4.4. SR 01-21-2020 - Laserfiche WebLink

Home Browse Search

.7 . APPLICATION AND CERTIFICATE FOR PAYMENT Page 1 of 2 SUBMITTED TO: RJM Construction, U_C PROJECT: ELK RIVER MULTI PURPOSE APPLICATION NO: 5 830 Boone Avenue North ELK RIVER, MN APPLICATION DATE' 12120/2019 Golden Valley, MN 55427 0 PERIOD FROM: SUBMITTED FROM: Weidner Plumbing & Heating Company ARCHITECT: 0 PERIOD TO: PO Box #1087 0 PROJECT NO_ 0 St. Cloud. MN 56302 0 CONTRACT DATE: 7115/2019 CONTRACT FOR: PLUMBING WORK CONTRACT NO.: 0 COMMITMENT: YESINO I hereby certify that the work performed and the material supplied to date, as shown here. ORIGINAL CONTRACT SUM.................................................................. $ 1,206,000.00 represent the actual value of accomplishment under the terms of the contract (and all authorized changes hereto) between the undersigned and RJM Construction relating to the above- NET CHANGE BY CHANGE ORDERS TO ................................................ (474.00) referenced project- I further certify that no labor or materials have been supplied under contracts, agreements, verbal or written, or any other arrangement of any type whatsoever, other CONTRACT SUM TO DATE .............. ............................... ,....... ,............. 1,205,526.00 than the contract duly authorized and executed change orders, and the undersigned does hereby releases RJM Construction from any claim or liability therefor For the period covered by this TOTAL COMPLETED AND STORED TO DATE ............... $ 304,733-00 application. I also certify that payments, less applicable retention, have been made through the period covered by previous payments received from the contractor to 1) all my subcontractors 5 % OF COMPLETED WORK $ 15,236.65 (sub -subcontractors) and 2) for all material and labor used in or in connection with the 5 % OF STORED MATERIAL $ - performance of this contract. I further certify that I have complied with Federal, State, and local tax laws, including Social Security laws, Unemployment Compensation Laws and Workman's TOTAL RETAINAGE............ ............... ............ ........,,.,.,...,................... $ 15,236.65 Compensation laws insofar as applicable to the performance this contract - PARTIAL WAIVER OF LIEN Now therefore, upon receipt of the payment of the current payment due on this application the undersigned does hereby irrevocably release and waive any and all mechanic"s liens or rights to claim any and all mechanic's liens or other liens against the above real estate or any part thereof for any of the materials and/or labopr therefore furnished or performed in connection with this project, reserving, however, all lien rights for labor and/or materials furnished after said date. The person signing below does here'oy verify that he/she is fully authorized and empowered to execute this instrument and to bind the undersigned hereto, and does in fact so execute this instrument. Weidner Plumbing & Heating Company PO Box #1087 St. Cloud, MN 56302 SIGNED: PRINTED, TITLE PC C1�—_ i a 't� n TOTAL EARNED LESS RETAINAGE--_.,.,................................................ $ 289,496.35 LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER ....................... $ - LESS PREVIOUS CERTIFICAES FOR PAYMENT. .............................. $ 211.596.25 CURRENT PAYMENT DUE.................................................................... $ 77.900-00 BALANCE TO FINISH INCLUDING RETAINAGE........................................ $ 916,029.65 State of: J-�, 7 County of: �.K7 Subscribed and sworn to before me this day of An E�e_}_� 20 NOTARY PUBLIC: Signed: c 9" �a~, �hl W SCHENK W. Pohtio 7 SW8 W.. Minnesota My Commission Expires: / f (:. 4 lion Expires Rlt;1fV31, 2024