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APPLICATION AND CERTIFICATE FOR PAYMENT Page 1 Of 2 SUBMITTED TO. RJM Constructlon, LLC PROJECT Elk River Ice Arena and Lion John Weicht Park Facilities APPLICATION NO: 4 630 Boone Avenue North 1000 School Street NUJ APPLICATION DATE. 12J2312019 Golden Vatey. MN 55427 Elk River, MN 55330 PERIOD FROM: 12/1/2019 SUBMITTED FROM: METRO UTILITIES, INC. ARCHITECT: 292 Design Group PERIOD TO: 12131 J2019 9656 161st Avenue NW 3533 East Lake Street PROJECT NO: 0 Elk River, MN 55330 Minneapolis MN 55406 CONTRACT DATE: 711112019 CONTRACT FOR. SITE UTILITIES (33A: Utilities) CONTRACT NO_: 4 COMMITMENT: YESJNO I hereby certify that the work performed and the material supplied to date, as shown here, 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 - 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 lype whatsoever, other 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 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 (sub -subcontractors) and 2) for all material and labor used in of in connection with the 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 Campensation 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 of any part thereof for any of the materials andJor labopr therefore furnished or performed in connection with this project. reserving, however, all lien rights for labor andlor materials furnished after said date. ORIGINAL CONTRACT SUM .............. ...............................................,,,. $ 586.000A00 NET CHANGE BY CHANGE ORDERS TO..... .........................,..,.,............ $ 33 037-15 CONTRACT SUM TO DATE .............................. ,,,....,,....................... ...,. S 619,037 15 TOTAL COMPLETED AND STORED TO IOATE...............,,......................... S 603.127.85 5 % Of: COMPLETED WORK S 30,156.39 5 % OF STORED MATERIAL $ - TOTAL RETAIN,AGE............................................... .................. ,,. $ 30.156.39 TOTAL EARNED LESS RETAINAGE....................................................... S 572,971.46 LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER ........................ $ - LESS PREVIOUS CERTIFICAES FOR PAYMENT. ................ .................... S 545,623.00 CURRENT PAYMENT DUE........ .. . ................................................... S 27.348.46 BALANCE TO FINISH INCLUDING RETAINAGE........................................ $ 46,065.69 State of: Minnesota The person signing below does hereby verify that he.rshe is fully authorized and empowered to execute this instrument and to bind the undersigned hereto, and does in fact so execute this County of Hennepin instrument. Subscribed and sworn to before ire this METRO UTILITIES, INC. 23rd day of December 9656 161 st Avenue NUJ ElkRiver Mtn 55330 NOTARY PUBLIC: f 1 q SIGNED- i Signed: (PRINTED, TITLE Dale VanNurden !Corp. Secretary My Commission Expires; 1'3V2025 20 19 STEVEN J. +CROSBY _Notaryr Publi*-Minnesota My Cmmftkn Ex*as,m at, 2025