4.4. SR 03-16-2020 - 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: 7 830 Boone Avenue North Lion John Weicht Park Facilities APPLICATION DATE: 2/20/2020 Golden Valley, MN 55427 1000 School Street N.W PERIOD FROM: 2/1/2020 SUBMITTED FROM: Rink-Tec International, Inc. ARCHITECT: 292 Design Group PERIOD TO: 2/29/2020 3485 Willow Lake Blvd. Suite # 500 3533 E. Lake Street PROJECT NO: 19005 Vadnais Heights, MN 55110 Minneapolis, MN CONTRACT DATE: 7/3/2019 CONTRACT FOR: Elk River Ice Arena CONTRACT NO.: COMMITMENT: YESlNO I hereby certify that the work performed and the material supplied to date, as shown here, ORIGINAL CONTRACT SUM.................................................................. $ 2,162,742.00 represent the actual value of accomplishment under the terns of the contract (and all authorized changes hereto) between the undersigned and RJM Construction relating to the above- NET CHANGE BY CHANGE ORDERS TO ................................................ $ referenced project. 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 whatsoever,other .................................................................. than the contract duly authorized and executed change orders, and the undersigned does hereby TOTAL COMPLETED AND STORED TO DATE ........................................ S 1,143,742.00 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 $ 57,187.10 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 0 % OF STORED MATERIAL $ - 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 TOTAL RETAINAGE............................................................................. $ 57,187,10 Compensation laws insofar as applicable to the performance this contract. TOTAL EARNED LESS RETAINAGE....................................................... $ 1,086,554.90 LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER ....................... $ - PARTIAL WAIVER OF LIEN Now therefore, upon receipt of the payment of the current payment due on this application the LESS PREVIOUS CERTIFICAES FOR PAYMENT ...................................... $ 854,754.90 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 CURRENT PAYMENT DUE.................................................................... $ 231,800.00 for any of the: materials and/or labopr therefore furnished or performed in connection with this BALANCE TO FINISH INCLUDING RETAINAGE$ 1,076,187,10 project, reserving, however, all lien rights for labor and/or materials furnished after said date. ........................................ State of: Minnesota 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 County of: Ramsey instrument. Subscribed and sworn to befor me this Rink-Tec International, Inc. 20 day 20-Faim u KATHY VARY BARTON 3485 Willow Lake Blvd. Suite # 500 Vadnais Heights, MN 55110 NOTAR P Notary Public t_r Minnesota �j F My Commission Expires SIGNED: /l [t/A /Ii �B/e /� /1 Signed: �j•'� .•.b'° Jan 31, 2ff23 PRINTED, T17LE Kyle Gillespie - President My Cop(mission f-yfiires: 31-Jan-23