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APPLICATION AND CERTIFICATE
<br />FOR PAYMENT
<br />-
<br />CONTRACT SUM TO DATE ............. .......................... :....,........,.............
<br />$
<br />2,162,742.00
<br />Page 1 of
<br />2
<br />SUBMITTED TO: RJM Construction, LLC
<br />PROJECT: Elk River Ice Arena
<br />APPLICATION NO:
<br />2
<br />830 Boone Avenue North
<br />Lion John Weicht Park Facilities
<br />APPLICATION DATE:
<br />8/21/2019
<br />Golden Valley, MN 55427
<br />1000 School Street N.W
<br />PERIOD FROM:
<br />8/1/2019
<br />SUBMITTED FROM: Rink -Tec International, Inc.
<br />ARCHITECT: 292 Design Group
<br />PERIOD TO:
<br />8/31/2019
<br />3485 Willow Lake Blvd. Suite # 500
<br />3533 E. Lake Street
<br />PROJECT NO:
<br />19005
<br />Vadnais Heights, MN 55110
<br />Minneapolis, MN
<br />CONTRACT DATE:
<br />7/3/2019
<br />CONTRACT FOR: Elk River Ice Arena
<br />CONTRACT NO.
<br />COMMITMENT:
<br />YES/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, f also certify that payments, less applicable retention, have been made through the
<br />period covered by previous payments received from the contractof to 1) all my subcontractors
<br />(sub-subcontrac(ors} 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 application the
<br />undersigned does hereby irrevocably release and waive any and all mechanic's liens or rights to
<br />claim any and all mechanic's liens or other liens against the above real estate or any part thereof
<br />for any of the materials andfor labopr therefore furnished or perforated in connection with this
<br />project, reserving, 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 />Rink -Tec International, Inc
<br />3485 Willow Lake Blvd. Suite # 500
<br />Vadnais Heights, MN 55110
<br />SIGNED:
<br />PRINTED, TITLE Kyle Gillespie - President
<br />ORIGINAL CONTRACT SUM ............... ......................... :..,....1,,—.,......... $ 2.162,742.00
<br />NET CHANGE BY CHANGE ORDERS TO.......... ......................................
<br />8
<br />-
<br />CONTRACT SUM TO DATE ............. .......................... :....,........,.............
<br />$
<br />2,162,742.00
<br />TOTAL COMPLETED AND STORED TO DATE....,. ................... .... .......... :.
<br />$
<br />175,000.00
<br />5 % OF COMPLETED WORK $ 8,750.00
<br />5 % OF STORED MATERIAL $
<br />TOTAL RETAINAGE...........................................................................
<br />$
<br />8,750.00
<br />TOTAL EARNED LESS RETAINAGE.. ....... ........ ...........................
<br />$
<br />166,250.00
<br />LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER........................
<br />S
<br />-
<br />LESS PREVIOUS CERTIFICAES FOR PAYMENT ........ ......... ............. .......
<br />$
<br />115,000.00
<br />CURRENT PAYMENT DUE.. .................. -- ........................
<br />$
<br />51,250.00
<br />BALANCE TO FINISH INCLUDING RETAINAGE— ............ ........... .........
<br />$
<br />1,996,492.00
<br />State of: Minnesota
<br />County of: Ramsey
<br />Subscribed and sworn to before ge this
<br />21 day of August 20 19
<br />KATHY MARY BARYON
<br />NOTARY PUB'• Notary Public
<br />Minnesota
<br />A �r MyCommissicnExpres
<br />Sig Jan 31, 2023
<br />My Commission E ills: 31 -Jan -23
<br />
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