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DocuSign Envelope ID: 27E728AB-E761-4D8D-8B46-447BC430C75D <br />APPLICATION FOR PAYMENT <br />To: RJM Construction, LLC. <br />830 Boone Avenue North <br />Golden Valley, MN 55427 <br />From: Ebert Construction <br />23350 County Road 10 <br />Corcoran, MN 55357 <br />Contract For: 195200033-024105 - Demolition <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 />Project: Elk River Multi -Purpose Facility and Lion <br />John Weicht Park <br />$223,800.00 <br />($16,335.60) <br />$207,464.40 <br />$207,464.40 <br />Application No.: <br />8 <br />Period To: <br />07/31/20 <br />Application Date: <br />07/17/20 <br />Project No.: <br />19520-0033 <br />Contract Date: <br />07/23/19 <br />Commitment: <br />195200033-024105 <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: Caleb Pelkey Date: 07/17/20 <br />State Of: <br />$10,373.22 County Of: <br />$10,373.22 <br />$197,091.18 <br />$194,069.57 <br />$3,021.61 <br />$10,373.22 <br />CHANGE ORDER SUMMARY <br />ADDITIONS <br />DEDUCTIONS <br />Total changes approved in previous months <br />$10,852.40 <br />$30,072.00 <br />Total approved this month <br />$2,884.00 <br />$0.00 <br />TOTALS <br />$13,736.40 <br />$30,072.00 <br />NET CHANGES by Change Orders <br />($16,335.60) <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 Architects 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 $3,021.61 <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 />