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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 Inc dba Eb ert Construction <br />23350 County Rd 10 <br />Corcoran, MN 55357 <br />CONTRACT FOR: 6A: Carpentry <br />Page 1 of 2 <br />PROJECT: Elk River Multi Purpose Facility and Lion John Weicht Park APPLICATION NO: <br />3 <br />APPLICATION DATE: <br />112012020 <br />PERIOD FROM: <br />1/1/2020 <br />ARCHITECT: 292 Design Group PERIOD TO: <br />1/31/2020 <br />PROJECT NO: <br />6979 <br />CONTRACT DATE: <br />CONTRACT NO.: COMMITMENT: <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 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 />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 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. <br />ORIGINAL CONTRACT SUM <br />............. $ 546,800.00 <br />NET CHANGE BY CHANGE ORDERS TO ................................................ $ - <br />CONTRACT SUM TO DATE................................................................... $ 546,800.00 <br />TOTAL COMPLETED AND STORED TO DATE .......................................... $ 122,522.39 <br />5 % OF COMPLETED WORK $ 6,126.12 <br />5 % OF STORED MATERIAL $ - <br />TOTALRETAINAGE............................................................................. $ 6,126.12 <br />TOTAL EARNED LESS RETAINAGE....................................................... $ 116.396.27 <br />LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER. <br />LESS PREVIOUS CERTIFICATES FOR PAYMENT <br />CURRENT PAYMENT DUE. <br />BALANCE TO FINISH INCLUDING RETAINAGE....... <br />State of: Minnesota <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 County of: Hennepin <br />instrument. Subscribed and sworn to before me this <br />It _ <br />T 07 non r,7 <br />T 10 Ar 7A <br />................ $ 430.403.73 <br />Ebert Inc dba Eb ert Construction 20th day of January 20 20 <br />23350 County Rd 10 <br />Corcoran, MN 55357 ` NOTARY PUBLIC: <br />SIGNED: Signed: �lJ [r. r•-iv4.a ii.'�1Z <br />ryTA <br />" i <br />PRINTED, TITLE Caleb Pelkey -Project Manager My Commission Expires: � � _ <br />