4.3. SR 09-16-2019 - Laserfiche WebLink

Home Browse Search

APPLICATION AND CERTIFICATE FOR PAYMENT Page 1 of 2 SUBMITTED TO: RJM Construction, LLC PROJECT: Elk River Ice Arena APPLICATION NO: 1 830 Boone Avenue North Lion John Weicht Park Facilities APPLICATION DATE: 7123/2019 Golden Valley, MN 55427 1000 School Street N. W Elk River, MN 55330 PERIOD FROM: 7/3/2019 SUBMITTED FROM: Rink -Tec International, Inc. ARCHITECT: 292 Design Group PERIOD TO: 7/3112019 3485 Willow Lake BNB. Suite # 500 3533 E. Lake Street PROJECT NO: 19005 Vadnais Heights, MN 55110 Minneapolis, MN CONTRACT DATE: 7/312019 CONTRACT FOR: Elk River Ice Arena CONTRACT NO.: 19005 COMMITMENT: YES/NO I hereby certify thal the work performee and She material supplied to date, as shown here, represent the acluaI value of accomplishment under lint: terms of the con Iracl [and a authorized changes hereto] between the undersigned and RJM Construction relaling to The above - referenced project I further cerlify IhEl no tabor or materials have been supplied under contracts, agreements, verb at or writlen, or any other arrangement of any type what soeve r. other than the contract duly authorized and executed change orders, and the undersigned does hereby releases RJM Construction lrom any claim or liability therefor for the period covered by this application. I also certify That payments, ess applicable retention, have been made through the period covered by previous payments re:eived from the contractor to 1 y all my suhgnrtlractom (sub -subcontractors) and 2) for all mverial and labor used in or in connection with the performance of this contract. I further certify that I have complied with Federal, Stale, and local tax laws, including Social Security laws. Unemploymerrl Compensation Laws and Workman's Compensation laws insofar as applicable io the performance this contract. PARTIAL WAIVER OF LIEN Now therefore, upon receipt of Sine paym:nt 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 etaim ally and all mechanic's liens or other liens against the above real estate or any {cart thereof for any of the materials andlor labopr therefore furnished or performed in conneclion with lois PF9jeCl. reserving, however, all Tien rig hls for tabor andlor materials turn Ished afler said dale. ORIGINAL CONTRACT SUM ....... .................... ................ ........ ........ ....... $ 2,162,742 00 NET CHANGE BY CHANGE ORDERS TO.................... ............................ $ CONTRACT SUM TO DATE ....... ........................ :... .......... ................ ..... $ 2,162.742.00 TOTAL COMPLETED AND STORED TO DATE.................... ...................... $ 115,000.00 5 % OF COMPLETED WORK $ 5.750.00 5 % OF STORED MATERIAL $ TOTALRETAINAGE.............................:........................:......::..........I.... $ 5,750.00 TOTAL EARNED LESS RETAINAGE........................................................ $ 109,250.00 LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER........................ $ LESS PREVIOUS CERTIFICATES FOR PAYMENT....; ............ ; .................. CURRENT PAYMENT DUE .................................................... ...._----.. .. $ 109.250.00 BALANCE TO FINISH INCLUDING RETAINAGE_ ............ ..................... ... $ 2,053,492.00 State of: Minnesota The person signing below does hereby verify 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 County of: Ramse instrument. Subscribed and sworn to before me this Rink -Tec International, Inc. 23 day of July 20 19 3485 Willow Lake Blvd. Suite # 500 NOTARY PUBLIC: ` '� KATHY MARY BARTON Vadnais Heights, MN 5511i1r j �F�� NofaryPiibtic f 4j Mirwresofa SIGNED: '` Signed: xranission Expires Jan 31, 2023 PRINTED, TITLE Kyle Gillesplq. Vdenl �� My Commission E ires: 31 -Jan -23