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DocuSign Envelope ID: 27E72&A13£761aD8D-8646447BC430C75D
<br />'
<br />420-4-8540-4520
<br />rPlease Remit Psym Construction, LLC
<br />830 Boone Ave North
<br />Golden Valley, MN 56427
<br />APPLICATION AND CERTIFICATE FOR PAYMENT
<br />To Owner City of Elk River
<br />Protect:19520.0033 Elk River Multi -Purpose Facility and Lion John
<br />Invoice #:
<br />9520003313
<br />Distribution to
<br />Attn: Justin Femdte
<br />SAM Street NW
<br />Application No.:
<br />13
<br />F-1 Owner
<br />13D65 Orono Parkway
<br />Elk River, MN 55330
<br />Appleation Date:
<br />713IJ2020
<br />LM Architect
<br />CJ Contractor
<br />Elk River, MN 55330
<br />Architect:
<br />Period From:
<br />711020
<br />To:
<br />713112020
<br />CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge,
<br />information, and belief, the work covered by this Application for Payment has been completed in
<br />Application is made for payment, as shown below, in connectwn with the Contract accordance with the Contract Documents. That all amounts have been paid by the Contractor for Work for
<br />Continuation Sheet is attached, which previous Certificates for Payment were issued and payments received from the Owner, and that
<br />current payment shown herein is now due.
<br />1. original Contract sum .......... . . . .... . ...
<br />$25,934,028.00
<br />2_ Net Change By Change Order ............ . .......
<br />$567,579.40
<br />3. Contract Sum To Date ..........................
<br />$26,501,607.40
<br />4. Total Completed and Stored To Date. .... ........
<br />$25,814,434.02
<br />5. Retainage:
<br />a. 4.71% of Completed Work $1,216,119.09
<br />to. 0.00% of Stored Material
<br />S0.00
<br />Total Retainage .............. .
<br />$1,216,119.09
<br />6. Total Earned Less Retainage ......................
<br />$24,598,314.93
<br />7. Less Previous Certificates For Payments ............
<br />$23,214,682.71
<br />8. Current Payment Due ...........................
<br />$1,383,632.22
<br />9. Balance To Finish, Plus Retainage ...... .. ......
<br />$1,903,292.47
<br />CHUNK E ORDER SUMMARY
<br />D _
<br />Total charges $956,343.73
<br />F strir
<br />$388,764.33
<br />Total Approved this Month $0.00
<br />$0.D0
<br />TOTALS $956,343.73
<br />$388,764,33
<br />Net Changes By Change Order $567,579.40
<br />CONTRACTOR: RJM Construction LLC
<br />" 8/10/2020
<br />y: [1: Date:
<br />State of: County of:
<br />Subscribed and sworn to before me this day of
<br />Notary Public:
<br />My Commission expires:
<br />In accordance with the Contract Documents, based on on -site observations and the data
<br />comprising the above application, the Architect corollas to the Owner that to the best of the
<br />Architects knowledge. information, and belief, the Work has progressed as indicated,
<br />the quality of the Work is in accordance with the Contract Documents, and the Contractor
<br />is entitled to payment of the AMOUNT CERTIFIED.
<br />ARCHITECT'S CERTIFICATE FOR PAYMENT
<br />AMOUNT CERTIFIED $1,383,632.22
<br />(Attach o"nafioo 1f amount omftd differs from the amount apphod. lnidial all figures on this Applicatim and
<br />on the Continuation Sheet that are changed to conform w9h the amount cerfiffed.)
<br />ARCHITECT:
<br />By: JW" M446- Date: 8110/20
<br />This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
<br />Contractor named herein. Issuance, payment, and acceptance of payment are without
<br />ongudice to any rights of the Owner or Contractor under this Contract.
<br />
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