4.7. SR 02-18-2020 - Laserfiche WebLink

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APPLICATION AND CERTIFICATE FOR PAYMENT Page of SUBMITTED TO: RJM Construction, LLC PROJECT: Elk River Ice Arena APPLICATION NO: 7 830 Boone Avenue North 1000 School Stret NW APPLICATION DATE: 1/17/2020 Golden Valley, MN 55427 Elk River, MN 55330 PERIOD FROM: 1/1/2020 SUBMITTED FROM: Minnesota Utilities & Excavating ARCHITECT: 13932 Lake Drive Forest Lake, MN 55025 CONTRACT FOR: City of Elk River 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 period covered by this application. I 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. The person signing below does hereby cerify that he/she is fully authorized and empowered to execute this instrument and to bind the undersigned hereto, and does in fact so execute this instrument. Minnesota Utilities & Excavating 13932 Lake Drive F t L k MN 0 JODI LYNN RUSS NOTARY PUBLIC - MINNESOTA My Commission Expires Jan. 31, 2021 ores a e, 55 25 _ f SIGNED: PRINTED, TITLE G�-ar�`��J • �� +1�{-{ �� 292 Design Group PERIOD TO: 1/31/2020 3533 East Lake Street PROJECT NO: 0 Minneapolis, MN 55406 CONTRACT DATE: 1/0/1900 0 COMMITMENT: YES/NO ORIGINAL CONTRACT SUM............................................................... $ 572,787.00 NET CHANGE BY CHANGE ORDERS TO.. ........ .................................... .. $ 88,954.30 CONTRACT SUM TO DATE... . ................ .............. :_.:......... ::............. $ 661,741.30 TOTAL COMPLETED AND STORED TO DATE ................... $ 461,575.00 5 % OF COMPLETED WORK $ 23,078.75 5 % OF STORED MATERIAL $ - TOTAL RETAINAGE...... ........ ......... ..._............... ............................... $ 23,078.75 TOTAL EARNED LESS RETAINAGE.......................,..._........................... $ 438,496,25 LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER ....................... $ - LESS PREVIOUS CERTIFICAES FOR PAYMENT .................................:..._, $ 379,505.05 CURRENT PAYMENT DUE ...... ............ ............................ :......_....,:....... $ 58,991.20 BALANCE TO FINISH INCLUDING RETAINAGE........................... ....... :,.... $ 223,245.05 State of: County of: p1(_ Subscribed and sworn to before me this day of 2GlGrr�---- 20 c�D NOTARY PUBLIC: Signed: My Commission Expires: