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F,XHIBIT C <br />APPLICATION AND CERTIFICATE FOR PAYMENT Page 1 of 2 <br />SUBMITTED TO: RJM Construclion, LLC PROJECT: Elk River Multi Purpose Facility & APPLICATPONNO: 2 <br />830 acone Avenue North Lion John Weicht Park <br />Golden Vafley, MN 55427 <br />SUBMITTED FROM: <br />Seating And Athletic Facility Enterprises <br />79554 325th Street <br />Ellendale, MN 56026 <br />CONTRACT F{�93417 Section 13 LLeTruss Bleacher System <br />ARCHITECT: 292 Design Group <br />3533 East Lake Street <br />Minneapolis, M 55406 <br />CONTRACT NO,: 19520-0033 <br />I Hereby certify that the work performed and 1.he material supplied to dare, as shown here, <br />represenl the actual value of amumpflshmenl under the terms of the conlract (and all authorized <br />changes hereto) between the undersigned and RJM Construction felaling to the above-refaranced <br />project. l further certify that no labor or materials have been suppifed under conlracts, <br />agreements, verbal or written, or any other arrangement of any typa 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. <br />arse certify lhat payments, less applicable refenlicm, have been made through the period covered <br />by prevfous payments received from the contractor to 1) all my subconlractors (sub - <br />subcontractors) and 2) for all malerlal and labor used in or in connection with the performance of <br />Ifils -contract. t further certify that I have compiled with Federal. Stale, and local lax fawn, indoding <br />Social Security Paws, Unemployment Compensalion Laws and Workman's Cumpensallon laws <br />insofar as applicable to the performance this contract. <br />PARTIAL WAIVER OF LIEN <br />Now therefore, upon rec;uipt or the payment of the current payment due on this application the <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 agarnst the above real estala or any part lhereof <br />for any of the materials and/or labopr therefore furnished or performed In connection with this <br />project, reserving, ho•,vever. all lien rights for labor andlor materials furnished after said date. <br />The person signing below does hereby ceNty (hat hefshe is fully authorized and empowered to <br />execute this instrument and to bind the undersigned herele, and does in fact so execute this <br />instrument. <br />SIGNED: f <br />.r <br />PRfNTED, TITLE President <br />APPL I6:AT1L}N DAiE. <br />12 -18 --19 <br />PERIOD FROM: <br />12 -1-19 <br />PERIOD TO: <br />12-31-19 <br />PROJECT NO: <br />19005.00 <br />CONTRACT DATE: <br />7 -11-19 <br />COMWTNIENT: <br />ORIGJNAL CONTRACTSUM ............ --................................................. 125, 797 . 00 <br />NET CHANGE BY CHANGE ORDERS TO ................................................. 0.010 <br />CONTRACT SUM TO DATE.................................................................... 125, 797. 00 <br />TOTAL COMPLETED AND STORED TO DATE.— ...... ............. 125, 797.00 <br />% OF COMPLETED WORK <br />% OF STORED MATERiAL <br />TOTAL RETAINAGE....................... .............. .......... ......... I ................. ,... 6,289.85 <br />TOTAL EARNED LESS RETAfNAGE......................................................... 119,507.15 <br />LESS OWNER DJRECT PAYMENT BY PURCHASE ORDER ..................,...... <br />LESS I REVIOU5 CERTIFICATES FOR PAYMENT ..................................... 25,040.10 <br />CURRENT PAYMENT DUE,................................................................- 94,467.05 <br />BALANCE TO FINISH INCLUDING RETAINAGE.......... ............................... 6, 289 . 85 <br />Staleof: Minnesota <br />County or: Freeborn <br />Subscribed and swam to before me this <br />18th day of December 7-bi 9 <br />NOTARY PUBLIC: <br />Signed'. <br />My Commission Expires-. <br />►+lobar Public <br />Aftnewte <br />ill C mamm E" iarKJ 11. <br />1, IZD A <br />