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APPLICATION AND CERTIFICATE <br />FOR PAYMENT <br />Page 1 of <br />2 <br />SUBMITTED TO: RJM Construction, LLC <br />830 Boone Avenue North <br />PROJECT: ELK RIVER ICE ARENA <br />APPLICATION NO: <br />1 <br />Golden Valley, MN 55427 <br />1000 SCHOOL ST. N.W. <br />APPLICATION DATE: <br />8/21/2019 <br />SUBMITTED FROM: SUNRISE PAINTING & WALLCOVERING, INC. <br />PERIOD FROM: <br />8/1/2019 <br />805 TOWER DRIVE <br />ARCHITECT: 292 DESIGN GROUP <br />PERIOD TO. <br />8/31/2019 <br />MEDINA, MN 55340 <br />PROJECT NO: <br />CONTRACT FOR: PAINTING & WALLCOVERING <br />CONTRACT DATE: <br />7/11/2019 <br />_ <br />CONTRACT NO.: <br />I hereby certify that the work performed and the material supplied to date, as shown here, <br />represent the actual value of accomplishment under the terms of the contract (and all authorized <br />changes hereto) between the undersigned and RJM Construction relating to the above - <br />referenced project. I further certify that no labor or materials have been supplied under <br />contracts, agreements, verbal or written, or any other arrangement of any type whatsoever, other <br />than the contract duly authorized and executed change orders, and the undersigned does hereby <br />releases RJM Construction from any claim or liability therefor for the period covered by this <br />application. I also certify that payments, less applicable retention, have been made through the <br />period covered by previous payments received from the contractor to 1) all my subcontractors <br />(sub -subcontractors) and 2) for all material and labor used in or in connection with the <br />performance of this contract. I further certify that I have complied with Federal. State, and local <br />tax laws, including Social Security laws, Unemployment Compensation Laws and Workman's <br />Compensation laws insofar as applicable to the performance this contract. <br />PARTIAL WAIVER OF LIEN <br />Now therefore, upon receipt of the payment of the current payment due on this appliaallon the <br />undersigned does hereby irrevocably release and waive any and all mechanie's liens or rights to <br />claim any and all mechanics liens Or other liens against the above real estate or any part thereof <br />for any of the materials andlor labopr lherefvre furnished or performed In connection with this. <br />project, reservtng, however. all lien rights for labor and/or materials furnished after said date. <br />The person signing below does hereby cerify that he/she is fully authorized and empowered to <br />execute this instrument and to bind the undersigned hereto, and does in fact so execute this <br />instrument. <br />SUNRISE PAINTING & WALLCOVERING, INC. <br />805 TOWER DRIVE <br />MEDINA, MN 55340 /1 <br />SIGNED: r <br />PRINTED, TITLE <br />COMMITMENT: YES <br />ORIGINAL CONTRACT SUM.............. <br />$ 412 7rin no <br />NET CHANGE BY CHANGE ORDERS TO ,. .. .. <br />CONTRACT SUM TO DATE ................. $ 412,750 00 <br />TOTAL COMPLETED AND STORED TO DATE........... ...... ........... ....... I 5 nno nn <br />5 % OF COMPLETED WORK $ 25000 <br />5 % OF STORED MATERIAL S _ <br />TOTAL RETAINAGE........... ... ..._ ....... $ 25000 <br />TOTAL EARNED LESS RETAINAGE.................................................... $ 4,750.00 <br />LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER... $ <br />LESS PREVIOUS CERTIFICATES FOR PAYMENT.._...., <br />CURRENT PAYMENT DUE .................. .............. S 4,750.00 <br />BALANCE TO FINISH INCLUDING RETAINAGE $ 408 000 00 <br />State of: / s <br />County of: <br />Subscribed and sworn to efore me this <br />z CIL� day of Sf 20 <br />NOTARY PUBLIC <br />Signed: 'A/&", ' <br />i <br />My Commission Expires: / /-Z' " <br />KIM J LAf43OfM-SEI <br />40fary Putriic <br />,. „ Minrreapiq <br />31, = <br />