4.7. SR 02-18-2020 - Laserfiche WebLink

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APPLICATION AND CERTIFICATE FOR PAYMENT Page � of s SUBMITTED TO: RJM Constmction, LLC PROJECT: Elk River Ice Arena & Lion's PaM APPLICATION NO' 6 830 Boone Avenue North 1000 School Street NW APPLICATION DATE: 1/22/2020 Golden Valley, MN 5542] EIk River, MN 55330 PERIOD FROM: 1/1/2020 SUBMITTED FROM: Crosstown Masonry, Incoryoatetl ARCHITECT: PERIOD TO: t/31I2020 1322 7591h Ave NE PROJECT NO: Hem Lake, MN 55304 CONTRACT DATE: CONTRACT FOR: Concrete 8 Masonry CONTRACT NO.: COMMITMENT: VESINO hereby ceNfy that the work performed and the material supplied to date, ea shown here, ORIGINAL CONTRACT SUM.................................................................. $ 2;935,000.00 represent the actual value of accomplishment untler the terms of the wntracl (antl all authorEed changes hereto) between the undersignetl antl RJM Construction relating to the above- NET CHANGE BV CHANGE ORDERS TO ............................................... $ 16,38500 referenced prolacl. I fudYier certify that no labor o materials have been supplied under r conVacts, agreemenLa, verbal or written, or any other arangement of any type whatsoever,other CONTRACT SUM TO DATE................................................................... $ 2,951,395.00 than the contract duly authorized and executed change ortlers, antl the untlersignetl tloes hereby releases RJM Construction from any claim or liability therefor for Me period covered by this TOTAL COMPLETED ANO STORED 70 DATE ......................................... $ 2,0]1,355.00 application. I also certify that payments, leas applicable retention, have been matle through the periotl coveretl by previous payments receivetl from the contractor to 1) all my subcontrctora 5 %OF COMPLETED WORK $ 103,5fi].]5 (sub -subcontractors) and 2) for all material antl labor usetl in nection with the pertormance of this contract. I further certify that I have complied with Federel, State, end local tax laws, including Social Security laws, Unemployment Compensation Lawe end WoMman's 5 %OF STORED MATERIAL $ - Compeneation laws insofar ea applicable to the peAonnence this contact. TOTAL REfAINAGE............................................................................. $ 703.58].75 TOTAL EARNED LESS RETAINAGE....................................................... $ 1,95],]e].25 LESS OWNER DIRECT PAVMENT BV PURCHASE ORDER ........................ $ - PARTIAL WAIVER OF LIEN Now therefore, upon receipt of the payment of the current payment due on this application the LESS PREVIOUS CERTIFICATES FOR PAVMENT.................................... $ t,3]],865.6g untlersigned tloes hereby irrevocably release and waive any and all mechanic's liens or dghte to claim any antl all mechanc's hens or other hens against the above real estate or any part thereof CURRENT PAYMENT DUE .................. ........ $ 590,]01.45 for any of the materials and/or labopr therefore furnished or performed in connection with this project, reserving, however, all lien dghls for labor antllor materials furnished after saitl date. BALANCE TO FINISH INCLUDING RETAINAGE........................................ $ 983,807.75 State of: Minnesota The person signing below tloes hereby cerify that he/she is fully authorized antl empoweretl to acute this Instrument antl to bintl the untlersignetl hereto, antl tloes in fact so execute this County of: Anoka nstnlment Subscribed and sworn to before me this Crosstown Masonry, Incor1poated 22nd tlay of Jenue 0 20 13221591h Ave NE ! AMANDgCHRI$TINE 9RANDT Ham Lake, MN 55304y/f � NOTARY PUB NOTARY PUBLIC SIGNED: �Signetl: � U.ti'QL�{ MINNESOTA oYesMn' Ja1.31.TOLi PRINTED, TITLE Tamm Boast tl, esitlent My Commission Expires: 1/31/2025