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APPLICATION AND CERTIFICATE FOR PAYMENT
<br />Page 1 of
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<br />SUBMITTED TO- RJM Construction, LLC PROJECT: Elk River Ice Arena
<br />APPLICATION NO:
<br />5
<br />830 Boone Avenue North Lion John Weicht Park Facilities
<br />APPLICATION DATE:
<br />12/20/2019
<br />Golden Valley, MN 55427 1000 School Street N.W
<br />PERIOD FROM:
<br />12/1/2019
<br />SUBMITTED FROM: Rink-Tec International, Inc. ARCHITECT: 292 Design Group
<br />PERIOD TO:
<br />12/31/2019
<br />3485 Willow Lake Blvd. Suite # 500 3533 E. Lake Street
<br />PROJECT NO:
<br />19005
<br />Vadnais Heights, MN 55110 Minneapolis, MN
<br />CONTRACT DATE:
<br />7f312019
<br />CONTRACT FOR: Elk River Ice Arena CONTRACT NO.:
<br />COMMITMENT:
<br />YESINO
<br />I hereby certify that the work performed and the material supplied to date, as shown here,
<br />ORIGINAL CONTRACT SUM .... ................... ............................. ............
<br />$ 2,162,742.00
<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-
<br />NET CHANGE BY CHANGE ORDERS TO ................................................
<br />S
<br />referenced project. I further certify that no labor or materials have been supplied under
<br />contracts, agreements, verbal or written, or any other arrangement of any type whatsoever, other
<br />CONTRACT SUM TO DATE.................................................................
<br />$ 2,162,742.00
<br />than the contract duly authorized and executed change orders, and the undersigned does hereby
<br />releases RJM Construction from any claim or liabifity therefor for the period covered by this
<br />TOTAL COMPLETED AND STORED TO DATE ........................................
<br />S 549,000.00
<br />application. I also certify that payments, less applicable retention, have been made through the
<br />5 % OF COMPLETED WORK $ 15.990.00
<br />period covered by previous payments received from the contractor to 1) all my subcontractors
<br />(sub -subcontractors) and 2) for all material and labor used in or in connection with the
<br />5 % OF STORED MATERIAL $ 11,500.00
<br />performance of this contract. I further certify that I have complied with Federal, State: and local
<br />tax laws, including Social Security laws, Unemployment Compensation Laws and Workman's
<br />TOTAL RETAI NAG E.. ...........................................................,., .......
<br />S 27,490.00
<br />Compensation laws insofar as applicable to the performance this contract.
<br />TOTAL EARNED LESS RETAINAGE..................,,..,....................,.,....,...
<br />S 521,510.00
<br />PARTIAL WAIVER OF LIEN
<br />LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER .......................
<br />$ -
<br />Now therefore, upon receipt of the payment of the current payment due on this application the
<br />LESS PREVJCUS CERTIFICAES FOR PAYMENT .....................................
<br />$ 303,810.00
<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
<br />CURRENT PAYMENT DUE.........................................................,,.........
<br />$ 217,700.00
<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 />BALANCE TO FINISH INCLUDING RETAINAGE..................................... ...
<br />$ 1,641 ,232.00
<br />State of: Mfnnesota
<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 />County of: Ramsey
<br />instrument.
<br />Subscribed and sworn to before me this
<br />Rink-Tec International, Inc. 20 day of Decem
<br />3485 Willow Lake Blvd. Suite # 500 !
<br />Vadnais Heights, MN 55110 NOTARY PUBU
<br />SIGNED: - , - 4vill Signed: t r
<br />PRINTED, TITLE Kyle Gillespie - President My Commission Expires: 31•Jan-23
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