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APPLICATION AND CERTIFICATE FOR PAYMENT <br />Page of <br />SUBMITTED TO: RJM Construction, LLC PROJECT: <br />APPLICATION NO: <br />830 Boone Avenue North <br />APPLICATION DATE: <br />Golden Valley, MN 55427 <br />PERIOD FROM: <br />SUBMITTED FROM: ARCHITECT: <br />PERIOD TO: <br />PROJECT NO: <br />CONTRACT DATE: <br />CONTRACT FOR: CONTRACT NO.: <br />COMMITMENT: <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 -referenced <br />project. I further certify that no labor or materials have been supplied under contracts, <br />agreements, verbal or written, or any other arrangement of any type whatsoever, other than the <br />contract duly authorized and executed change orders, and the undersigned does hereby releases <br />RJM Construction from any claim or liability therefor for the period covered by this application. I <br />also certify that payments, less applicable retention, have been made through the period covered <br />by previous payments received from the contractor to 1) all my subcontractors (sub - <br />subcontractors) and 2) for all material and labor used in or in connection with the performance of <br />this contract. I further certify that I have complied with Federal, State, and local tax laws, including <br />Social Security laws, Unemployment Compensation Laws and Workman's Compensation laws <br />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 />SIGNED: <br />PRINTED, TITLE <br />ORIGINAL CONTRACT SUM <br />NET CHANGE BY CHANGE ORDERS TO <br />CONTRACT SUM TO DATE. <br />TOTAL COMPLETED AND STORED TO DATE. <br />% OF COMPLETED WORK <br />% OF STORED MATERIAL <br />TOTAL RETAINAGE. <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 <br />County of: <br />Subscribed and sworn to before me this <br />day of <br />NOTARY PUBLIC: <br />Signed: <br />My Commission Expires: <br />20 <br />