|
Lus
<br /> APPLICATION AND CERTIFICATE FOR PAYMENT
<br /> CONSTRUCTION
<br /> SUBMITTED TO: City of Elk River PROJECT: Elk River Public Works INVOICE NO: 1109039616
<br /> Attn:Tim Simon 19000 Proctor Road APPLICATION DATE: 12/31/2012
<br /> 13065 Orono Parkway Elk River, MN 55330
<br /> Elk River, MN 55330 PERIOD END DATE: 12/31/2012
<br /> PROJECT NO: 2011-09-0396
<br /> REMIT TO: RJM CONSTRUCTION LLC ARCHITECT: CONTRACT DATE: (p
<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 $ 8,730,705.00
<br /> WAIVER& RELEASE OF LIEN TOTAL COMPLETED AND STORED TO DATE $ 8,150,429.07
<br /> Where the undersigned Contractor has provided labor,services,materials,or equipment for the above project, 5%OF COMPLETED WORK $ 370,203.38
<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 $ 370,203.38
<br /> claimed to be liable,or any sureties,for labor,services,materials,or equipment,as provided by the TOTAL EARNED LESS RETAINAGE $ 7,780,225.69
<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 $ 7,637,379.82
<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 $ 142,845.87
<br /> BALANCE TO FINISH INCLUDING RETAINAGE $ 950,479.31
<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 /> RJM CONSTRUCTION, LLC
<br /> 7003 W. LAKE ST., SUITE 400 ARCHITECTS CERTIFICATE FOR PAYMENT
<br /> ST. LOUIS PARK, MN 55426 In accordance with the Contract Documents,based on on-site observations and the data comprising this
<br /> P 952-837-8600 -832-960 application,the Architect certify to the Owner that to the best of their knowledge,information and belief the Work
<br /> 1141--8 has progressed as indicated,the quality of the Work is in accordance with the Construction Documents,and the
<br /> SIGNED: DATED: 3 Contractor is entitled to payment of the AMOUNT CERTIFIED. ��gg
<br /> AMOUNT CERTIFIED . $ /1; gl6 �7
<br /> PRINTED TITLE: pi,3.,e,c,,f- 4,14 ,/ 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 /> Architect:
<br /> County of i
<br /> C
<br /> Subscribed and sworn to before me this ay of 1j By: Date: /9/241,3
<br /> This ificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named
<br /> Notary P blic herein. Issuance,payment and acceptance of payment are without prejudice to any rights of the
<br /> ' ' 1/ t e r'1�J V\—� Owner or Contractor under this Contract.
<br /> Signed �t l
<br /> My commission expires: gal i r'D
<br /> s
<br /> le SAM J.TAHTINEN
<br /> (VARY PUBLIC-MINNESOTA
<br /> My Cam fission Eames Jan.31,2015.
<br />
|