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APPLICATION AND CERTIFICATE FOR PAYMENT
<br />Page 1 of 3
<br />SUBMITTED TO: RJM Construction, LLC PROJECT: Elk River Ice Arena & Lion's Park
<br />APPLICATION NO:
<br />5
<br />530 Boone Avenue North 1000 School Street NW
<br />APPLICATION DATE:
<br />12/1912019
<br />Golden Valley, MN 55427 Elk River, MN 55330
<br />PERIOD FROM:
<br />12/112019
<br />SUBMITTED FROM: Crosstown Masonry, Incorporated ARCHITECT:
<br />PERIOD TO:
<br />1213112019
<br />'1322 159th Ave NE
<br />PROJECT NO:
<br />Ham Lake, MN 55304
<br />CONTRACT DATE --
<br />CONTRACT FOR: Concrete & Masonry CONTRACT NO.:
<br />COMMITMENT:
<br />YESINO
<br />I hereby certify that the work performed and the material supplied to date, as shown here,
<br />ORIGINAL CONTRACT SUiV.................................................................. $ 2,935,000.00
<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 />NET CHANGE BY CHANGE ORDERS TO. ..... ... ........ .. $ 30,915.00
<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 />CONTRACT SUM TO DATE .......................... $ 2,965,915,00
<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 />TOTAL COMPLETED AND STORED TO DATE .......................................... $ 1,449,564.00
<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 />5 % OF COMPLETED WORK $ 72,478.20
<br />performance of this contract. I further certify that I have complied with Federal, State, and local
<br />tax laws, including Sccial Security laws, Unemployment Compensation Laws and Workman's
<br />5 % OF STORED MATERIAL &
<br />Compensation laws insofar as applicable to the performance this contract.
<br />TOTAL_ RETAINAGE..........................................................---...........72,478,20
<br />TOTAL EARNED LESS RETAINAGE....................................................... $ 1,377,085.80
<br />OWNER DIRECT PAYMENT BY PURCHASE ORDER ........................ $ -
<br />PARTIAL WAIVER OF LIENLESS
<br />Now therefore, upon receipt of (he payment of the current payment due on this application the
<br />LESS PREVIOUS CERTIFICATES FOR PAYMENT—_ ........ ....... $ 1,092,085.80
<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 />CURRENT PAYMENT DUE. ...... _._ ...... ................................... ------- $ 285,000.00
<br />for any of the materials andlor labopr therefore Furnished or performed in connection with this
<br />project, reserving, however, all lien rights for labor andlor materials furnished after said date.
<br />BALANCE TO FINISH INCLUDING RETAINAGE........................................ $ 1,588,829.20
<br />State of: Minnesota
<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 />County of: Anoka
<br />instrument.
<br />Subscribed and sworn to before me this
<br />Crosstown Masonry, Incorporated
<br />1322 159th Ave NE
<br />Ham Lake, MN 55304
<br />SIGNED: 1, 7' ?-b !' / ✓t,f; f.'
<br />PRINTED, TITLE Tammy Braastad4�Ppesident
<br />19th day of December
<br />NOTARY PUB
<br />Signed, -
<br />My Commission Expires:
<br />1/3112025
<br />20 -19
<br />AMANDACHRWNE BRAW
<br />NOTARY PUBLIC
<br />MINNESOTA
<br />MY 60-1+ilon EVII65 lM. 31.2X 5
<br />
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