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#03 - City Center-Public Works Pay Request 7
STAFF REPORT DATE: August 16, 2022 CONSENT AGENDA ITEM: City Center-Public Works Addition Pay Request #7 SUBMITTED BY: Kristina Handt, City Administrator BACKGROUND: At the November 3rd meeting, Council awarded bids for the new city center and public works addition. Also established at that time was Guaranteed Maximum Price (GMP) with H+U for construction costs. The GMP was $13,402,788. ISSUE BEFORE COUNCIL: Should Council approve Pay Request #7 for the City Center and Public Works Addition project? PROPOSAL: Pay request #7 is for $1,106,163.49. A copy is included in your packet. FISCAL IMPACT: With this pay request, the project remains within budget. OPTION: 1) Approve pay request #7 2) Don’t approve pay request #7 RECOMMENDATION: “Motion to approve Pay Request #7 for the New City Center and Public Works Addition.” ATTACHMENTS: • Pay Request #7 APPLICATION AND CERTIFICATE FOR PAYMENTTO (OWNER): PROJECT:LAKE ELMO CITY HALL, FIRE DEPARTMENT APPLICATION NO: 7Distribution to:City of Lake Elmo & PUBLIC WORKS FACILITIES REMODELXOWNER3880 Laverne Ave N PERIOD TO:7/31/2022Lake Elmo, MN 55042ARCHITECT FROM (CM): OVERALLCONST. MANAGERHOFFMANN + UHLHORN CONSTRUCTION, INC.5555 W 78TH ST, SUITE AXFILEMINNEAPOLIS, MN 55439CONTRACT DATE:APPLICATION FOR PAYMENTApplication is made for Payment, as shown below,CHANGE ORDER SUMMARYContinuation Sheet, AIA Document G703, is attached.Change Orders Approved inADDITIONSDEDUCTIONS1. COMMITTED COST$13,402,788.00previous months by Owner2. Net Change by Change Orders$0.00TOTAL$0.00$0.003. SUM TO DATE (Line 1+2)$13,402,788.00Approved this Month4. TOTAL COMPLETED & STORED TO DATE $3,564,544.52NumberDate Approved (Column G on G703) 5. RETAINAGE:$0.00$0.00 a. _5_ % of Completed Work$178,227.22 (Column D+E on G703) b. ___ % of Stored Material$0.00 (Column F on G703)Total Retainage (Line 5a + 5b or Total in Column I of G703)$178,227.22TOTALS$0.00$0.006. TOTAL EARNED LESS RETAINAGE$3,386,317.30Net change by Change Orders$0.00 (Line 4 less Line 5 Total)The undersigned Construction Manager certifies that to the best of his 7. LESS PREVIOUS CERTIFICATES FORknowledge, information and belief the Work covered by this Application for PAYMENT (Line 6 from prior Certificate)$2,280,153.81Payment has been completed in accordance with the Contract Documents, 8. CURRENT PAYMENT DUE$1,106,163.49and that current payments shown herein are now due.9. BALANCE TO FINISH, PLUS RETAINAGE $10,016,470.70 (Line 3 less Line 6)CONSTRUCTION MANAGER:HOFFMANN + UHLHORN CONSTRUCTION, INC.State of: MINNESOTACounty of:Anoka County Subscribed and sworn to before me this 8/4/2022Notary Public:By:Date:8/4/2022My Commission expires:31-Jan-23ARCHITECT'S CERTIFICATE FOR PAYMENTAMOUNT CERTIFIED$In Accordance with the Contract Documents, based on on-site observations and the(Attach explaination if amount certified differs from the amount applied for).data comprising the above application, the Architect certifies to the Owner that to theARCHITECT:best of the Architect's knowledge, information and belief the Work has progressed asindicated, the quality of the Work is in accordance with the Contract Documents, andBy:Date:the Contractors are entitled to payment of the Amounts Certified.WASHINGTON COUNTY SHERRIFF SUBSTATION2022-08-09LEO A DALY CITY OF LAKE ELMO - OVERALLAPPLIC. FOR PAYMENT NO.#7H+U CONSTRUCTION EDITION OF AIA DOCUMENT G703PERIOD ENDING 7/31/2022 AIA Document G723,APPLICATION AND CERTIFICATE FOR PAYMENT, containing Contractor's signed Certification is attached.In tabulations below, amounts are stated to the nearest dollar. ABCDEF GHITEMDESCRIPTION OF WORKSCHEDULEDCHANGEREVISED WORK COMPLETEDTOTAL%BALANCERETAINAGENO.VALUEORDERSSCHEDULEFROMTHIS PERIODCOMPLETED(F/C)TO FINISHVALUEPREV. APPL.AND STORED(C-F)(A+B) TO DATE (D+E)InsuranceBuilders Risk Insurance25,000.000.0025,000.0021,204.000.0021,204.0085%3,796.001,060.200Payment and Performance Bond127,464.000.00127,464.00127,424.000.00127,424.00100%40.006,371.201General Conditions243,080.000.00243,080.0034,425.815,503.1539,928.9616%203,151.041,996.45ReimburseConstruction Management Reimbursables488,555.000.00488,555.00170,043.7532,140.00202,183.7541%286,371.2510,109.19FeeConstruction Management Fee82,595.000.0082,595.0015,500.317,519.6123,019.9228%59,575.081,151.00TrailerTemporary City Office Trailer53,170.000.0053,170.0026,016.992,458.8928,475.8854%24,694.121,423.79ContingencyConstruction Contingency588,330.00(47,919.34)540,410.660.000.000.000%540,410.660.00TestingTesting & Special Inspections28,000.000.0028,000.000.000.000.000%28,000.000.00#0330Cast-In-Place Concrete668,316.0011,438.00679,754.00110,000.00213,038.00323,038.0048%356,716.0016,151.90#0341Strutctural Precast1,755,999.000.001,755,999.00381,004.00343,994.55724,998.5541%1,031,000.4536,249.93#0510Steel Erection93,400.000.0093,400.0016,000.000.0016,000.0017%77,400.00800.00#0512Steel Supply485,000.009,215.00494,215.00251,409.187,375.00258,784.1852%235,430.8212,939.21#0610Carpentry & GC1,027,000.000.001,027,000.00197,436.5411,000.00208,436.5420%818,563.4610,421.83#0750Roofing & Metal Panels1,113,300.000.001,113,300.000.00243,465.00243,465.0022%869,835.0012,173.25#0790Caulking & Firestopping72,350.000.0072,350.000.000.000.000%72,350.000.00#0810Doors, Frames, Hardware - Supply171,697.000.00171,697.000.000.000.000%171,697.000.00#0833Coiling & Sectional Doors350,000.000.00350,000.000.000.000.000%350,000.000.00#0840Aluminum Storefronts & Curtainwall400,410.000.00400,410.0014,955.006,250.0021,205.005%379,205.001,060.25#0920Drywall & Fireproofing543,770.0025,699.00569,469.0093,000.0031,000.00124,000.0022%445,469.006,200.00#0930Tile154,980.000.00154,980.000.000.000.000%154,980.000.00#0950Acoustical Ceilings & Panels126,000.000.00126,000.000.000.000.000%126,000.000.00#0965Resilient Flooring & Carpet131,940.000.00131,940.0089,940.000.0089,940.0068%42,000.004,497.00#0990Painting and Wallcovering157,727.000.00157,727.000.000.000.000%157,727.000.00#1420Conveying Equipment82,000.000.0082,000.0021,577.000.0021,577.0026%60,423.001,078.85#2100Fire Protection112,915.000.00112,915.005,796.000.005,796.005%107,119.00289.80#2200Plumbing & Heating854,000.000.00854,000.00177,227.16194,200.93371,428.0943%482,571.9118,571.40#2300HVAC & Controls962,000.000.00962,000.00101,898.150.00101,898.1511%860,101.855,094.91#2600Electrical1,454,170.00(3,227.66)1,450,942.34126,235.0051,325.00177,560.0012%1,273,382.348,878.00#3100Earthwork & Site Utilities575,790.004,795.00580,585.00406,860.0015,112.50421,972.5073%158,612.5021,098.63#3210Asphalt Paving317,200.000.00317,200.0012,209.000.0012,209.004%304,991.00610.45#3290Landscaping & Fencing144,630.000.00144,630.000.000.000.000%144,630.000.00#TBDHoist12,000.000.0012,000.000.000.000.000%12,000.000.00TOTAL CONTRACT AMOUNTS13,402,788.000.0013,402,788.002,400,161.891,164,382.633,564,544.5227%9,838,243.48178,227.22 APPLICATION AND CERTIFICATE FOR PAYMENTTO (OWNER): PROJECT:LAKE ELMO CITY HALL, FIRE DEPARTMENT APPLICATION NO: 7Distribution to:City of Lake Elmo & PUBLIC WORKS FACILITIES REMODELXOWNER3880 Laverne Ave N PERIOD TO:7/31/2022Lake Elmo, MN 55042ARCHITECT FROM (CM): LABORCONST. MANAGERHOFFMANN + UHLHORN CONSTRUCTION, INC.5555 W 78TH ST, SUITE AXFILEMINNEAPOLIS, MN 55439CONTRACT DATE:APPLICATION FOR PAYMENTApplication is made for Payment, as shown below,CHANGE ORDER SUMMARYContinuation Sheet, AIA Document G703, is attached.Change Orders Approved inADDITIONSDEDUCTIONS1. COMMITTED COST$6,492,541.00previous months by Owner2. Net Change by Change Orders$0.00TOTAL$0.00$0.003. SUM TO DATE (Line 1+2)$6,492,541.00Approved this Month4. TOTAL COMPLETED & STORED TO DATE $1,392,391.82NumberDate Approved (Column G on G703) 5. RETAINAGE:$0.00$0.00 a. _5_ % of Completed Work$69,619.58 (Column D+E on G703) b. ___ % of Stored Material$0.00 (Column F on G703)Total Retainage (Line 5a + 5b or Total in Column I of G703)$69,619.58TOTALS$0.00$0.006. TOTAL EARNED LESS RETAINAGE$1,322,772.24Net change by Change Orders$0.00 (Line 4 less Line 5 Total)The undersigned Construction Manager certifies that to the best of his 7. LESS PREVIOUS CERTIFICATES FORknowledge, information and belief the Work covered by this Application for PAYMENT (Line 6 from prior Certificate)$1,044,095.34Payment has been completed in accordance with the Contract Documents, 8. CURRENT PAYMENT DUE$278,676.90and that current payments shown herein are now due.9. BALANCE TO FINISH, PLUS RETAINAGE $5,169,768.76 (Line 3 less Line 6)CONSTRUCTION MANAGER:HOFFMANN + UHLHORN CONSTRUCTION, INC.State of: MINNESOTACounty of:Anoka County Subscribed and sworn to before me this 8/4/2022Notary Public:By:Date:8/4/2022My Commission expires:31-Jan-23ARCHITECT'S CERTIFICATE FOR PAYMENTAMOUNT CERTIFIED$In Accordance with the Contract Documents, based on on-site observations and the(Attach explaination if amount certified differs from the amount applied for).data comprising the above application, the Architect certifies to the Owner that to theARCHITECT:best of the Architect's knowledge, information and belief the Work has progressed asindicated, the quality of the Work is in accordance with the Contract Documents, andBy:Date:the Contractors are entitled to payment of the Amounts Certified.WASHINGTON COUNTY SHERRIFF SUBSTATION2022-08-09LEO A DALY CITY OF LAKE ELMO - LABOR & GENERAL CONDITIONSAPPLIC. FOR PAYMENT NO.#7H+U CONSTRUCTION EDITION OF AIA DOCUMENT G703PERIOD ENDING 7/31/2022 AIA Document G723,APPLICATION AND CERTIFICATE FOR PAYMENT, containing Contractor's signed Certification is attached.In tabulations below, amounts are stated to the nearest dollar. ABCDEF GHITEMDESCRIPTION OF WORKSCHEDULEDCHANGEREVISED WORK COMPLETEDTOTAL%BALANCERETAINAGENO.VALUEORDERSSCHEDULEFROMTHIS PERIODCOMPLETED(F/C)TO FINISHVALUEPREV. APPL.AND STORED(C-F)(A+B) TO DATE (D+E)InsuranceBuilders Risk Insurance25,000.000.0025,000.0021,204.000.0021,204.0085%3,796.001,060.200Payment and Performance Bond127,464.000.00127,464.00127,424.000.00127,424.00100%40.006,371.201General Conditions243,080.000.00243,080.0034,425.815,503.1539,928.9616%203,151.041,996.45ReimburseConstruction Management