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APPLICATION AND CERTIFICATE FOR PAYMENT Page / of v? <br />SUBMITTED TO: RJM Construction, LLC <br />830 Boone Avenue North <br />Golden Valley, MN 55427 <br />SUBMITTED FROM: Minnesota Utilities & Excavating <br />13932 Lake Drive <br />Forest Lake, MN 55025 <br />CONTRACT FOR: City of Elk River <br />PROJECT: Elk River Ice Arena <br />1000 School Stret NW <br />Elk River, MN 55330 <br />ARCHITECT: 292 Design Group <br />3533 East Lake Street <br />Minneapolis, MN 55406 <br />CONTRACT NO.: 0 <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 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 date. <br />APPLICATION NO: 2 <br />APPLICATION DATE: 8/20/2019 <br />PERIOD FROM: 8/1/2019 <br />PERIOD TO: <br />8/31/2019 <br />PROJECT NO: <br />0 <br />CONTRACT DATE: <br />1/0/1900 <br />COMMITMENT: <br />YES/NO <br />ORIGINAL CONTRACT SUM ............ ......... ........ :....,;.::::,.... ;;.................. $ 572,787.00 <br />NET CHANGE BY CHANGE ORDERS TO.,....._.....,, ... .................... ......... $ <br />CONTRACT SUM TO DATE .............. .................. ...................... $ 572,787.00 <br />TOTAL COMPLETED AND STORED TO DATE; .............. ,.::..... S 43,171.66 <br />5 % OF COMPLETED WORK $ 2,158.58 <br />5 % OF STORED MATERIAL $ <br />TOTAL RETAINAGE... .. .. $ 2,158.58 <br />TOTAL EARNED LESS RETAINAGE .......................... $ 41,013.08 <br />LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER......:,,..:..........:: $ <br />LESS PREVIOUS CERTIFICAES FOR PAYMENT .....................................- $ 6,640.50 <br />CURRENT PAYMENT DUE.... . $ 34,372.58 <br />BALANCE TO FINISH INCLUDING RETAINAGE. ....................... ___ ......... $ 531,773.92 <br />State of: <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 County of: <br />instrument. Subscribed and sworn to before me this <br />,�Q <br />Minnesota Utilities &Excavating JQQ! LYNN RUBS NOTARY PUBLIC • MINNESOTA day of 20! <br />13932 Lake Drive ��; �� � COmmiss6an Expires dart. 31, ZD21 <br />Forest Lake, MN 55025 �"" NOTARY PUBLIC <br />SIGNED: �.-�� <br />t.�L-�' Signed: <br />PRINTED, TITLE L �e Pv ) Iii i?'�MR% r4 Ct�liC_My Commission Expires: �a7% <br />