4.3. SR 09-21-2020 - Laserfiche WebLink

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APPLICATION FOR PAYMENT To: RJM Construction, LLC. 830 Boone Avenue North Golden Valley, MN 55427 From: Ebert Construction 23350 County Road 10 Corcoran, MN 55357 Contract For: 195200033-064015 - Carpentry 1. ORIGINAL CONTRACT AMOUNT 2. NET CHANGE BY CHANGE ORDERS 3. CONTRACT SUM TO DATE 4. TOTAL COMPLETED AND STORED TO DATE (Column G) 5. RETAINAGE 5.00% of Completed Work (Columns D + E) 5.00% of Stored Materials (Columns F) Total Retainage (Line 5a + Line 5b OR Sum of Column 1) 6. TOTAL EARNED LESS RETAINAGE (Line 4 less Line 5 Total) 7. LESS PRIOR CERTIFICATES FOR PAYMENT (Line 6 from prior Certificate) 8. CURRENT PAYMENT DUE 9. BALANCE TO FINISH, INCLUDING RETAINAGE (Line 3 less Line 6) Project: Elk River Multi -Purpose Facility and Lion John Weicht Park $546,800.00 ($30,158.54) $516,641.46 $516,641.46 $25,832.09 $25,832.09 $490,809.37 $491,306.01 ($496.64) $25,832.09 CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS Total changes approved in previous months $1,976.48 $21,720.00 Total approved this month $8,303.41 $18,718.43 TOTALS 1 $10,279.89 $40,438.43 NET CHANGES by Change Orders ($30,158.54) Application No.: 9 Period To: 08/31/20 Application Date: 08/19/20 Project No.: 19520-0033 Contract Date: 11/12/19 Commitment: 195200033-064015 The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and belief the Work covered by the Application for Payment has been completed in accordance with the Contract Documents, that all amounts have been paid by the Contractor for Work for which previous Certificates for Payment were issued and payments received from the Owner, and that current payment shown herein is now due. CONTRACTOR: By: Caleb Pelkey Date: 08/19/20 State Of: County Of: Subscribed and sworn to before me this Notary Public: My commission expires: ARCHITECTS CERTIFICATE FOR PAYMENT day of In accordance with the Contract Documents, based on the on -site observations and the data compromising this application, the Architect certifies to the owner that to the best of the Architects knowledge, information and belief the Work under the Architect's Contract has progressed as indicated, the quality of Work is in accordance with the Contract Documents, and the Contractor is entitled to payment of the AMOUNT CERTIFIED. AMOUNT CERTIFIED ($496.64) (Attach explanation if amount certified differs from the amount applied for. Initial all figures on the Application for Payment and on the Continuation sheet that are changes to conform to the amount certified.) ARCHITECT: By: Date: The Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract. Page 1 of 1