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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: Top -All Roofing, Inc. <br />2231 Edgewood Ave. South <br />Minneapolis, MN 55426 <br />CONTRACT FOR: Roofing & Sheet Metal <br />PROJECT: Elk River Ice Arena & Lion John Weicht Facilities <br />1000 School Street NW <br />Elk River. MN 55330 <br />ARCHITECT: <br />CONTRACT NO.: <br />Page 1 of 2 <br />APPLICATION NO: Two (2) <br />APPLICATION DATE: 12/23/2019 <br />PERIOD FROM: 12/1/2019 <br />PERIOD TO: 12/31/2019 <br />PROJECT NO: <br />19005.00 <br />CONTRACT DATE: <br />10/23/2019 <br />COMMITMENT: <br />YES/NO <br />I hereby certify that the work performed and the material supplied to date, as shown here, ORIGINAL CONTRACT SUM ............................ ... .................... $ 1,020,690.00 <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- NET CHANGE BY CHANGE ORDERS TO............ . ............................. <br />referenced project. I further certify that no labor or materials have been supplied under contracts, <br />agreements, verbal or written, or any other arrangement of any type whatsoever,other than the CONTRACT SUM TO DATE ............................ . . $ 1,020,690.00 <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 TOTAL COMPLETED AND STORED TO DATE .......... .... .......... $ 473,375.00 <br />also certify that payments, less applicable retention, have been made through the period covered <br />by previous payments received from the contractor to 1) all my subcontractors (sub - <br />subcontractors) % OF COMPLETED WORK $ 23,668.75 <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, <br />including Social Security laws, Unemployment Compensation Laws and Workman's 5 % OF STORED MATERIAL $ <br />Compensation laws insofar as applicable to the performance this contract. <br />TOTAL RETAINAGE...................... ........ ........ _...... .. $ 23,668 75 <br />TOTAL EARNED LESS RETAINAGE............ _... _ $ 449,706.25 <br />PARTIAL WAIVER OF LIEN LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER.. _ .. $ <br />Now therefore, upon receipt of the payment of the current payment due on this application the LESS PREVIOUS CERTIFICATES FOR PAYMENT .............. .. .. ..... $ 31,350.00 <br />undersigned does hereby irrevocably release and waive any and all mechanic's liens or rights to <br />claim any and all mechanic's liens or other liens against the above real estate or any part thereof CURRENT PAYMENT DUE................................................................. $ 418,356.25 <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. BALANCE TO FINISH INCLUDING RETAINAGE................ .. ......... $ 570,983.75 <br />State of: <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: keri (l"i n <br />instrument. Subscribed and sworn to before me this <br />Top -All Roofing, Inc. �1�J'rCi I--, rje l <br />2231 Edgewood Ave. South <br />Minneapolis, MN 55426 n <br />SIGNED: <br />PRINTED, TITLE Lori Stevens, Project Accountant <br />day of roLIe t-y r 1 , 20 <br />NOTARY PUBLIC: <br />QREW AGEN <br />Signed: u b I i c <br />{6 <br />22 Y Commission Expires <br />My Commission Expires: Januar S 1 . 2024 <br />