Reimbursables488,555.000.00488,555.00170,043.7532,140.00202,183.7541%286,371.2510,109.19FeeConstruction Management Fee82,595.000.0082,595.0015,500.317,519.6123,019.9228%59,575.081,151.00TrailerTemporary City Office Trailer53,170.000.0053,170.0026,016.992,458.8928,475.8854%24,694.121,423.79ContingencyConstruction Contingency588,330.00(47,919.34)540,410.660.000.000.000%540,410.660.00TestingTesting & Special Inspections28,000.000.0028,000.000.000.000.000%28,000.000.00#0330Cast-In-Place Concrete428,316.0011,438.00439,754.0050,000.00153,038.00203,038.0046%236,716.0010,151.90#0341Strutctural Precast333,704.000.00333,704.000.000.000.000%333,704.000.00#0510Steel Erection93,400.000.0093,400.0016,000.000.0016,000.0017%77,400.00800.00#0610Carpentry & GC459,000.000.00459,000.00178,636.546,000.00184,636.5440%274,363.469,231.83#0750Roofing & Metal Panels614,800.000.00614,800.000.000.000.000%614,800.000.00#0790Caulking & Firestopping54,050.000.0054,050.000.000.000.000%54,050.000.00#0833Coiling & Sectional Doors175,000.000.00175,000.000.000.000.000%175,000.000.00#0840Aluminum Storefronts & Curtainwall78,450.000.0078,450.0010,375.000.0010,375.0013%68,075.00518.75#0920Drywall & Fireproofing314,360.0016,224.00330,584.0043,000.0016,000.0059,000.0018%271,584.002,950.00#0930Tile86,880.000.0086,880.000.000.000.000%86,880.000.00#0950Acoustical Ceilings & Panels51,000.000.0051,000.000.000.000.000%51,000.000.00#0965Resilient Flooring & Carpet41,010.000.0041,010.000.000.000.000%41,010.000.00#0990Painting and Wallcovering128,196.000.00128,196.000.000.000.000%128,196.000.00#1420Conveying Equipment35,260.000.0035,260.000.000.000.000%35,260.000.00#2100Fire Protection55,395.000.0055,395.005,796.000.005,796.0010%49,599.00289.80#2200Plumbing & Heating363,000.000.00363,000.00103,600.1629,056.96132,657.1237%230,342.886,632.86#2300HVAC & Controls300,000.000.00300,000.0012,148.150.0012,148.154%287,851.85607.41#2600Electrical646,070.00(2,100.00)643,970.0041,130.0028,815.0069,945.0011%574,025.003,497.25#3100Earthwork & Site Utilities366,400.004,245.00370,645.00242,155.0012,812.50254,967.5069%115,677.5012,748.38#3210Asphalt Paving136,566.000.00136,566.001,592.000.001,592.001%134,974.0079.60#3290Landscaping & Fencing83,490.000.0083,490.000.000.000.000%83,490.000.00#TBDHoist12,000.000.0012,000.000.000.000.000%12,000.000.00TOTAL CONTRACT AMOUNTS6,492,541.000.006,474,428.661,099,047.71293,344.111,392,391.8222%5,082,036.8469,619.58 INVOICE SUMMARY-PAYMENT APPLICATION NO. #7CITY OF LAKE ELMO - LABOR & GENERAL CONDITIONSPERIOD ENDING 7/31/2022ITEM NO# DESCRIPTION VENDORDATENUMBERAMOUNTRETAINAGEDUE1General ConditionsH+U Construction7/31/22Applic #7$5,503.15$275.16$5,227.99ReimburseConstruction Management ReimbursablesH+U Construction7/31/22Applic #7$32,140.00$1,607.00$30,533.00FeeConstruction Management FeeH+U Construction7/31/22Applic #7$7,519.61$375.98$7,143.63TrailerTemporary City Office TrailerH+U Construction7/31/22Applic #5$2,458.89$122.94$2,335.95#0330Cast-In-Place ConcreteAxel H. Ohman, Inc.7/31/22Applic #2$153,038.00$7,651.90$145,386.10#0610Carpentry & GCEbert Construction7/31/22Applic #8$6,000.00$300.00$5,700.00#0920Drywall & FireproofingCommercial Drywall7/31/22Applic #4 & #5$16,000.00$800.00$15,200.00#2200Plumbing & HeatingPeterson Sheet Metal7/31/22Applic #3$29,056.96$1,452.85$27,604.11#2600ElectricalVinco, Inc.7/31/22Applic #5$28,815.00$1,440.75$27,374.25#3100Earthwork & Site UtilitiesPark Construction Company7/31/22Applic #4$12,812.50$640.63$12,171.87SUBTOTAL AMOUNT DUE$293,344.11$14,667.21$278,676.90 TOTAL AMOUNT DUE $278,676.90 INVOICE : 220208 PROJECT: J21001 JULY 31, 2022 PAGE 1 OF 2 TO:CITY OF LAKE ELMO 3880 Laverne Ave N Lake Elmo, MN 55042 ATTN:ACCOUNTING RE:LAKE ELMO CITY CENTER & LAKE ELMO PUBLIC WORKS ADDITION Invoice for Construction Management services performed during the month of July, 2022 CONSTRUCTION MANAGEMENT REIMBURSABLES Project Director 1.25 hrs. @ 150.00 $187.50 Project Controller 3.00 hrs. @ 125.00 $375.00 Senior Project Manager 59.50 hrs. @ 125.00 $7,437.50 Project Manager 59.00 hrs. @ 105.00 $6,195.00 Project Administrator/Accountant 19.00 hrs. @ 65.00 $1,235.00 Project Superintendent 142.00 hrs. @ 105.00 $14,910.00 Truck, Travel, & Small Tools 1 mo. @ 1,400.00 $1,400.00 Field Office Equipment 1 mo. @ 400.00 $400.00 $32,140.00 GENERAL CONDITIONS Temporary City Office Trailer $2,458.89 Plan Prints/Shipping $149.26 Expendable Supplies $90.48 Drinking Water $8.59 Temporary Toilets $193.28 Equipment Rental $1,057.16 Xcel Energy - Utility Service $133.15 Trash Removal $485.00 Scaffold Rental $236.23 Mobilize Trailer $1,350.00 Mobilize Skid Steer $1,800.00 $7,962.04 $40,102.04 Subtotal Construction Management Reimbursables Subtotal Reimbursable Expenses Total INVOICE : 220208 PROJECT: J21001 JULY 31, 2022 PAGE 2 OF 2 TO:CITY OF LAKE ELMO 3880 Laverne Ave N Lake Elmo, MN 55042 ATTN:ACCOUNTING RE:LAKE ELMO CITY CENTER & LAKE ELMO PUBLIC WORKS ADDITION Contractor's Pay Applications July 31, 2022 #0330-Labor Axel H. Ohman, Inc.$153,038.00 #0330-Material Axel H. Ohman, Inc.$60,000.00 #0341-Material Wells Concrete $343,994.55 #0512-Material Construction Systems, Inc.