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DocuSign Envelope ID: B21CAEBD-7600-4BB5-BB91-7BFCFA6AOB90 <br />APPLICATION AND CERTIFICATE FOR PAYMENT <br />Page 1 of <br />2 <br />SUBMITTED TO: RJM Construction, LLC PROJECT, Elk River Multi -Purpose Facilities <br />APPLICATION 1\110: <br />6 <br />830 Boone Avenue North 1000 School Street North <br />APPLICATION DATE_ <br />911/2020 <br />Golden Valley, MIN 55427 Elk River, MN <br />PERIOD FROM: <br />712712020 <br />SUBMITTED FROM: Quality Cutting & Caring, Inc ARCHITECT: <br />PERIOD TO: <br />812412020 <br />1471 9st Ave. N.E., Blaine, MN 55449 <br />PROJECT NO: <br />19520-0033 <br />CONTRACT DATE: <br />CONTRACT FOR: concrete cutting CONTRACT NO.: 19520-0033 <br />COMMITMENT: <br />YES/NO <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 - <br />referenced project. I further certify that no labor or materials have been supplied under <br />contracts, agreements, verbal or written, or any other arrangement of any type whatsoever. other <br />than the contract duly authorized and executed change orders, and the undersigned does hereby <br />releases RJM Construction from any claim or liability therefor for the period covered by this <br />application. I also certify that payments, less applicable retention, have been made through the <br />period covered by previous payments received from the contractor to 1) all my subcontractors <br />(sub -subcontractors) and 2) for all material and labor used in or in connection with the <br />performance of this contract. I further certify that I have complied with Federal, State, and local <br />tax laws, including Social Security laws, Unemployment Compensation Laws and Workman I s <br />Compensation laws insofar as applicable to the performance this contract. <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 rner-hanio'F, 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 helshe is fully authorized and empowered to <br />execute this instrument and to bird the undersigned hereto, and does in fact so execute this <br />instrument. <br />Quality Cutting & Coring, Inc, <br />1471 9st Ave. N.E., Blaine, MIN 55449 <br />SIGNED: <br />PRINTED, TITLE Karl L. Landrus, President <br />ORIGINAL CONTRACT SUM, . .................................. ....... ....... $ 117764.00 <br />NET CHANGE BY CHANGE ORDERS TO, ............... __ , $ 9,655.00 <br />CONTRACT SUM TO DATE.........._ . _ ............ ......... ...... ....... $ 27,419.00 <br />TOTAL COMPLETED AND STORED TO DATE..... ....... ......... ....... . ......... $ 27,41900 <br />5 % OF COMPLETED WORK $ 1,370.95 <br />5 0,/o OF STORED MATERIAL $ - <br />TOTAL RETAINAGE ............ .. .. ...... ............ 1,370.95 <br />TOTAL EARNED LESS RETAINAGE ..... ....... . ....... 26,048.05_ <br />LESS OWNER DIRECT PAYMENT BY PURCHASE ORDER... ....... .......... <br />LESS PREVIOUS CERTIFICATES FOR PAYMENT___ ............. ..... ....... $ 21 239.15 <br />CURRENT PAYMENT DUE ............. ....... ........ ........ ............... . . 4.808.90 <br />BALANCE TO FINISH INCLUDING RETAINAGE................... .......... 1,370.95 <br />State of: Minnesota <br />County of: <br />Subscribed and sworn to before me this <br />I day of 20 <br />NOTARY PUBLIC: <br />Tela Lee Souten <br />Signed: <br />N-,, �-- lublic <br />My Commission Expires: <br />Minnesota 2 <br />oaDU jgquafy3t2 202IL <br />