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APPLICATION AND CERTIFICATE FOR PAYMENT Page of <br />SUBMITTED TO: RJM Construction, LLC PROJECT: &LK kwok MaLn-paw-loc5 APPLICATION NO: b <br />830 Boone Avenue North l A,-d 45it) Jo RA) WfflCttr b4i-• APPLICATION DATE: - _;?z zz, <br />Golden Valley, MN 55427 PERIOD FROM: <br />SUBMITTED FROM: qOAbi 14 - 3oTn ARCHITECT: Z RZ _0(:;516 ) 6VLOLIP4 PERIOD TO: <br />l yG_gDD-2y-iCi7zs <br />PO f3t <br />'U11>d T�,� pA1UL� �N Stu ��% PROJECT NO: � CY3�c�L� <br />1 CONTRACT DATE: 7—iC --% <br />CONTRACT FOR: ?-'34 l y-ljl C -sm-7--a 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. 1 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 />COMMITMENT: YES/NO <br />ORIGINAL CONTRACT SUM.................................................................. <br />% -. 1 • 0_1, <br />NET CHANGE BY CHANGE ORDERS TO .............................. <br />.................. <br />CONTRACT SUM TO DATE................................................................... <br />TOTAL COMPLETED AND STORED TO DATE....`., .................................... <br />(FYI, •�� <br />5 % OF COMPLETED WORK $ <br />5 % OF STORED MATERIAL $ <br />TOTAL RETAINAGE............................................................................. <br />$ -�� <br />TOTAL EARNED LESS RETAINAGE....................................................... <br />$SV <br />—$ <br />LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER ........................ <br />LESS PREVIOUS CERTIFICATES FOR PAYMENT .................................... <br />rJJ <br />CURRENTPAYMENT DUE.................................................................... <br />$ <br />BALANCE TO FINISH INCLUDING RETAINAGE........................................ <br />$ 0-'A, 1�5��, — <br />State of: ���•�� ,,�j al�-- <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:�' <br />instrument. Subscribed and sworn to before me this <br />