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: 6 B30 Boone Avenue North Lion John Welcht Park Facilities APPLICATION DATE: 1/17/2520 Golden Valley, MN 55427 1000 School Street N. W PERIOD FROM: 1112O20 SUBMITTED FROM: Rink -Tee International, Inc. ARCHITECT: 292 Design Group PERIOD TO: 1/312D20 3485 Willow Lake Blvd, Suite # 500 3533 E. Lake Street PROJECT NO: 19005 Vadnais Heights, MN 55110 Minneapolis, MN CONTRACT DATE: 7/32019 CONTRACT FOR: Elk River ice Arena CONTRACT NO.: COMMITMENT. YES/NO 1 hereby cediry that the work performed and the material supplied to date, as shown here, TOTAL ORIGINAL CONTRACT SUM .................._. ...... $ 2,162,742.00 represent the actual value of accomplishment under the terms of the contract (and all authorized $ - changes hamlet between the undersigned and RJM Constmdion relating to the above- NET CHANGE BY CHANGE ORDERS TO ................................................ referenced pri I further certify that no labor or materials have been supplied under CONTRACT SUM TO DATE_ $ 2, 162, 742.00 contracts, agreements, verbal or written, or any other arrangement of any type whatscaver,other ................................................................. than the contract duly authorized and executed change orders, and the undersigned does hereby TOTAL COMPLETED AND STORED TO DATE ......................................... $ 899,742.00 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 $ 29,4110.00 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 5 %OF STORED MATERIAL $ 15.497.10 Performance of this contract. t further certify that I have complied with Federal, State, and local $ M,987.10 tax laws, including Social Security laws, Unemployment Compensation Laws and Workman's TOTAL RETAINAGE.............__....................................... I ...... _. Compensation laws insofar as applicable to the performance this contract. EARNED LESS RETAINAGE 4.90 ...... $ 854,75 PARTIAL WAIVER OF LIEN Now therefore, upon receipt of the payment of the curent payment due on this application the undersigned deals hereby irrevocably release and waive any and all mechanics liens or rights to claim any and all mechanic's liens or other liens against the above real estate or any pad thereof for any of the materials and/or spoor therefore furnished or Performed in connection with this project, reserving, however, all lien rights for tabor and/or materials furnished after said date. ................................................. LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER._ .................... $ - LESSPREVIOUSCERTIFICAESFORPAYMENT..... ....... ..... _......... .... .... . $ 521,519,00 CURRENT PAYMENT DUE... ........... — ....... . ...... $ 333,244.90 BALANCE TO FINISH INCLUDING RETAINAGE........................................E 1,307,987.10 State of: Minnesota The person signing below does hereby verify that he/she is fully authored and empowered to execute this instrument and to bind the undersigned hereto, and does in fact so execute this County of Ramsey instrument. Subscribed and sworn no before me this Rink-Tec International, Inc. 20 day of 3485 Willow Lake Blvd Suite # 500 1 Vadnais Heights, MN 55110 NOTARY P Ul SIGNED: Signed: PRINTED, TITLE Kyle Gillespie - President My Commission Expires: 20 20