4.3. SR 09-16-2019 - Laserfiche WebLink

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APPLICATION AND CERTIFICATE FOR PAYMENT Page of SUBMITTED TO: RJM Construction, LLC PROJECT: Elk River Ice Arena & Lion John Weichl Park Facilities APPLICATION NO: 1 830 Boone Avenue North 1000 School Street NW; Elk River, MN 55330 APPLICATION DATE: Golden Valley, MN 55427 104 Lions Park Drive; Elk River, MN 55330 PERIOD FROM: SUBMITTED FROM: Ebert Construction ARCHITECT: 292 Design Group 23350 County Road 10 Corcoran, MN 55357 CONTRACT FOR: 32B: .Concrete Sidewa!t;s l Curb & Gutter CONTRACT NO.: Ebert Job #6308 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. PARTIAL WAIVER OF LIEN New therefore, upon receipt of the payment of the current payment due on this application the undersigned does hereby irrevocably release and waive any and all niechanic's liens or rights to claim any and all mechanic's liens or other liens against the above real estate ur any part thereof 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. ORIGINAL CONTRACT SUM... ....................................... PERIOD TO: PROJECT NO: #6966 CONTRACT DATE: 7110/2019 COMMITMENT: ... $ 387,400.00 NET CHANGE BY CHANGE ORDERS TO ........................ ..:.................. ". CONTRACT SUM TO DATE ............................ $ 387,40D.00 TOTAL COMPLETED AND STORED TO DATE .......................................... $ 10,303.52 5 % OF COMPL FTED WORK $ 515.18 5 % OF STORED MATERIAL S TOTAL RETAINAGE .... ........... ............................. ___ ......................... S 515.18 TOTAL EARNED LESS RETAINAGE ............................................. ...._..... $ 9,788.34 LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER .......... :.............. $ - LESS PREVIOUS CERTIFICATES FOR PAYMENT .......................:._...._..... CURRENT PAYMENT DUE ....... ........................................ ,....•__... $ 9.788.34 BALANCE TO FINISH INCLUDING RETAINAGE ....... $ 377,61168 State of: Minnesota 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 County of: Hennepin instrument. Sub ibed and sworn to before me this Ebert Construction ' ,, �' BRENDA M, SCHULTZ r day of^ 20 19 23350 County Road 10 J"� f� NoTARYPUBLIC -MINt{E5UTA Corcoran, MN 55357'u! _,+ M; Commlesion Expires Jan, 31, X11 Zy PUBLIC�,,.,1t. , • r�J[Y'ti SIGNED PRINTED, TITLE David Swanson. Project Signed: Brenda M Schultz My Commission Expires: 1131/2021