$7,375.00 #0610-Labor Ebert Construction $6,000.00 #0610-Material Ebert Construction $5,000.00 #0750-Material Palmer-West Construction $243,465.00 #0840-Material Empirehouse Inc.$6,250.00 #0920-Labor Commercial Drywall, Inc.$16,000.00 #0920-Material Commercial Drywall, Inc.$15,000.00 #2200-Labor Peterson Sheet Metal, Inc.$29,056.96 #2200-Material Peterson Sheet Metal, Inc.$165,143.97 #2600-Labor Vinco, Inc.$28,815.00 #2600-Material Vinco, Inc.$22,510.00 #3100-Labor Park Construction Company $12,812.50 #3100-Material Park Construction Company $2,300.00 $1,116,760.98 $7,519.61 $1,164,382.63 Retainage Current Retainge 58,219.14 Prior Retainage 120,008.08 Retainage-To-Date 178,227.22 Total Amount Due $1,106,163.49 CONSTRUCTION MANAGEMENT FEE Total Contractor's Pay Applications July 1 - July 31 Total Before Retainage Customer No. C51148 H U Construction 5555 W78th St Suite A Minneapolis, MN 55439 Bill to:Ship to:City of Lake Elmo 24x60 Doublewide Office s/n 15809A/10B Gabe 651-395-0055 3800 Laverne Ave. North Lake Elmo, MN 55042 Satellite Quote No. RC520567 Contract No Matt Lawellin Salesperson 08/04/2022 Due Date Customer PO No. RQ152297 Lake Elmo DW Trailer Invoice No.: Invoice Date:07/05/2022 INV584468 Tracy DickensonAccount Rep: PO Box 860700 Minneapolis, MN 55486-0700 Phone: (763) 553-1900 Rental Insurance Status:Customer No. C51148 H U Construction 5555 W78th St Suite A Minneapolis, MN 55439 Bill to:Ship to:City of Lake Elmo 24x60 Doublewide Office s/n 15809A/10B Gabe 651-395-0055 3800 Laverne Ave. North Lake Elmo, MN 55042 Satellite Quote No. RC520567 Contract No Matt Lawellin Salesperson 08/04/2022 Due Date Customer PO No. RQ152297 Lake Elmo DW Trailer Invoice No.: Invoice Date:07/05/2022 INV584468 Tracy DickensonAccount Rep: PO Box 860700 Minneapolis, MN 55486-0700 Phone: (763) 553-1900 Rental Insurance Status:Customer No. C51148 H U Construction 5555 W78th St Suite A Minneapolis, MN 55439 Bill to:Ship to:City of Lake Elmo 24x60 Doublewide Office s/n 15809A/10B Gabe 651-395-0055 3800 Laverne Ave. North Lake Elmo, MN 55042 Satellite Quote No. RC520567 Contract No Matt Lawellin Salesperson 08/04/2022 Due Date Customer PO No. RQ152297 Lake Elmo DW Trailer Invoice No.: Invoice Date:07/05/2022 INV584468 Tracy DickensonAccount Rep: PO Box 860700 Minneapolis, MN 55486-0700 Phone: (763) 553-1900 NO INS No.Description Serial No. Rental From Date Rental To Date Qty.Unit Price Amount Customer Project RC520567 0 0.00 0.00 FA204334 24x60 Doublewide Office w/RR s/n 15809A/10B 15809A/10B 07/05/22 08/01/22 1 2,000.00 2,000.00 RR not utilized no need to winterize. STEPS Steps - Rental 07/05/22 08/01/22 2 45.00 90.00 44130 Damage Waiver Chg - No Insurance on File 1 200.00 200.00 Subtotal:2,290.00 Tax:168.89 Total:2,458.89 Thank You For Your Business! 20050 75th Ave N Hamel, MN 55340-9459 Phone No.: 763-420-2001 Fax No.: 763-420-2034 Satellite Shelters, Inc - Minneapolis InvoiceSatellite Shelters, Inc - Minneapolis Lockbox Remit to address:Page 1 of 1 ARC DOCUMENT SOLUTIONS LLC 4730 PARK GLEN RD SAINT LOUIS PARK MN 55416-5701 54MNI90519737/8/2022 INVOICEDATE Page 1/1 5555 WEST 78TH STREET SUITE AMINNEAPOLIS, MN 55439 P: (952) 837-3309 F: (952) 831-1268 H+U CONSTRUCTION BILL TO:SHIP TO: Luke Nelson 5555 WEST 78TH STREETSUITE A MINNEAPOLIS, MN 55439 P: (952) 837-3309F: (952) 831-1268 H+U CONSTRUCTION 54MNO90482757/8/2022NET30ARC DELIVERY1016013ASI 23 OrderOrder Due DatePayment TermsShipping MethodCustomer IDPurchase Order # Lake ElmoJ21001Lisa Knox Project NameProject NumberOrdered By Extended PricePriceDescriptionItem NumberUOM Quantity BO Quantity Shipped Quantity Ordered 1 set of 4 (30.00x42.00) $3.96$0.10989Bond Prints - First Set1600SQFT0.0036.0036.00 $35.00$35.00Supply / Delivery Charge5201EACH011 $5.00$5.00Energy / Fuel Surcharge5205EACH011 $47.28Total Due Amount Received $47.28Total $0.00Trade Discount $0.00Freight $3.32Tax $0.00Misc $43.96SubtotalllakotasBiller: $47.287/8/202254MNI90519731016013 AMOUNT DUEDOC DATEINVOICECUSTOMER NO ARC DOCUMENT SOLUTIONS LLC NEW REMIT TO ADDRESS PO BOX 645913CINCINNATI, OH 45264-5913 (216) 539-1501 We accept: Visa | MasterCard | American Express | Discover Card/Check Number:______________________ Exp. Date: __________ Signature:_______________________________ Amount: $___________ REMIT PAYMENT TO HTTPS://PAY.ARCREMOTE.COM/P/423304C5-74A6-41E3-BB70-1B71FC4A3273 QuickPay Online Payment Scan or Click ARC DOCUMENT SOLUTIONS LLC 4730 PARK GLEN RD SAINT LOUIS PARK MN 55416-5701 54MNI90520817/15/2022 INVOICEDATE Page 1/1 5555 WEST 78TH STREET SUITE AMINNEAPOLIS, MN 55439 P: (952) 837-3309 F: (952) 831-1268 H+U CONSTRUCTION BILL TO:SHIP TO: Luke Nelson 5555 WEST 78TH STREETSUITE A MINNEAPOLIS, MN 55439 P: (952) 837-3309F: (952) 831-1268 H+U CONSTRUCTION 54MNO90484437/15/2022NET30ARC DELIVERY1016013Fire Alarm OrderOrder Due DatePayment TermsShipping MethodCustomer IDPurchase Order # Lake ElmoJ21001Lisa Knox Project NameProject NumberOrdered By Extended PricePriceDescriptionItem NumberUOM Quantity BO Quantity Shipped Quantity Ordered 1 set of 7 (30.00x42.00) $6.92$0.10989Bond Prints - First Set1600SQFT0.0063.0063.00 $35.00$35.00Supply / Delivery Charge5201EACH011 $5.00$5.00Energy / Fuel Surcharge5205EACH011 $50.46Total Due Amount Received $50.46Total $0.00Trade Discount $0.00Freight $3.54Tax $0.00Misc $46.92SubtotalllakotasBiller: $50.467/15/202254MNI90520811016013 AMOUNT DUEDOC DATEINVOICECUSTOMER NO ARC DOCUMENT SOLUTIONS LLC NEW REMIT TO ADDRESS PO BOX 645913CINCINNATI, OH 45264-5913 (216) 539-1501 We accept: Visa | MasterCard | American Express | Discover Card/Check Number:______________________ Exp. Date: __________ Signature:_______________________________ Amount: $___________ REMIT PAYMENT TO HTTPS://PAY.ARCREMOTE.COM/P/107B1160-E50A-4BC5-BB25-624272614FB8 QuickPay Online Payment Scan or Click ARC DOCUMENT SOLUTIONS LLC 4730 PARK GLEN RD SAINT LOUIS PARK MN 55416-5701 54MNI90524267/26/2022 INVOICEDATE Page 1/1 5555 WEST 78TH STREET SUITE AMINNEAPOLIS, MN 55439 P: (952) 837-3309 F: (952) 831-1268 H+U CONSTRUCTION BILL TO:SHIP TO: Luke Nelson 5555 WEST 78TH STREETSUITE A MINNEAPOLIS, MN 55439 P: (952) 837-3309F: (952) 831-1268 H+U CONSTRUCTION 54MNO90486057/26/2022NET30ARC DELIVERY1016013ASI #23R OrderOrder Due DatePayment TermsShipping MethodCustomer IDPurchase Order # Lake ElmoJ21001Lisa Knox Project NameProject NumberOrdered By Extended PricePriceDescriptionItem NumberUOM Quantity BO Quantity Shipped Quantity Ordered 1 set of 8 (30.00x42.00) $7.91$0.10989Bond Prints - First Set1600SQFT0.0072.0072.00 $35.00$35.00Supply / Delivery Charge5201EACH011 $5.00$5.00Energy / Fuel Surcharge5205EACH011 $51.52Total Due Amount Received $51.52Total $0.00Trade Discount $0.00Freight $3.61Tax $0.00Misc $47.91SubtotalllakotasBiller: $51.527/26/202254MNI90524261016013 AMOUNT DUEDOC DATEINVOICECUSTOMER NO ARC DOCUMENT SOLUTIONS LLC NEW REMIT TO ADDRESS PO BOX 645913CINCINNATI, OH 45264-5913 (216) 539-1501 We accept: Visa | MasterCard | American Express | Discover Card/Check Number:______________________ Exp. Date: __________ Signature:_______________________________ Amount: $___________ REMIT PAYMENT TO HTTPS://PAY.ARCREMOTE.COM/P/D3B8547F-D85F-4AD0-B3EB-C54393EB8A1F QuickPay Online Payment Scan or Click Branch:100 St. Paul 1367678 Invoice Date Page INVOICE 3246273 ORDER NUMBER Columbus, MN 55025 9205 Lake Drive NE Viking Industrial Center 1 of 1651-646-6141 INVOICE 7/25/2022 Please Note New Remittance Address Bill To:Ship To: Lake Elmo, MN 55042 3800 Laverne Ave N H+U Construction - Lake Elmo City CenterH+U Construction 5555 West 78th Street Suite A Minneapolis, MN 55439 Customer ID:106629 Ordered By: Gabe . Delivery Instructions:Contact Gabe 651.395.0055 DOUG GEIST Tracking #:Carrier: Net Due Date Discount AmountDisc Due DateTerm DescriptionPO Number Lake Elmo Net 30 8/24/2022 8/24/2022 0.00 Primary Salesrep NameOrder Date Pick Ticket No Taker 7/18/2022 12:56:20 2274139 Douglas P. Geist TWOODBURY Item ID Item DescriptionOrderedShippedRemaining Quantities UOM Disp.Unit Size Pricing UOM Unit PriceUnit Size Price Extended 4.00 0.00 EA V8G-SCGREEN EA 21.067593 84.27 1.0 1.0000 4.00 KLEEN SWEEP GREEN SWEEPING COMPOUND 50# Kleen Sweep Green Sweeping Compound 50LB (1815) SUB-TOTAL:Total Lines:1 84.27 MN STATE TAX 5.79: MN SPECIAL TAX 0.42: 90.48AMOUNT DUE: ORIGINAL12.17.2242 - 11/12/15 Goods may be returned within 30 days of this invoice for credit, exchange or replacement only with authoriztion, and subject to inspection and restocking charges. ALL Respiratory, Fall Protection, Special Order and Custom Items are NON-RETURNABLE. Interest at 1.5% per month (18% annum) will be charged on past due accounts. Rev 2 Biffs, Inc6430 County Rd 101 EShakopee MN 55379-5202952.403.1221 Invoice #W871251 7/13/2022 W871251 1 of 2 Bill To C57180Hoffman & Uhlhorn Const Inc5555 W 78th StSte AMinneapolis MN 55439United States Location L136962Lake Elmo Public Facilities3800 Laverne Ave NLake Elmo MN 55042United States Invoice Total $193.28 Balance Due $193.28 Due Date: 8/10/2022 Terms Due Date PO #Sales Rep Builders Club# Net 28 8/10/2022 -Jeff Foley Qty Item Days Sales Order #Service Level Rate Amount 1 RENTAL RegularUnit Jun 15-Jul 12 28 385563 -$4.00 $4.00 1 SERVICEService Jun 15-Jul 12 28 385563 1X/wk $70.00 $70.00 1 SERVICEClimateSvc Jun 15 to Jul 12 28 385563 1X/wk $16.00 $16.00 1 RENTAL HandSani Jun 15-Jul 12 28 385563 -$0.00 $0.00 1 RENTALRegularUnit Jun 15-Jul 12 28 386930 -$4.00 $4.00 1 SERVICE Service Jun 15-Jul 12 28 386930 1X/wk $70.00 $70.00 1 SERVICEClimateSvc Jun 15 to Jul 12 28 386930 1X/wk $16.00 $16.00 1 RENTAL HandSani Jun 15-Jul 12 28 386930 -$0.00 $0.00 0 TAX-MNTax-MN ---$0.00 $12.38 0 TAX-WASH Tax-WASH ---$0.00 $0.90 Subtotal $193.28 Invoice Total $193.28 Credits/Payments Applied $0.00 Balance Due $193.28 Biffs, Inc6430 County Rd 101 EShakopee MN 55379-5202952.403.1221 Invoice #W871251 7/13/2022 W871251 2 of 2 Biffs Inc.Remittance Slip Make Checks Payable To Customer L136962 Hoffman & Uhlhorn Const Inc : Lake Elmo Public Facilities Biffs, Inc6430 County Rd 101 EShakopee MN 55379-5202 Please return this portion with your payment. Invoice #W871251 Amount Due $193.28 Amount Paid ______________________ 126521501-0002 PO BOX 409211 ATLANTA, GA 30384-9211 661003 7/13/22 1 LAKE ELMO H + U CONSTRUCTION 3880 LAVERNE AVE N LAKE ELMO, MN 55042 9627 C#: 952-837-3309 J#: 651-395-0055 3880 LAVERNE AVE N, LAKE ELMO 3 - H + U CONSTRUCTI 126521501 SHAKOPEE MN PC1016 800 VALLEY INDUSTRIAL CIR S SHAKOPEE, MN 55379 1852 952-656-9400 1016 984.55 72.61 1057.16 H + U CONSTRUCTION 5555 WEST 78TH STREET, SUITE A MINNEAPOLIS, MN 55439 . QTY EQUIPMENT # Min Day Week 4 Week Amount . 