4.3. SR 09-16-2019 - Laserfiche WebLink

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APPLICATION AND CERTIFICATE FOR PAYMENT Page 1 of ____._2 SUBMITTED TO: RJM Construction, LLC 830 Boone Avenue North Golden Valley, MN 55427 SUBMITTED FROM: Weidner Plumbing & Heating Company PO Box #1087 St. Cloud, MN 56302 CONTRACT FOR: PLUMBING WORK PROJECT: ELK RIVER MULTI PURPOSE ELK RIVER, MN ARCHITECT: CONTRACT NO.: 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 whatsoever, 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. APPLICATION NO: 1 APPLICATION DATE: 8/20/2019 PERIOD FROM: 7/15/2019 PERIOD TO: 8/20/2019 PROJECT NO: CONTRACT DATE: 7/15/2019 COMMITMENT: YES/NO ORIGINAL CONTRACT SUM.................................................................. $ 1,206,000.00 NET CHANGE BY CHANGE ORDERS TO ................................................ CONTRACT SUM TO DATE....... .................:................................... $ 1,206,000.00 TOTAL COMPLETED AND STORED TO DATE ....................... -.....s.......... $ 31,333.00 5 % OF COMPLETED WORK $ 1,566.65 5 % OF STORED MATERIAL A. - TOTAL RETAINAGE....................................................4...................... 5 1,566.65 TOTAL EARNED LESS RETAINAGE....................................................... $ 29,766.35 PARTIAL WAIVER OF LIEN LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER...... .......:.......... $ Now therefore, upon receipt of the payment of the current payment due on this application the LESS PREVIOUS CERTIFICATES FOR PAYMENT ............... ... 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 CURRENT PAYMENT DUE.................................................................... $ 29,766.35 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. BALANCE TO FINISH INCLUDING RETAINAGE ....... :....................... ......... $ 1,176,233.65 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. Weidner Plumbing & Heating Company PO Box #1087 St. Cloud, MN 56302 SIGNED: �r PRINTED, TITLE PRESIDENT State of: MN County of: BENTON Subscribed and sworn to before me this 19TH day of AUGUST 20 19 NOTARY PUBLIC: e "y KAREN A SCHENK Signed: G{ ��^ Notary Public State of Minnesota M Commission Expires: t My Commission Expires Y P January 31, 2024