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APPLICATION AND CERTIFICATES FOR PAYMENT <br />Page of �� <br />SUBMITTED TO: RJM Construction, LLC PROJECT: L� P—LUb7L Irtpg,f.Lri —Vuw-fwS(- APPLICATION NO: <br />334 Boone Avenue North VIVO LLoV Jow t&L-ic fr Ptx- -- APPLICATION DATE: 12--1"d-( f <br />Golden Valley, MN 55427 J PERIOD FROM: l _ —1 <br />SUBMITTED FROM: 5044-3117n Shy' r ARCHITECT: a<12— D�-5t610 C1kU) "1A PERIOD To: t2-31—/5 <br />,7 <br />F` 0 2LV, 40r) PROJECT NO: / � Gi0 <br />WA L M' 119 , .k, 14 r11 Sfo <br />CONTRACT DATE: 7`10 --1 <br />CONTRACT FOR: Z�34 Hv-ml nL Wsr&"ys CONTRACT NO.: COMMITMENT: YES/NO <br />I hereby certify that the work performed and the material supplied to date, as shown here, <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 />referenced project. I further certify that no tabor or materials have been supplied under <br />contracts, agreements, verbal or written, or any other arrangement of any type whatsoever,other <br />than the contract duly authorized and executed change orders, and the undersigned does hereby <br />releases RJM Constriction from any claim or liability therefor For the period covered by this <br />application. I also certify that payments, less applicable retention, have been made through the <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 />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 />Compensation laws insofar as applicable to the performance this contract. <br />PARTIAL WAIVER OF LIEN <br />Now therefore, upon receipt of 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 against the above real estate or any part thereof <br />for any of the materials andlor labopr therefore furnished or performed in connection with this <br />project, reserving, however, ail lien rights for labor andlor materials furnished after said date. <br />The person signing below does hereby verify 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 />instrument, <br />ORIGINAL CONTRACT SUM_ <br />NET CHANGE BY CHANGE ORDERS TO ................... <br />I, <br />.................. <br />CONTRACT SUM TO DATE ....... ............. ................................... I ......... .., <br />TOTAL COMPLETED AND STORED TO DATE .......................................... <br />5 % OF COMPLETED WORK $ L4[ % YE) <br />5 % OF STORED MATERIAL $ <br />zz. <br />TOTAL RETAINAGE............................................................................. $ L4r1J�'-S-T) <br />TOTAL EARNED LESS RETAINAGE ........................ $ 2 S : 2—ir) <br />LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER ........................ $ 40 '— <br />LESS PREVIOUS CERTIFICATES FOR PAYMENT..... I Lj <br />CURRENT PAYMENT DUE......—.— ...... ....... --- ................................ 5 uiiF <br />BALANCE TO FINISH INCLUDING RETAfNAGE........................................ $ <br />State of: <br />County of:�✓ <br />Subscribed and swom to before me this <br />