1.00 BOX BROOM 145.00 145.00 425.00 970.00 970.00 10212412 Make: BRADCO Model: 21560M-0022 Ser #: 1928039 Rental Sub-total: 970.00 SALES ITEMS: Qty Item number Unit Price 1 ENVIRONMENTAL EA 14.550 14.55 ENVIRONMENTAL/HAZMAT FEE 2133XXX0000 BILLED FOR FOUR WEEKS 6/28/22 THRU 7/25/22. . 984.55. 4 WEEK BILL NET 30 ANNA CLARK anna.clark@sunbeltrentals.com DOMINIC, DOMINIC Invoice Date 7/31/2022 Invoice # 350135Customer HU Construction, Inc. 5555 W 78th St Suite A Minneapolis, MN 55439 Service Address LECC 3880 Laverne Ave N Lake Elmo, MN 55042 P.O. No.Terms Net 30 Total Balance Due Payments/Credits All invoices paid by credit card are subject to a convenience fee. Questions on this invoice? Want your invoices to be emailed? Please send your request to ar@atomicrecycling.com Service Date DescriptionTicket QtyUnit of Measure Rate Amount 7/29/2022 30 Yard Container711132 1Each 371.00 371.00 7/29/2022 Solid Waste Management Tax calculated at $0.60/yard. This ticket includes $18.00 of solid waste disposal tax. 711132 30Yards 0.60 18.00 7/29/2022 1 Appliance @ $44.00711132 1Each 44.00 44.00 7/29/2022 2 Tires @ $26.00711132 2Each 26.00 52.00 $485.00 $485.00 $0.00 Invoice A117913 Scaffold Service P.O.Box 74008409 Chicago, IL 60674-8409 Send Payment To: Customer H + U CONSTRUCTION 5555 W 78TH ST ATTN: ACCOUNTS PAYABLE MINNEAPOLIS, MN 55439-2702, USA Order PO: J21001 Number A14121 Job Site 11170 - LAKE ELMO CITY STAIR 7/6/2022Date Job Site Shipping Address: 3880 LAVERNE AVE N LAKE ELMO, MN 55042-9627 Created: 7/7/2022 M: Minimum rental appliesR: Rate change applies Rental Items Shipment Part Number Description Qty From To Days 28-Day Ra Total DEL-308542 28-Day Rent Base Rental Package, per 28 Days 1 6/9/2022 7/6/2022 28 $220.0000 0 $220.00 Rent $220.00 Subtotal $236.23 Other tax: (none)$0.00 $16.23 $220.00 Sales tax: MN - LAKE ELMO CITY TAX (7.375%) Invoice Total Printed: July 07, 2022 7:06:09 AM Page 1 of 1A117913 145,386.107/27/22 5,700.007/27/22 7/27/22 7/27/22 2712,171.877/27/22 APPLICATION AND CERTIFICATE FOR PAYMENTTO (OWNER): PROJECT:LAKE ELMO CITY HALL, FIRE DEPARTMENT APPLICATION NO: 7Distribution to:City of Lake Elmo & PUBLIC WORKS FACILITIES REMODELXOWNER3880 Laverne Ave N PERIOD TO:7/31/2022Lake Elmo, MN 55042ARCHITECT FROM (CM): MATERIALCONST. MANAGERHOFFMANN + UHLHORN CONSTRUCTION, INC.5555 W 78TH ST, SUITE AXFILEMINNEAPOLIS, MN 55439CONTRACT DATE:APPLICATION FOR PAYMENTApplication is made for Payment, as shown below,CHANGE ORDER SUMMARYContinuation Sheet, AIA Document G703, is attached.Change Orders Approved inADDITIONSDEDUCTIONS1. COMMITTED COST$6,910,247.00previous months by Owner2. Net Change by Change Orders$0.00TOTAL$0.00$0.003. SUM TO DATE (Line 1+2)$6,910,247.00Approved this Month4. TOTAL COMPLETED & STORED TO DATE $2,172,152.70NumberDate Approved (Column G on G703) 5. RETAINAGE:$0.00$0.00 a. _5_ % of Completed Work$108,607.64 (Column D+E on G703) b. ___ % of Stored Material$0.00 (Column F on G703)Total Retainage (Line 5a + 5b or Total in Column I of G703)$108,607.64TOTALS$0.00$0.006. TOTAL EARNED LESS RETAINAGE$2,063,545.06Net change by Change Orders$0.00 (Line 4 less Line 5 Total)The undersigned Construction Manager certifies that to the best of his 7. LESS PREVIOUS CERTIFICATES FORknowledge, information and belief the Work covered by this Application for PAYMENT (Line 6 from prior Certificate)$1,236,058.47Payment has been completed in accordance with the Contract Documents, 8. CURRENT PAYMENT DUE$827,486.59and that current payments shown herein are now due.9. BALANCE TO FINISH, PLUS RETAINAGE $4,846,701.94 (Line 3 less Line 6)CONSTRUCTION MANAGER:HOFFMANN + UHLHORN CONSTRUCTION, INC.State of: MINNESOTACounty of:Anoka County Subscribed and sworn to before me this 8/4/2022Notary Public:By:Date:8/4/2022My Commission expires:31-Jan-23ARCHITECT'S CERTIFICATE FOR PAYMENTAMOUNT CERTIFIED$In Accordance with the Contract Documents, based on on-site observations and the(Attach explaination if amount certified differs from the amount applied for).data comprising the above application, the Architect certifies to the Owner that to theARCHITECT:best of the Architect's knowledge, information and belief the Work has progressed asindicated, the quality of the Work is in accordance with the Contract Documents, andBy:Date:the Contractors are entitled to payment of the Amounts Certified.WASHINGTON COUNTY SHERRIFF SUBSTATION2022-08-09LEO A DALY CITY OF LAKE ELMO - MATERIALAPPLIC. FOR PAYMENT NO.