4.4. SR 01-21-2020 - Laserfiche WebLink

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APPLICATION AND CERTIFICATE FOR PAYMENT fAIA DOCUMENT G7021CMa) TO OWNER; PROJECT: APPLICATION NO: TWO (2) Distribution to: City of Elk River Elk {liver Ice Arena & Lion John Weicht Park Facilities OWNER El 13065 Orono Parkway NW 1000 School Street NW PERIOD TO: 12-30-19 Elk River, MN 55330 Elk River, MN 55330 CONSTRUCTION MANAGER El CONTRACT DATE: 07-10-19 VIA CONSTRUCTION MANAGER: ARCHITECT FROM CONTRACTOR: RJM Construction, LLC PROJECT NO-. 0 High Five Erectors II, Inc. CONTRACTOR 3005 4th Avenue East, P.G. Sox 477 VIA ARCHITECT: Shakopee, MN 55379 292 Desi n Group CONTRACT FOR: Install Steel & Misc. Metals L1 CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, Information and belief the Application is made for payment, as shown below, in connection with the Contract. Work covered by this Application for Payment has been completed in accordance with the Contract Documents, Continuation Sheet, AIA Document G703, is attached. that all amounts have been paid by the Contractor for Work for wich previous Certificates for Payment were 1. ORIGINAL CONTRACT SUM ............................................. $ 435,750.00 issued and payments received from the Owner, and that current payment shown herein is now due. "-1 r 2. Net Change by Change Orders ...................................... $ (2,698.15) CONTRACTOR: e � 3. CONTRACT SUM TO DATE (Line 9 1-2) .................................. $ 433,051.85 By: _4c'�'�Y! vi Date: '"" I 4. TOTAL COMPLETED & STORED TO DATE (column G on 3703).. $ 215,217.00 1. S. RETAINAGE: State af; Minnesota a. 5% of Completed Work County of: Scott (Column D + D on G703) $ 10,760.85 Subscribed and sworn to before b. 0% of Stared Material me this ' `day of Q- 4-u-,— ,r 20_� �� A.STOCK (Column F on G703) $ Notary Pur7llc. , � 4 (� NOTARY PUBLIC - MINNESOTA �� MY COMNSSION EXPIRES 01)31020 Total Retainage (Lines 5a + 5b or Total in Column I of G703) $ 10,760.85 - My Commission expires: 6. TOTAL EARNED LESS RETAINAGE.................................. $ 204,456.15 CERTIFICATE FOR PAYMENT (Line 4 less Line 5 Total) In accordance with the Contract Documents, based on on -site observations and the data comprising this 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT ............... $ 168,886.25 application, the Construction Manager and Architect certify to the Owner that to the best of their knowledge, (Line s from prior Certificate) information and belief the Work has progressed as indicated, the quality of the Work is in accordance with the 8. CURRENT PAYMENT DUE ................... $ 35,569.9[} Contract Documents, and the Contractor is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH, INCLUDING RETAINAGE ................. (Line 3 less Line 3) $ 228,595.70 CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS Total Changes approved in previous months by Owner $ $ Total approved this Mono; 4,490.00 (6,888,15) GO #1 - PR 2 Lease Space CO #2 - Deduct from Allowance TOTALS $ (2,698.15) $ - NET CHANGES by Change Orders $ (2,698.15) AMOUNT CERTIFIED ............................................. $ {Attach explanation if amount certified diners from the amount applied. iniow aii hguies on this Application and on the Continuation Sheet That are changed 10 Cpnrprrn with the BM*trnt Certified. f CONSTRUCTION MANAGER: By: ARCHITECT; Date: By: Date: This Certificate is not negotiable- The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract.