4.4. SR 01-21-2020 - Laserfiche WebLink

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i Zolr_�, APPLICATION AND CERTIFICATE FOR PAYMENT Page 1 of 2 SUBMITTED TO: RJM Construction, LLC PROJECT; Elk River Ice Arena & APPLICATION NO: 2 830 Boone Avenue North Lion John Weicht Park Facilities APPLICATION. DATE: 12/14/2019 Golden Valley, MN 55427 Elk River, MN 55330 PERIOD FROM- 12/0112019 SUBMITTED FROM: Fabcon Precast, LLC ARCHITECT: 292 Design {Group PERIOD TO: 12l3112019 12520 Quentin Ave. S., Suite 200 3533 E Lake Street PROJECT NO. 012813 Savage, MN 55378 Minneapolis, MN 55406 CONTRACT DATE: 7/100019 CONTRACT FOR: precast concrete panles CONTRACT NO.: 0 COMMITMENT: YES/NO I hereby certify that the work performed and the material supplied to date, as shown here, ORIGINAL CONTRACT SUM ........... ......... ._,_,_........................................ $ 1,190,000.00 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 ... ................. ........... .---------- ...,._ S - referenced project. I further certify that no labor or materials have been supplied under CONTRACT SUM TO DATE_ _ ......... 5 1,190,000.00 contracts, agreements, verbal or written, or any other arrangement of any type whatsoever,other than the contract duly authorized and executed change orders, and the undersigned does hereby TOTAL COMPLETED AND STORE€? TO DATE .......................................... S 949,000.00 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 5 % OF COMPLETED WORK $ 47,450,00 period covered by previous payments received from the contractor to 1) all my subcontractors 5 % OF STORED MATERIAL $ (sub -subcontractors) and 2) for all material and labor used in or in connection with the performance of this contracL I further certify that I have complied with Federal, State,. and local TOTAL RETAINAGE..................... ...................................................._... S 47,450.00 tax laws, including Social Security laws, Unemployment Compensation Laws and Workman's Compensation laws insofar as applicable to the performance this contract. TOTAL EARNED LESS RETAINAGE..............._.„_,,.................................. S 901,550.00 PARTIAL WAIVER OF LIEN LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER ......:................. $ Now therefore, upon receipt of the payment of the current payment due on this application the LESS PREVIOUS CERTIFICAES FOR PAYMENT............ ...............__....._... S 621,775.00 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 Gens against the above real estate or any part thereof CURRENT PAYMENT DUE..... .... ........................ ........... S 279,775.00 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. BALANCE TO FINISH INCLUDING REIAINAGE........................................ $ 288,450.00 State of: MINNESOTA The person signing below does hereby cerify 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 County of: SCOTT instrument. Subscribed and sworn to before me this 12/14/2019 14 day of December 20 19 Fabcon Precast, LLC '" .r � NOTARY PUBLIC: �(/f�� J yaelF_ S1-!AR{3N SIGNED: ram`"" T +.` L Signed: �r 'Z.�. K FA$RY PRINTED, TITLE ! ack Becker !Credit Manager ' My Commission Expires: 1131/2024 PUBLIC. MINNESM _c0AdMMQNE]iPlraDT131!24