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DocuSign Envelope ID: 18BCC2EB-5C45-4AO3-BBDA-FOAFAF992DFC <br />APPLICATION FOR PAYMENT <br />To: RJM Construction, LLC. Project: Elk River Multi -Purpose Facility and Lion Application No.: 3 <br />830 Boone Avenue North John Weicht Park <br />Golden Valley, MN 55427 Period To: 04/30/20 <br />From: Rachel Contracting, Inc. Application Date: 04/24/20 <br />4125 Napier Court NE Project No.: 19520-0033 <br />Saint Michael, MN 55376 <br />Contract Date: 07/23/19 <br />Contract For: 195200033-024405 - Mass Structure Commitment: 195200033-024405 <br />Demoltion <br />1. ORIGINAL CONTRACT AMOUNT <br />2. NET CHANGE BY CHANGE ORDERS <br />3. CONTRACT SUM TO DATE <br />4. TOTAL COMPLETED AND STORED TO DATE <br />(Column G) <br />5. RETAINAGE <br />5.00% of Completed Work <br />(Columns D + E) <br />5.00% of Stored Materials <br />(Columns F) <br />Total Retainage <br />(Line 5a + Line 5b OR Sum of Column 1) <br />6. TOTAL EARNED LESS RETAINAGE <br />(Line 4 less Line 5 Total) <br />7. LESS PRIOR CERTIFICATES FOR PAYMENT <br />(Line 6 from prior Certificate) <br />8. CURRENT PAYMENT DUE <br />9. BALANCE TO FINISH, INCLUDING RETAINAGE <br />(Line 3 less Line 6) <br />$178,890.00 <br />($9,731.49) <br />$169,158.51 <br />$166,199.51 <br />$7,842.45 <br />$7,842.45 <br />$158, 357.06 <br />$154, 089.53 <br />$4,267.53 <br />$10,801.45 <br />CHANGE ORDER SUMMARY <br />ADDITIONS <br />DEDUCTIONS <br />Total changes approved in previous months <br />$8,255.00 <br />$17,986.49 <br />Total approved this month <br />$0.00 <br />$0.00 <br />TOTALS <br />$8,255.00 <br />$17,986.49 <br />NET CHANGES by Change Orders <br />($9,731.49) <br />The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and <br />belief the Work covered by the Application for Payment has been completed in accordance with the <br />Contract Documents, that all amounts have been paid by the Contractor for Work for which previous <br />Certificates for Payment were issued and payments received from the Owner, and that current <br />payment shown herein is now due. <br />CONTRACTOR: <br />By: Jennifer Amenrud Date: 04/24/20 <br />State Of: <br />County Of: <br />Subscribed and sworn to before me this <br />Notary Public: <br />My commission expires: <br />ARCHITECTS CERTIFICATE FOR PAYMENT <br />day of <br />In accordance with the Contract Documents, based on the on -site observations and the data <br />compromising this application, the Architect certifies to the owner that to the best of the Architects <br />knowledge, information and belief the Work under the Architect's Contract has progressed as <br />indicated, the quality of Work is in accordance with the Contract Documents, and the Contractor is <br />entitled to payment of the AMOUNT CERTIFIED. <br />AMOUNT CERTIFIED $4,267.53 <br />(Attach explanation if amount certified differs from the amount applied for. Initial all figures on the <br />Application for Payment and on the Continuation sheet that are changes to conform to the amount <br />certified.) <br />ARCHITECT <br />By: Date: <br />The Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named <br />herein. Issuance, payment and acceptance of payment are without prejudice to any rights of the <br />Owner or Contractor under this Contract. <br />Page 1 of 1 <br />