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APPLICATION AND CERTIFICATE FOR PAYMENT
<br />Page of
<br />SUBMITTED TO: RJM Construction, LLC PROJECT:
<br />Elk River Multi Purpose Facility
<br />APPLICATION NO:
<br />2
<br />830 Boone Avenue North
<br />APPLICATION DATE:
<br />01/30/2020
<br />Golden Valley, MN 55427
<br />Elk River, MN
<br />PERIOD FROM:
<br />25-Feb
<br />SUBMITTED FROM: RAM Construction Services of Minnesota, LLC ARCHITECT:
<br />292 Design Group
<br />PERIOD TO:
<br />29-Feb
<br />9937 Goodhue Street NE
<br />3533 East Lake Street
<br />PROJECT NO:
<br />401132
<br />Blaine, MN 55449
<br />Minneapolis, MN 55406
<br />CONTRACT DATE:
<br />07/11/2019
<br />CONTRACT FOR: Waterproofing CONTRACT NO.:
<br />0
<br />COMMITMENT:
<br />YES
<br />I hereby certify that the work performed and the material supplied to date, as shown here,
<br />ORIGINAL CONTRACT SUM ..........................
<br />._.._.........._........ $
<br />39,630.00
<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 />(8,000.00)
<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 />CONTRACT SUM TO DATE... .........................
<br />......... ........... $
<br />31,630.00
<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 />TOTAL COMPLETED AND STORED TO DATE...
<br />::...:.:.......
<br />.,..:. $
<br />23,520.00
<br />application. I also certify that payments, less applicable retention, have been made through the
<br />5 % OF COMPLETED WORK $
<br />1,176,00
<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 />5 % OF STORED MATERIAL $
<br />-
<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 />TOTAL RETAINAGE............................... .......
<br />............................. .......... $
<br />1,176.00
<br />Compensation laws insofar as applicable to the performance this contract.
<br />TOTAL EARNED LESS RETAINAGE..__.,_,,.,.....,..._.
<br />.................................. $
<br />22,344.00
<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 />LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER ....................... $ -
<br />LESS PREVIOUS CERTIFICAES FOR PAYMENT .................................:,_.. $ 12,217.00
<br />CURRENT PAYMENT DUE .......................................................... $ 10,127.00
<br />BALANCE TO FINISH INCLUDING RETAINAGE........................ :......... :...:... $ 9,286.00
<br />State of: Minnesota
<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 County of: Ramsey
<br />instrument. Subscribed and sworn to before me this
<br />RAM Construction Services of Minnesota, LLC
<br />9937 Goodhue Street NE
<br />Blaine, MN 55449
<br />SIGNED:f� J
<br />PRINTED, TITLE Jeff Holmgren, Regional Manager
<br />30th l-aav of — J
<br />y,n�■�� LAURIE M VANCURA
<br />NOTA Y PU IC_ 4 Notary Public
<br />State of Minnesota
<br />My Commission Expires
<br />Signs a Januaiy31,2022
<br />My Commission Expires: 31-Jan-22
<br />20
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