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DocuSign Envelope ID: BCE22727-B3F4-40B7-AA4D-8AA95B6A8D07 <br />APPLICATION FOR PAYMENT <br />To: RJM Construction, LLC. Project: Elk River Multi -Purpose Facility and Lion <br />Application No.: <br />11 <br />830 Boone Avenue North John Weicht Park <br />Golden Valley, MN 55427 <br />Period To: <br />11/30120 <br />From: Kendall Doors $ Hardware, Inc. <br />Application Date: <br />11/30/20 <br />1312 Northland Drive <br />Project No.: <br />19520-0033 <br />Suite 100 <br />Contract Date: <br />11l13/19 <br />Mendota Heights, MN 55120 <br />Contract For: 195200033-081105 - Hollow Metal Doors & <br />Commitment: <br />195200033-081105 <br />Frames <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 />- of Completed Work <br />(Columns 0 + E) <br />- of Stored Materials <br />(Columns F) <br />Total Retalnage <br />(Line So + 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 />$92,614.00 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 />$202,997.35 Contract Documents, that all amounts have been paid by the Contractor for Work for which previous <br />Certificates for Payment were issued and payments reoe'wed from the Owner, and that current <br />$295,611.35 payment shown herein is now due. <br />$295,611.35 CONTRACTOR: <br />By: Jason Self Date: 12/02/20 <br />$0.00 <br />State Of: <br />County Of: <br />Subscribed and swom to before me this day of <br />Notary Public: <br />My commission expires: <br />ARCHITECTS CERTIFICATE FOR PAYMENT <br />$295,611.35 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 Archltecfa Contract has progressed as <br />indicated, the quality of Work is In accordance with the Contract Documents, and the Contractor is <br />$294,803.13 entitled to payment of the AMOUNT CERTIFIED. <br />$808.22 <br />$0.00 <br />CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS <br />Total changes approved in previous months $203,511.63 $1,322.50 <br />Total approved this month $808.22 $0.00 <br />TOTALS $204,319.85 $1,322.50 <br />NET CHANGES by Change Orders $202,997.35 <br />AMOUNT CERTIFIED $808.22 <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 shoat 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 />