#7H+U CONSTRUCTION EDITION OF AIA DOCUMENT G703PERIOD ENDING 7/31/2022 AIA Document G723,APPLICATION AND CERTIFICATE FOR PAYMENT, containing Contractor's signed Certification is attached.In tabulations below, amounts are stated to the nearest dollar. ABCDEF GHITEMDESCRIPTION OF WORKSCHEDULEDCHANGEREVISED WORK COMPLETEDTOTAL%BALANCERETAINAGENO.VALUEORDERSSCHEDULEFROMTHIS PERIODCOMPLETED(F/C)TO FINISHVALUEPREV. APPL.AND STORED(C-F)(A+B) TO DATE (D+E)#0330Cast-In-Place Concrete240,000.000.00240,000.0060,000.0060,000.00120,000.0050%120,000.006,000.00#0341Strutctural Precast1,422,295.000.001,422,295.00381,004.00343,994.55724,998.5551%697,296.4536,249.93#0512Steel Supply485,000.009,215.00494,215.00251,409.187,375.00258,784.1852%235,430.8212,939.21#0610Carpentry & GC568,000.000.00568,000.0018,800.005,000.0023,800.004%544,200.001,190.00#0750Roofing & Metal Panels498,500.000.00498,500.000.00243,465.00243,465.0049%255,035.0012,173.25#0790Caulking & Firestopping18,300.000.0018,300.000.000.000.000%18,300.000.00#0810Doors, Frames, Hardware - Supply171,697.000.00171,697.000.000.000.000%171,697.000.00#0833Coiling & Sectional Doors175,000.000.00175,000.000.000.000.000%175,000.000.00#0840Aluminum Storefronts & Curtainwall321,960.000.00321,960.004,580.006,250.0010,830.003%311,130.00541.50#0920Drywall & Fireproofing229,410.009,475.00238,885.0050,000.0015,000.0065,000.0027%173,885.003,250.00#0930Tile68,100.000.0068,100.000.000.000.000%68,100.000.00#0950Acoustical Ceilings & Panels75,000.000.0075,000.000.000.000.000%75,000.000.00#0965Resilient Flooring & Carpet90,930.000.0090,930.0089,940.000.0089,940.0099%990.004,497.00#0990Painting and Wallcovering29,531.000.0029,531.000.000.000.000%29,531.000.00#1420Conveying Equipment46,740.000.0046,740.0021,577.000.0021,577.0046%25,163.001,078.85#2100Fire Protection57,520.000.0057,520.000.000.000.000%57,520.000.00#2200Plumbing & Heating491,000.000.00491,000.0073,627.00165,143.97238,770.9749%252,229.0311,938.55#2300HVAC & Controls662,000.000.00662,000.0089,750.000.0089,750.0014%572,250.004,487.50#2600Electrical808,100.00(1,127.66)806,972.3485,105.0022,510.00107,615.0013%699,357.345,380.75#3100Earthwork & Site Utilities209,390.00550.00209,940.00164,705.002,300.00167,005.0080%42,935.008,350.25#3210Asphalt Paving180,634.000.00180,634.0010,617.000.0010,617.006%170,017.00530.85#3290Landscaping & Fencing61,140.000.0061,140.000.000.000.000%61,140.000.00TOTAL CONTRACT AMOUNTS6,910,247.000.006,928,359.341,301,114.18871,038.522,172,152.7031%4,756,206.64108,607.64 INVOICE SUMMARY-PAYMENT APPLICATION NO. #7CITY OF NEWPORT - MATERIALPERIOD ENDING 7/31/2022ITEM NO# DESCRIPTION VENDORDATENUMBERAMOUNTRETAINAGEDUE#0330Cast-In-Place ConcreteAxel H. Ohman, Inc.7/31/22Applic #2$60,000.00$3,000.00$57,000.00#0341Strutctural PrecastWells Concrete7/31/22Applic #4$343,994.55$17,199.73$326,794.82#0512Steel SupplyConstruction Systems, Inc.7/31/22Applic #3$7,375.00$368.75$7,006.25#0610Carpentry & GCEbert Construction7/31/22Applic #6$5,000.00$250.00$4,750.00#0750Roofing & Metal PanelsPalmer West Construction7/31/22Applic #1$243,465.00$12,173.25$231,291.75#0840Aluminum Storefronts & CurtainwallEmpirehouse, Inc.7/31/22Applic #2$6,250.00$312.50$5,937.50#0920Drywall & FireproofingCommercial Drywall7/31/22Applic #3$15,000.00$750.00$14,250.00#2200Plumbing & HeatingPeterson Sheet Metal7/31/22Applic #4$165,143.97$8,257.20$156,886.77#2600ElectricalVinco, Inc.7/31/22Applic #5$22,510.00$1,125.50$21,384.50#3100Earthwork & Site UtilitiesPark Construction Company7/31/22Applic #4$2,300.00$115.00$2,185.00SUBTOTAL AMOUNT DUE$871,038.52$43,551.93$827,486.59 TOTAL AMOUNT DUE $827,486.59 57,000.007/27/22 Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com 7,006.257/27/22 4,750.007/27/22 7/27/22 Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com 07/21/2022 Brown & Brown of Minnesota 530 W Pleasant St. Suite 100 Mankato MN 56001 Elisabeth Thompson (507) 344-4503 (866) 800-6597 Elisabeth.Thompson@bbrown.com Palmer West Construction 14595 James Road Rogers MN 55374 Integrity Insurance Company 14303 22-23 A CPP2799178 01/01/2022 01/01/2023 1,000,000 300,000 10,000 1,000,000 2,000,000 2,000,000 A CA2799179 01/01/2022 01/01/2023 1,000,000 A CUP2799180 01/01/2022 01/01/2023 10,000,000 10,000,000 Project: Lake Elmo City Center 3880 Laverne Avenue North Lake Elmo, MN 55042 and Lake Elmo Public Works Addition 3445 Ideal Avenue North Lake Elmo, MN 55042 Roofing and Sheet Metal Materials Stored in the amount of $235,865 City of Lake Elmo 3880 Laverne Avenue North Suite 100 Lake Elmo MN 55042 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED?(Mandatory in NH) DESCRIPTION OF OPERATIONS belowIf yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCEDAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIREDAUTOS ONLY 5,937.50 321,960.00 0.00 321,960.00 10,830.00 541.50 10,288.50 4,351.00 0.00 0.00 10,830.00 Page 1 Certificate of the Subcontractor: 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 changes thereto) between the undersigned and H+U Construction relating to the above-referenced project. 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) and (2) for all materials and labor used in connection with the performance of this contract. 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 performance of this contract. 