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5,080.60 <br />78,450.00 <br />45,349.00 <br />123,799.00 <br />99,389.00 <br />4,969.45 <br />94,419.55 <br />89,338.95 <br />0.00 <br />0.00 <br />99,389.00 <br />Page 1 <br />Certificate of the Subcontractor: <br /> <br />I hereby certify that the work performed and the materials supplied to date as shown on the above represent the actual value of accomplishment under the terms of the contract (and all authorized <br />changes thereto) between the undersigned and H+U Construction relating to the above-referenced project. <br /> <br />I also certify that Payments, less applicable retention, have been made through the period covered by previous payments received from the contractor, to (1) all my subcontractors (sub-subcontractors) <br />and (2) for all materials and labor used in connection with the performance of this contract. <br /> <br /> I further certify I have complied with Federal, State and Local tax laws, including Social Security laws and unemployment laws and Workmen's Compensation laws insofar as applicable to the <br />performance of this contract. <br />Furthermore, in consideration of this request of the payments received and upon receipt of the amount of this request, the undersigned does hereby waive, release, and relinquish all claims or right of lien <br />which the undersigned may now have upon the premises above described except for claims or right of lien for contract and/or change order work performed to the extent that payment is being retained or will <br />subsequently become due. <br />Original contract sum <br />Net change by change orders (as per attached breakdown) <br />Contract sum to date <br />Completed to date (as per attached breakdown) <br />Total retainage (5.0%) <br />Total earned less retainage <br />Less previous certificates of payment <br />Sales tax at 0.000% on 0.00 <br />Amount of this request <br />Stored material (as per attached breakdown) <br />Total completed and stored to date <br />Subtotal 5,080.60 <br />Empirehouse Inc. <br />5200 Quincy Street <br />Mounds View, MN 55112 <br />To: <br />From: <br />Phone: <br />Project:Lake Elmo City Center (L) <br />3880 Laverne Avenue N. <br />Lake Elmo, MN 55042 <br />Application No: 8 Date: 02/01/23 <br />Period To: 02/28/23 <br />Contract For: <br />Contract Date: <br />Contractor Job <br />Number:21152 <br />Date: __________________________________ <br />Subscribed and sworn to before me this _ _ day <br /> <br />of ____________, _________ (year). <br /> <br />Notary public: _____________________________ <br /> <br />My commission expires _ _. <br />Contractor: Empirehouse Inc. <br />By: ____________________________________ <br />Title: ___________________________________ <br />(763) 535-1150 <br />Application and Certificate For Payment <br />H+U Construction <br />5555 West 78th Street <br />Suite A <br />Edina, MN 55439 <br />Date: __________________________________ <br />Subscribed and sworn to before me this __ _ day <br /> <br />of ____________, _________ (year). <br /> <br />Notary public: _____________________________ <br /> <br />My commission expires _ _. <br />Contractor: Empirehouse Inc. <br />By: ____________________________________ <br />Title: ___________________________________ <br />Date: __________________________________ <br />Subscribed and sworn to before me this __ _ day <br /> <br />of ____________, _________ (year). <br /> <br />Notary public: _____________________________ <br /> <br />My commission expires _ _. <br />Contractor: Empirehouse Inc. <br />By: ____________________________________ <br />Title: ___________________________________ <br />February 2023 <br />Kristine Hutera, CEO <br />20 <br />February 20, 2023 <br />January 31, 2025