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APPLICATION AND CERTIFICATE FOR PAYMENT <br />SUBMITTED TO: RJM Construction, LLC <br />830 Boone Avenue North <br />Golden Valley, MN 55427 <br />SUBMITTED FROM: Kendell Doors & Hardware <br />PO Box 211520 <br />Eagan, MN 55121 <br />CONTRACT FOR: <br />PROJECT: Elk River Ice Arena & <br />Lion John Weicht Park <br />ARCHITECT: <br />CONTRACT NO.: <br />I hereby certify that the work Derformed and the mater a} supplied to date, as shown here. <br />represent the actual value of acromplishment under, the Germs of the contract (and afl authorized <br />chances hereto) between the undersigned and RJM Construction relating to the atxrv. eierertcPo <br />project. I further certiry that no tabor or materials have been supplied under =Ira=, <br />agreetnerifs. verbal or written, or :any other arrangement of any type whatsoever,other than the <br />contract duly authorized and executed change orders, and the undersigned does hereby releases <br />RJM Construction frorn any claim or liability therefor for the period covered by this application. I <br />also certify that payments, tess applicable retention, have beer: made through the period coveted <br />by previous payments received from she Contractor to 1) all my subcontractors (sub - <br />subcontractors) and 2) for all Material and labor used In or in onnection with the performance of <br />this contracL I further certify that I have complied with Federat, State. and local tax laws, including <br />Social Security laves, Unemployment Compensation Laces and Wiarkman's Compensation lawns <br />insofar as applicable to the perormanoe- this contract. <br />PARTIAL WAIVER OF LIEN <br />Now therefore, upon receipt of the payment of the wrrent payment due on thn application the <br />undersigned does hereby irrevocably release and waive any and all mechanic's liens or rights to <br />claim any and all mechanids liens or other liens against the above real estate or any part thereof <br />for any of the materials and/or labopr therefore iurnshed or performcnJ in connect on with this <br />project, reserving, however, all lien rights for labor and/or materials furnished after said date. <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 />instrument. <br />C <br />SIGNED: <br />PRINTED, TITLE <br />ORIGINAL CONTRACT SUM ................................... <br />NET CHANGE BY CHANGE ORDERS TO .................... <br />Page of <br />APPLICATION NO: 1 <br />APPLICATION DATE: 12/19/19 <br />PERIOD FROM: �1 1 /20/19 <br />PERIOD TO: 12/20/19 <br />PROJECT NO: NO PO IN CONTRA( <br />CONTRACT DATE: <br />COMMITMENT: <br />92,614-00 <br />CONTRACT SUM TO DATE ................................................... 92,614.00 <br />TOTAL COMPLETED AND STORED TO DATE...........................a...... 13,717.63 <br />5 % OF COMPLETED WORK 685.88 <br />% OF STORED MATERIAL <br />TOTAL RETAINAGE........................................................ 685.88 <br />TOTAL EARNED LESS RETAINAGE ............................ 13,031.75 <br />LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER ..................... <br />LESS PREVIOUS CERTIFICATES FOR PAYMENT..-,,.....„ .............. . <br />CURRENT PAYMENT DUE .................. 13,031.75 <br />BALANCE TO FINISH INCLUDING RETAINAGE...................................... 49.582.25 <br />State of- MN <br />County of: Ramsey <br />Subscribed and sworn to before me this <br />. _ day of e "'xe <br />NOTARY PUBLIC: <br />Signed: "y�� taw; �u�al_l� M��(ISj}�;• <br />_ f <br />My Commission Expires: 4 - gry�r.-"r•^^+� <br />20 J Y <br />