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APPLICATION AND CERTIFICATE FOR PAYMENT Page 1 of 2 SUBMITTED TO: RJM Construction, LLC PROJECT: Elk River Multi Purpose Facility and Lion John Weicht Park APPLICATION NO: 2 830 Boone Avenue North APPLICATION DATE: 12/18/2019 Golden Valley, MN 55427 PERIOD FROM: 12/1/2019 SUBMITTED FROM: Ebert Inc dba Eb ert Construction ARCHITECT: 292 Design Group 23350 County Rd 10 Corcoran, MN 55357 CONTRACT FOR: 6A: Carpentry CONTRACT NO.: 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 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 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. PERIOD TO: 12/31/2019 PROJECT NO: 6979 CONTRACT DATE: COMMITMENT: ORIGINAL CONTRACT SUM.................................................................. $ 546,800.00 NET CHANGE BY CHANGE ORDERS TO ................................................ $ - CONTRACT SUM TO DATE................................................................... $ 546,800.00 TOTAL COMPLETED AND STORED TO DATE .......................................... $ 102,137.39 5 % OF COMPLETED WORK $ 5,106.87 5 % OF STORED MATERIAL $ - TOTALRETAINAGE............................................................................. $ 5,106.87 TOTAL EARNED LESS RETAINAGE....................................................... $ 97,030.52 LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER ........................ $ - LESS PREVIOUS CERTIFICATES FOR PAYMENT .................................... $ 37,966.75 CURRENT PAYMENT DUE.................................................................... $ 59,063.77 BALANCE TO FINISH INCLUDING RETAINAGE........................................ $ 449,769.48 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. Subscribed and sworn to before me this Ebert Inc dba Eb ert Construction 18th day of December 20 19 23350 County Rd 10 Corcoran, MN 55357 NOTARY i=UBLIC: :;'' �' > ��_� CANDACE LEE GREEN SIGNED: Signed: i W_ NOTARY PUBLIC �" = �' TA My Commission Expires Jan. 31, 2022 PRINTED, TITLE Caleb Pelkey - roject Manager My Commission Expires: - -^'