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APPLICATION AND CERTIFICATE FOR PAYMENT <br />� <br />of <br />/p��� ����Page <br />SUBMITTED TO: RJM Construction, LLC PROJECT: u•-r� klXb L ptgilL� 7-pI1K.PC5Ls-+ <br />APPLICATION NO: � <br />830 Boone Avenue North R)ArO U CN QottN ldb_Irer Paxx- <br />APPLICATION DATE: <br />Golden Valley, MN 55427 <br />q'0P+V4 Shm AtenuI <br />PERIOD FROM:,—/-Z6J?.iA <br />SUBMITTED FROM: -r3pp0TA ARCHITECT: ZQL De:f516 ) (5KVL/LA <br />PERIODTO: 1-:31-'VZD <br />�O B010W� <br />PROJECTNO: �0 <br />yVaLM tk, wtN <br />CONTRACT DATE: %-)O -) <br />CONTRACTFOR: Z3,4I j5ygr&yW CONTRACT NO.: <br />COMMITMENT:r/{{{YEESSaINr O..��✓✓11 <br />I hereby certify that the work performed and the material supplied to date, as shown here, ORIGINAL CONTRACT SUM .. ......... ..... ....... .... ...................................... <br />. <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 />NET CHANGE BY CHANGE ORDERS TO........ ................................ <br />........ <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 CONTRACT SUM TO DATE <br />/p,/{' q <br />$ / NAW -19 <br />................................................................... <br />than the contract duly authorized and executed change ortlers, and the undersigned does hereby <br />releases RJM Construction from any daim or liability therefor for the period covered by this <br />TOTAL COMPLETED AND STORED TO DATE <br />n <br />) u <br />(Y <br />application. I also codify that payments, less applicable retention, have been made through the ... ...................... <br />.... ,.........,. <br />period covered by previous payments received from the contractor to 1) all my subcontractors q <br />(sub -subcontractors) and 2) for all material and labor used in or in connection with the 5 %OF COMPLETED WORK $ <br />,(ro <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 5 %OF STORED MATERIAL $ <br />Compensation laws insofar as applicable to the performance this contract. Y <br />TOTAL RETAINAGE.............. ............................. .................................. <br />��yyqq <br />$ INL •-!JO <br />TOTAL EARNED LESS RETAINAGE.......... ._........... <br />p <br />............. .............. .. 5 S EU <br />PARTIAL WAIVER OF LIEN LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER ........................ $ ^ 0-- <br />Now therefore, upon receipt of the payment of the current payment due on this application the LESS PREVIOUS CERTIFICATES FOR PAYMENT .................................... <br />a <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 CURRENT PAYMENT DUE.................................................................... <br />S �O <br />�3y <br />for any of the materials andlor labopr therefore furnished or performed in connection with this <br />project,reserving,however, all lien rights for labor andlor materials furnished after said date. BALANCE TO FINISH INCLUDING RETAINAGE....... ............ <br />..._._......_.... $ <br />State cf. <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 fad so execute this County of v+/ysp/Lrii <br />instrument. Subscribed and sworn to before me this <br />0 dayof jvl/vvµy 20 24-O <br />0 Y <br />0 NOTARYPUBLIC' _ pp <br />SIGNED: Signed: �._ JEFFREY P. WALETZKO <br />NOTARY PUBLIC - MINNESOTA <br />PRINTED, TITLE 'w9 Ar,- /L4s".( /c My Commissio sires: I f' xtlt wS <br />