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APPLICATION AND CERTIFICATE <br />FOR PAYMENT <br />Page of <br />SUBMITTED TO: RJM Construction, LLC <br />PROJECT: Elk River Ice Arena & Lion John Weicht Park Facilities <br />APPLICATION NO: <br />4 <br />830 Boone Avenue North <br />1000 School Street NW <br />APPLICATION DATE: <br />2/20/2020 <br />Golden Valley, MN 55427 <br />Elk River, MN 55330 <br />PERIOD FROM: <br />2/1/2020 <br />SUBMITTED FROM: High Five Erectors II, Inc. <br />ARCHITECT: 292 Design Group <br />PERIOD TO: <br />2/28/2020 <br />3005 4th Avenue East <br />Shakopee, MN 55379 <br />CONTRACT FOR: 5B Structural & Misc. Steel Installation CONTRACT NO.: <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 />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 <br />instrument. <br />High Five Erectors II, Inc. <br />3005 4th Avenue East <br />Shakopee, MN 5537 <br />SIGNED: <br />PRINTED, TITLE Tara Thompson, President <br />ORIGINAL CONTRACT SUM ......................... <br />NET CHANGE BY CHANGE ORDERS TO........ <br />CONTRACT SUM TO DATE .......................... <br />TOTAL COMPLETED AND STORED TO DATE. <br />5 % OF COMPLETED WORK <br />5 % OF STORED MATERIAL <br />TOTAL RETAINAGE............. <br />PROJECT NO: <br />CONTRACT DATE: 7/10/2019 <br />COMMITMENT: YES/NO <br />.................................. $ 435,750.00 <br />$ 14,718.60 <br />TOTAL EARNED LESS RETAINAGE................... <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 />County of: Scott <br />Subscribed and sworn to before me this <br />.......... $ (2,198.15) <br />$ 433,551.85 <br />.......... $ 294,372.00 <br />......... $ 14,718.60 <br />.......... $ 279,653.40 <br />......... $ <br />216,790.95 <br />......... $ <br />62,862.45 <br />......... $ <br />153,898.45 <br />f* day of lc7Q )(�IY L'tarN 20 <br />NOTARY PUBLIC: <br />Signed: <br />M mmission Expires: <br />KIM A STOCK <br />Notary Public - Minnesota <br />,ommission Expires 01131/2025 <br />