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Please Remit Payment to: RJM Construction, LLC <br />DocuSign Envelope ID: 22607B13-F901-4553-8DF1-B540099F82EA <br />APPLICATION AND CERTIFICATE FOR PAYMENT <br />CONSTRUCTION <br />Distribution to : <br />1-1 Owner <br />Architect <br />Q Contractor <br />C`1 -- N <br />O <br />N <br />CD N M M <br />Application No. <br />Project: 19520-0180 City of Ramsey Public Works <br />4,) <br />0 <br />0 <br />Period From: <br />Ramsey, MN 55303 <br />F-- <br />0 <br />4-- <br />c 0.. a) <br />9) a) as <br />O E a) t-- <br />L a) a) <br />C <br />U — >5 <br />«1 <br />a) o 0 <br />c <br />s -a <br />0 .0 O (a <br />Q M (1) <br />_a Q <br />a) u) <br />0 >,F- <br />.0 ai <br />..0 a) c c `0 <br />CD a) a) <br />!, 0 0 CO C <br />ai-©�'0 L = <br />C) 0 }_+ 42 U- L) <br />�4-.0 U , <br />c a) ` <br />U a) _c <br />-o U <br />u) <br />c:5) (0 <br />CLS <br />0 a. d <br />c <br />E o c a) <br />..0 0 U <br />F-- .2 (0 4 0 <br />U <br />(� <br />C <br />O <br />0 <br />a) <br />c <br />0 <br />U <br />a) <br />}-" C <br />z og <br />.c <br />>- <br />Q 0 <br />EL a3 <br />o <br />o <br />a)� <br />a) <br />--� ao <br />CL al al <br />CL <br />0 �) <br />(J) a) a) <br />CL (i) <br />o E <br />U <br />c <br />F— U <br />Q .C� C <br />C.)< U <br />RJM Construction LLC <br />Z <br />0 <br />$16,361,624.00 <br />d <br />0 <br />0 <br />0 <br />O <br />0 <br />m <br />a) <br />O) <br />0 <br />z <br />N <br />$16,361,624.00 <br />3. Contract Sum To Date <br />0 <br />C O <br />U -C3 <br />O c) <br />CO O <br />O <br />(5) 69 <br />cD <br />6) <br />mot' <br />CO <br />5 <br />(1) <br />0 <br />0 <br />0 as <br />al <br />a) <br />E O <br />U U) <br />o 0 <br />a) <br />CD <br />al L <br />(33 o U <br />ro <br />c <br />0 <br />(13 <br />U <br />Q <br />() <br />0 <br />a) <br />CD U) <br />U <br />(B <br />Co ' F• <br />ca -o~ oo id .� <br />to a)O <br />a) C a C Q i4) <br />- 0. (C5 <br />a o 2) <br />FT).� CIO . _ <br />o <br />U U W o <br />co 5 LL >- Ili <br />o <br />a) <br />c c -0 U Cs co a <br />03 <br />c c ~ p N <br />o .2 (0 c� Z !L ' <br />C <br />o c O 0 0 I..* co <br />1:50 - Q <br />E � <br />< <br />{.j t-= <br />— <br />c •o 0 c o <br />O CL <br />F- <br />U (8.�.� o <br />a) `o c W <br />_c o 7--) a) U <br />' <br />_o a) <br />as � Q) >5 - <br />O a) O ��-. a <br />U c ,-- U <br />C SG O O W <br />• O 0 (a a) _ <br />.c a) <br />0 c. a-c U <br />(a E 0 a) a) CL <br />c (Q. .(n Q <br />O Lc) co <br />co ice- t-- <br />N o0 (6 <br />cc s— O <br />a� (N <br />CO CO <br />CO CO CO <br />N �c-- <br />Total Retainage <br />• <br />• <br />7. Less Previous Certificates For Payments <br />AMOUNT CERTIFIED <br />N <br />CO <br />N <br />N <br />rn <br />0) <br />0 <br />8. Current Payment Due <br />9. Balance To Finish, Plus Retainage <br />(0 <br />(0 <br />c <br />a) <br />ccs <br />U <br />n <br />0) <br />as <br />Deductions <br />0 <br />0 <br />0 <br />co <br />0 <br />co <br />0 <br />0 <br />0 <br />O <br />O <br />p <br />p <br />C <br />64 <br />0 <br />0 <br />Q <br />CHANGE ORDER SUMMARY <br />Total changes approved <br />in previous months by Uwner <br />Total Approved this Month <br />TOTALS <br />Net Changes By Change Order <br />