4.7. SR 02-18-2020 - Laserfiche WebLink

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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 1000 SCHOOL ST. N.W. APPLICATION DATE: 1/21/2020 Golden Valley, MN 55427 PERIOD FROM: 1/1/2020 SUBMITTED FROM: SUNRISE PAINTING & WALLCOVERING, INC. ARCHITECT: 292 DESIGN GROUP PERIOD TO: 1/31/2020 805 TOWER DRIVE MEDINA, MN 55340 CONTRACT FOR: PAINTING & WALLCOVERING CONTRACT NO.: 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 type 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 nPrind rnvarari by thrc application. 1 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 or 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 Compensation 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 or any part thereof 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. PROJECT NO: CONTRACT DATE: COMMITMENT: 711112019 YES ORIGINAL CONTRACT SUM.................................................................. $ 412,750.00 NET CHANGE BY CHANGE ORDERS TO ................................................ $ CONTRACT SUM TO DATE .............................................. .................. $ 412,750.00 1 V 1 AL COMPLETED ED AND STORED TO DAT E.......................................... $ 34,000.00 5 % OF COMPLETED WORK $ 1,700.00 5 % OF STORED MATERIAL $ - TOTALRETAINAGE........... ........... ............. ........................_............ $ 1.700.00 TOTAL EARNED LESS RETAINAGE ....................... ... R Z) Qnn nn LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER ....................... $ LESS PREVIOUS CERTIFICATES FOR PAYMENT ............... ................... $ 4,750.00 CURRENT PAYMENT DUE.................................................................... $ 27,550.00 BALANCE TO FINISH INCLUDING RETAINAGE....................................... $ 380,450.00 The person signing below does hereby cerify that he/she is fully authorized and empowered to State of: MINNESOTA 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 me this SUNRISE PAINTING & WALLCOVERING, INC. 805 TOWER DRIVE MEDINA, MN 55340 SIGNED: PRINTED, TITLE Kea 21 ST day of JANUARY NOTARY PUBLIC: / Signed: (_.. / G My Commission Expires: 20 20 AAinr�sote tutV � E=zfVief�.{xmw 9! 7MR