4.3. SR 09-16-2019 - Laserfiche WebLink

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APPLICATION AND CERTIFICATE FOR PAYMENT Page of SUBMITTED TO: RJM Construction, LLC PROJECT: Elk River Ice Arena APPLICATION NO: 1 830 Boone Avenue North 1000 School St NW APPLICATION DATE: 8-21-2019 Golden Valley, MN 55427 Elk River, MN 55330 PERIOD FROM: 8-1-2019 SUBMITTED FROM: Distinctive Iron, LLC ARCHITECT: 292 Design Group PERIOD TO: 8-30-2019 19128 Industrial Blvd NW 3533 E Lake St PROJECT NO: 19520-0033 Elk River, MN 55330 Minneapolis, MN 55406 CONTRACT DATE: 7-10-2019 CONTRACT FOR: Elk River Ice Arena & Lion John Weicht Park CONTRACT NO.: 19520-0033 COMMITMENT: YESINO I hereby certify that the work performed and the material supplied to date, as shown here, represent the actual value of accomplishment under the terms of the contract (and all authorized changes hereto) between the undersigned and RJM Construction relating to the above - referenced project. I further certify that no labor or materials have been supplied under contracts, agreements, verbal or written, or any other arrangement of any type whalsoever,other than the contract duly authorized and executed change orders, and the undersigned does hereby releases RJM Construction from any claim or liability therefor for the period covered by this application. I also certify that payments, less applicable retention, have been made through the period covered by previous payments received from the contractor to 1) all my subcontractors (sub -subcontractors) and 2) for all material and labor used in or in connection with the performance of this contract. I further certify that I have complied with Federal, State, and local tax laws, including Social Security laws, Unemployment Compensation Laws and Workman's Compensation laws insofar as applicable to the performance this contract. PARTIAL WAIVER OF LIEN Now therefore, upon receipt of the payment of the current payment due on this application the undersigned does hereby irrevocably release and waive any and all mechanic's liens or rights to claim any and all mechanic's liens or other liens against the above real estate or any part thereof for any of the materials and/or labopr therefore furnished or performed in connection with this project, reserving, however, all lien rights for labor and/or materials furnished after said date. The person signing below does hereby cerify that he/she is fully authorized and empowered to execute this instrument and to bind the undersigned hereto, and does in fact so execute this instrument. #REF! Distinctive Iron, LLC 19128 Industrial cl W SIGNED: L: PRINTED, TITLE , 1'�k ORIGINAL CONTRACT SUM-.... .... ___ NET CHANGE BY CHANGE ORDERS TO. ....................................... $ 1,308,353.00 CONTRACT SUM TO DATE ....................... ....................................... :.... $ 1,308,353.00 TOTAL COMPLETED AND STORED TO DATE ..............................,.......... $ 75,000.00 5 % OF COMPLETED WORK $ 3,750.00 5 % OF STORED MATERIAL $ - TOTAL RETAINAGE ........... ............................ :...:...:......... .................... . $ 3,750.00 TOTAL EARNED LESS RETAINAGE....................................................... $ 71,250.00 LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER ...... ............ ....... $ - LESS PREVIOUS CERTIFICATES FOR PAYMENT .................................... CURRENT PAYMENT DUE..................................................................... $ 71,250.00 BALANCE TO FINISH INCLUDING RETAINAGE ........................................ $ 1,237,103.00 State of: County of: J� Subscribed and sworn to before me this day of fiuc, 20 j f -- NOTARY PUBLIC: n Signed: �U,x j ! r]'� MICHELLE L JOHNSON My Commission Expires: _ J �J ✓ "'p 1, NOTARY PUBLIC MINNESOTA Jan, 31, 2024