upon receipt of the above amount for labor,services, CURRENT PAYMENT DUE $ 781,84237
<br /> materials,or equipment as described herein,he does herby grant this release unconditionally.
<br /> BALANCE TO FINISH INCLUDING RETAINAGE $ 1,093,325.18
<br /> The person signing below does hereby certify that he/she is hilly authorized and empowered to execute this
<br /> instrument and to bind the undersigned hereto,and does in fact so execute this instrument
<br /> RJM CONSTRUCTION,LLC ARCHITECT'S CERTIFICATE FOR PAYMENT
<br /> 7003 W.LAKE ST.,SUITE 400
<br /> ST.LOUIS PARK,MN 55426 In accordance with the Contract Documents,based on on-site observations and the data comprising this
<br /> P 952''-$37 8600 .-832-59,... application,the Architect certify to the Owner that to the best of their knowledge,information and belief the Work
<br /> f jr has progressed as indicated,the quality of the Work is in accordance with the Construction Documents,and the
<br /> SIGNED: ` Gq i ! DATED: 12- t�2t/Z Contractor is entitled to payment of the AMOUNT CERTIFIED, 9542.s7
<br /> PRINTED TITLE: I Va,? e.-T AMOUNT CERTIFIED $
<br /> "°�' 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 Architect: ..
<br /> County of 0,04416-CA--- /�,,,, By: '"`-• Date: I , '�' �-
<br /> Subscnbed and sworn to before me this
<br /> /2-f44'
<br /> day of l G f?.._.- This ' .riificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named
<br /> Notary Public herein. Issuance,payment and acceptance of payment are without prejudice to any rights of the
<br /> / Owner or Contractor under this Contract.
<br /> Signed: At
<br /> My commission expires: 1/ ( #90 j5-.
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