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APPLICATION AND CERTIFICATE FOR PAYMENT Page __]-_ of <br />SUBMITTED TO: RJM Construction, LLC PROJECT: &w kLUF,`,L muLri-?wc-P�,5,9 APPLICATION NO: 1 <br />830 Boone Avenue North 010 Lto) Softer V L-Kef r- PAX—L APPLICATION DATE: <br />Golden Valley, MN 55427 /� PERIOD FROM: 8-1-17 <br />� <br />SUBMITTED FROM: � � h" ""V�' ARCHITECT: Z'32_ _003k,/J 61i'tOl,IP4 PERIOD TO: 0 ^ <br />PO eo4 uoo PROJECT NO: e W <br />,WARM" 1p, "If ate,A) 9103f-7 <br />CONTRACT DATE: ']`1D •-/ <br />CONTRACT FOR: Z3/y' H -04 e. l eswa CONTRACT NO.: COMMITMENT: 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 [his <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 />lax 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 and/or labopr therefore furnished or performed in connection with this <br />project, reserving, however, all lien rights for labor and/or materials furnished after said dale. <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 />0 <br />0 <br />0 <br />SIGNED: <br />PRINTED, TITLE' <br />ORIGINAL CONTRACT SUM...........................-...-........................-........- 7lPti•..t <br />ID <br />NET CHANGE BY CHANGE ORDERS TO.. .......... _ .... .. ......... ............ ... <br />CONTRACT SUM TO DATE................................................................... s <br />TOTAL COMPLETED AND STORED TO DATE ............................... .. ,;27 <br />5 % OF COMPLETED WORK 5 <br />5 % OF STORED MATERIAL $ <br />TOTAL RETAINAGE.......................................................... I__ ......... <br />..-. <br />TOTAL EARNED LESS RETAINAGE...................................................... <br />LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER ........................ $ - <br />LESS PREVIOUS CERTIFICATES FOR PAYMENT .................................... d <br />CURRENT PAYMENT DUE .................................... <br />BALANCE TO FINISH INCLUDING RETAINAGE ....................................... <br />State of: <br />County of: �]�� ✓�✓ <br />Subscribed and sworn to before me this <br />��Z <br />day of U/,LJS! - • - - ---•• 20 <br />NOTARY PUBL <br />Signed, N EFFREY p WALETZKO <br />NOTARY PUBLIC - MINNESOTA <br />My Commission Expires: <br />Cv�iutiisvion Expires Jan.31, 2020 <br />