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EXHIBIT E <br />APPLICATION AND CERTIFICATE <br />FOR PAYMENT <br />Page 1 <br />0f 2 <br />SUBMITTED TO: RJM Construction, LLC <br />PROJECT: Elk River Ice Arena <br />APPLICATION NO: <br />1 <br />830 Boone Avenue North <br />1000 School Street NW <br />APPLICATION DATE: <br />12 / 16 / 19 <br />Golden Valley, MN 55427 <br />Elk River, MN 55330 <br />PERIOD FROM: <br />11/25/19 <br />SUBMITTED FROM: <br />ARCHITECT: <br />PERIOD TO: <br />12/16/19 <br />Stevens Insulation, LLC <br />15751 Central Avenue NE <br />Ham Lake, MN 55304 <br />CONTRACT FOR: CONTRACT NO.: <br />I hereby certify that the work performed and the material supplied to date, as shown here, <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 -referenced <br />project. I further certify that no labor or materials have been supplied under contracts, <br />agreements, vernal 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 from any claim or liability therefor for the period covered by this application. I <br />also certify that payments, less applicable retention, have been made through the period covered <br />by previous payments received from the contractor to t} all my subcontractors (sub - <br />subcontractors) and 2) for all material and labor used in or in connection with the performance of <br />this contract. I further certify that I have complied with Federal, State, and local tax laws, including <br />Social Security laws, Unemployment Compensation Laws and Workman's Compensation laws <br />insofar as applicable to the performance this contract. <br />PARTIAL WAIVER OF LIEN <br />Now therefore, upon receipt of the payment of the current payment due on this application the <br />undersigned does hereby irrevocably release and waive any and all mechanids liens or rights to <br />claim any and all mechanic's Iiens or other liens against the above real estate or any ,part thereof <br />for any of the materials and/or labopr therefore furnished or performed in connection with this <br />project, reserving, however, all lien rights for labor and/or materials furnished after said date. <br />ORIGINAL CONTRACT SUM__ .................. <br />NET CHANGE BY CHANGE ORDERS TO.--. <br />CONTRACT SUM TO DATE-------- --------------- <br />TOTAL COMPLETED AND STORED TO DATE. <br />5 % OF COMPLETED WORK 363.60 <br />% OF STORED MATERIAL <br />PROJECT NO: <br />CONTRACT DATE: 12 / 6 / 19 <br />COMMITMENT: <br />... .... $7, 272. 00 <br />0.00 <br />TOTAL RETAINAGE..... .................................................... <br />TOTAL EARNED LESS RETAINAGE...................................... <br />LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER..--.. <br />LESS PREVIOUS CERTIFICATES FOR PAYMENT --------. <br />CURRENT PAYMENT DUE...... ....... __ -_------------------------ <br />BALANCE TO FINISH INCLUDING RETAINAGE--_-------------- <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 County of: Anoka <br />instrument. Subscribed and sworn to before me this <br />$7,272.00 <br />----_ ---- --- $7, 272. 00 <br />--------- 363.60 <br />$6,908.40 <br />0.00 <br />0.00 <br />.$fi_9nR-4n <br />................ $363.60 <br />16th day of December 1 24 19 <br />_ NOTARY PUBLIC: <br />SIGNED: Signed: Q,.6.,c <br />PRINTED, TITLE Donnie Stevens, President My Commission Expires: <br />1/31/2020 <br />RACHEL BOBEICA <br />Nofory Public <br />Mate of Minnesota <br />My Commission Expires <br />Januory 3 i , 2020 <br />