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APPLICATION AND CERTIFICATE FOR PAYMENT Page of <br />SUBMITTED TO: RJM Construction, LLC PROJECT: Elk River Ice Arena and Lion John Weicht Park Facilities APPLICATION NO: 4 <br />830 Boone Avenue North 1000 School St. NW APPLICATION DATE- 12/16/2019 <br />Golden Valley, MN 55427 Elk River, MN 55330 PERIOD FROM: 12/1/2019 <br />SUBMITTED FROM: Summit Fire Protection ARCHITECT: 292 Design Group PERIOD TO: 12/3112019 <br />575 Minnehaha Avenue West 3533 East Lake Street PROJECT NO: 0 <br />St. Paul, MN 55103 Minneapolis. MN 55406 CONTRACT DATE` 7/11/2019 <br />CONTRACT FOR: Fire Sprinklers CONTRACT NO. 0 COMMITMENT: YESINO <br />hereby certify that the work performed and the me"eriai supplied to date, as shown here, ORIGINAL CONTRACT SUM_ __ --------- ----------------------_ ___ ............. $ 256.485.00 <br />represent the actual value of accomplishment under the terms of the contract (and all authorized <br />changes hereto) between the undersigned and RJPdi Construction relating to the above- NET CHANGE BY CHANGE ORDERS TO ................. ............... ....... ____ $ 11,955.00 <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 CONTRACT SUM TO DATE.. . ...... ............................... ................ ........ S 268,440.00 <br />than the contract duly authorized and executed change orders, and the undersigned does hereby <br />releases RJM Construction from any claim or liability therefor for the period covered by this TOTAL COMPLETED AND STARED TO DATE......_.... ............................ $ 104,i81.00 <br />application. I also certify that payments, less applicable retention, have been made through the 5 % OF COMPLETED WORK $ 5,209.06 <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 5 % OF STORED MATERIAL $ <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 TOTAL RETAINAGE.............................................. $ 5.209.06 <br />Compensation laws Insofar as applicable to the performance this contract. <br />TOTAL EARNED LESS RETAiNAGE...__..............°-.,___.._.__.._...._........... S 98.971,94 <br />PARTIAL WAIVER OF LIEN LESS OWNER ❑IRECT'OAYMENT BY PURCHASE ORDER ....................... $ - <br />Now therefore, upon receipt of the ,payment of the current payment due on this application the LESS PREVIOUS CERTIFICAES FOR PAYMENT ...................................... $ 37,989,07 <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 DJE............ ........................ ................................ S 60,982.87 <br />for any of the materials and/or labopr therefore furnished or performed in connection w'th this <br />project, reserving, however, all lien rights for labor and/or materials furnished after said date. BALANCE TO FINISH INCLUDING RETAINAGE........................................ $ 169,468.06 <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: Ramsey <br />instrument. Subscribed and swom to before me this <br />Summit Fire Protection r <br />? 1 _ day of _ � c� tM. �� 20 1 <br />575 Minnehaha Avenue <br />St. Paul, MN 55103 NOTARY PUBLIC: <br />q ,, ]nsHua Jaynes Scott <br />SIGNED: Signed: �_ _ 'Notary rub+, - Minnesota <br />$ F. + My Commwsslnii Eapkres 0 113 1I2020 <br />PRINTED, TITLE Il, %Majl��l My Commission Expires: <br />