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ZRti <br />APPLICATION AND CERTIFICATE FOR PAYMENT <br />SUBMITTED TO: RJM Construction, LLC <br />830 Boone Avenue North <br />Golden Valley, MN 55427 <br />SUBMITTED FROM: Ebert Construction <br />23350 County Road 10 <br />Corcoran, MN 55357 <br />CONTRACT FOR: 3213: Concrete Sidewalks / Curb & Gutter <br />PROJECT: Elk River Ice Arena & Lion John Weicht Park Facilities <br />1000 School Street NW; Elk River, MN 55330 <br />104 Lions Park Drive: Elk River. MN 55330 <br />nzy:lirrx.�� <br />CONTRACT NO. <br />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 labor 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 Construction 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 />292 Design Group <br />0 <br />0 <br />Ebert Job #6968 <br />ORIGINAL CONTRACT SUM....... <br />NET CHANGE BY CHANGE ORDERS TO ............. <br />CONTRACT SUM TO DATE ..................................... <br />Page of <br />APPLICATION NO: <br />39 <br />APPLICATION DATE: <br />PERIOD FROM: <br />PERIOD TO: <br />PROJECT NO: <br />#6968 <br />CONTRACT DATE: <br />7/10/2019 <br />COMMITMENT: <br />0 <br />TOTAL COMPLETED AND STORED TO DATE .............................. <br />5 % OF COMPLETED WORK <br />5 % OF STORED MATERIAL <br />TOTAL RETAINAGE................... <br />TOTAL EARNED LESS RETAINAGE <br />$ 2,313.70 <br />LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER ................ <br />PARTIAL WAIVER OF LIEN <br />Now therefore, upon receipt of the payment of the current payment due on this application the LESS PREVIOUS CERTIFICAES FOR PAYMENT...... <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 DUE ..................................... <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. BALANCE TO FINISH INCLUDING RETAINAGE......... <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 />instrument. <br />Ebert Construction <br />23350 County Road 10 <br />Corcoran, MN 55357 <br />SIGNED: �AA <br />PRINTED, TITLE :(7L ,�C PI-0 j GC-4— Vn<,cyf <br />$ 387,400.00 <br />....... $ <br />(4,106.97) <br />....... $ <br />383,293.03 <br />$ <br />46,283.23 <br />....... $ <br />2,313.70 <br />....... $ <br />43,969.53 <br />....... $ <br />....... $ <br />40,086.85 <br />....... $ <br />3,882.68 <br />....... $ <br />339,323.50 <br />State of: `jet <br />County of: <br />Subscribed and sworn to Ilefore me this <br />day of 20 <br />NOTARY PUBLIC: <br />Signed: �%_F-� r _ •-•. ,, ef^I`Infi7 <br />;A <br />My Commission Expires: , 7:Q1 <br />