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APPLICATION AND CERTIFICATE FOR PAYMENT Page of SUBMITTED TO: RJM Construction, LLC PROJECT: Elk River Ice Arena & Lion Jahn Weicht Park Facilities APPLICATION NO: 2 830 Boone Avenue North 1000 School Street NW APPLICATION DATE: 12/2512019 Golden Valley, MN 55427 Elk River, MN 55330 PERIOD FROM: 12/1/2019 SUBMITTED FROM: High Five Erectors 11, Inc. ARCHITECT: 292 Resign Group PERIOD TOE 12/30/2019 3005 4th Avenue East PROJECT NO: Shakopee, MN 55379 CONTRACT DATE; 7/10/2019 CONTRACT FOR: 5B Structural & Misc, Steel Installaticn CONTRACT NO,: COMMITMENT: YES1NO I hereby certify that the work performed and the material supplied to date, as shown here, ORIGINAL CONTRACT SUM ........................... represent the actual value of accomplishment under the te•ms of the contract (and all authorized changes hereto) between the undersigned and RJM Construction relating to the above- NET CHANGE BY CHANGE ORDERS TO.......,. referenced project. I further certify that no labor or materials have been supplied urder contracts, agreements, verbal or written, or any other arrangement of any type whatsoever, other CONTRACT SUM TO DATE ...................... . 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 TOTAL COMPLETED AND STORED TO DATE.. 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 5 °la OF COMPLETED WORK 5 (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 5 % OF STORED MATERIAL $ tax laws, including Sac al Security laws, Unemployment Compensation Laws and Workman's Compensation laws insofar as applicable to the performance this contract. TOTAL RETAINAGE..................................... PARTIAL WAIVER OF LIEN Now 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 mechanic's liens or rights to claim any and all mechanic's liens or other liens against the above real estate or any part thereof for any of the materials andlor labopr therefore furnished or performed in connection with this project, reserving, however, all lien rights for labor andlor materials furnished after said date. 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 instrument. High Five Erectors 11, Inc 3005 4th Avenue East Shakopee, MN 55379 SIGNED. (j PRINTED, TITLE To ra Thompson, President $ 435,750.00 I— ................. $ (2,698.15) $ 433,051.85 .................................... $ 215,217.00 10,760.85 ....... .................. .......--- ... $ 10.760.85 TOTAL EARNED LESS RETAINAGE............................................._..I......1. $ 204,456,15 LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER ........................ $ - LESS PREVIOUS CERTIFICATES FOR PAYMENT...... $ 168,88625 CURRENT PAYMENT DUE. ............. ................. ...... $ 35,569.90 BALANCE TO FINISH INCLUDING RETAINAGE................................. ....... $ 228.595,70 State of: Minnesota County of: Scott Subscribed and sworn to before me this i day ofj yr NOTARY PUBLIC: i My Commission Commission Expires oI f�` 1 ?_0 20 19 -AIM A. STOCK NOTARY PUBLIC - MINNESOTA CC)MSSICN EXPIRES 01/31320