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 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 subsequently become due. Original contract sum Net change by change orders (as per attached breakdown) Contract sum to date Completed to date (as per attached breakdown) Total retainage (5.0%) Total earned less retainage Less previous certificates of payment Sales tax at 0.000% on 0.00 Tax Exempt Amount of this request Stored material (as per attached breakdown) Total completed and stored to date Subtotal 5,937.50 Empirehouse Inc. 5200 Quincy StreetMounds View, MN 55112 To: From: Phone: Project:Lake Elmo City Center (M)3880 Laverne Avenue N. Lake Elmo, MN 55042 Application No: 2 Date: 07/01/22 Period To: 07/31/22 Contract For: Contract Date: Contractor Job Number:21153 Date: __________________________________ Subscribed and sworn to before me this _____ day of ____________, _________ (year). Notary public: _____________________________ My commission expires ____________________. Contractor: Empirehouse Inc. By: ____________________________________ Title: ___________________________________ (763) 535-1150 Application and Certificate For Payment H+U Construction5555 West 78th Street Suite A Edina, MN 55439 July 21, 2022 21 July 2022 January 31, 2025 Kristine Hutera, CEO 010500 010600 020500 020502 021000 021001 021002 030500 030501 030502 040500 041000 042000 055000 4,580.00 4,580.00 0.00 0.00 4,580.00 100.00 229.000.00 26,100.00 0.00 6,250.00 0.00 6,250.00 23.95 312.5019,850.00 49,080.00 0.00 0.00 0.00 0.00 0.00 0.0049,080.00 17,575.00 0.00 0.00 0.00 0.00 0.00 0.0017,575.00 57,775.00 0.00 0.00 0.00 0.00 0.00 0.0057,775.00 47,640.00 0.00 0.00 0.00 0.00 0.00 0.0047,640.00 63,500.00 0.00 0.00 0.00 0.00 0.00 0.0063,500.00 17,565.00 0.00 0.00 0.00 0.00 0.00 0.0017,565.00 7,530.00 0.00 0.00 0.00 0.00 0.00 0.007,530.00 10,000.00 0.00 0.00 0.00 0.00 0.00 0.0010,000.00 6,010.00 0.00 0.00 0.00 0.00 0.00 0.006,010.00 6,465.00 0.00 0.00 0.00 0.00 0.00 0.006,465.00 120.00 0.00 0.00 0.00 0.00 0.00 0.00120.00 8,020.00 0.00 0.00 0.00 0.00 0.00 0.008,020.00 321,960.00 4,580.00 6,250.00 0.00 10,830.00 3.36 541.50311,130.00 To:H+U Construction From (Subcontractor):Empirehouse Inc. Project:Lake Elmo City Center (M) Application and Certificate For Payment -- page 2 Application No: 2 Date: 07/01/22 Item Number Description ScheduledValue Work Completed Previous Application This Period Materials Presently Stored Completed and Stored to Date %Balance to Finish Retention Memo Bonds Submittals/PM/CAD/Admin SF Metal Materials CW Metal Materials Jeld-wen Vinyl Windows StormDefend Windows Bullet Resistant Windows SF Glass Materials CW Glass Materials Skyligtht Glass Material Interior Glass Materials Heavy Wall Glass Materia Mirror Materials Testing Application Total Period To: 07/31/22 Contractor's Job Number: 21153 Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com 7/27/22 Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com Click to buy NOW!P D F -XChange ww w.docu-tr a c k .comClick to buy NOW!P D F -XChange ww w.docu-tra c k .com 07/20/2022 Twin City Group 4500 Park Glen Rd. ste 400 Minneapolis MN 55416 Nick Proudfoot (952) 924-6900 (952) 925-0631 nproudfoot@twincitygroup.com Peterson Sheet Metal Inc Quello Investments LLC 3728 Bemidji Ave N Suite 300 Bemidji MN 56601 Integrity Property & Casualty 12986 Integrity Mutual 14303 22/23 All Lines A/B B0621PPETE002122 Pollution/Prof Dates 6/21/22-6/1/23 Pollution/Professional CPP 2855924 04/01/2022 04/01/2023 1,000,000 300,000 10,000 1,000,000 2,000,000 2,000,000 Each Claim/Aggregate 2,000,000 A CA 2855925 04/01/2022 04/01/2023 1,000,000 A 0 CUP 2855926 04/01/2022 04/01/2023 10,000,000 10,000,000 B N WCP 2855926 04/01/2022 04/01/2023 1,000,000 1,000,000 1,000,000 A Installation Floater Rented Equipment CPP 2855924 04/01/2022 04/01/2023 Max per Jobsite/Loc $750,000 Any One Item $150,000 Stored Materials/Lake Elmo City Lake Elmo 3880 Laverne Avenue N Lake Elmo MN 55042 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED?(Mandatory in NH) DESCRIPTION OF OPERATIONS belowIf yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCEDAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIREDAUTOS ONLY Peterson Sheet Metal IncTwin City Group 25 Certificate of Liability Insurance: Remarks Certificate holder & any party required by written contract or agreement are included with the following coverage and forms: General Liability (Form IL 20)Blanket Primary and Noncontributory basis and Blanket waiver of subrogation apply when both parties have agreed in writing in a contract or agreement or that such person or organization be added as an additional insured on your policy. (CG2010 0704) Blanket Additional Insured, (CG 2037 07 04) Blanket Additional Insured -Completed operations Automatic status when required in contract or agreement.Commercial Auto: (CA 60) Blanket Additional Insured, Blanket Primary and Noncontributory basis and Blanket waiver of subrogation apply when both parties have agreed in writing in a contract or agreement or that such person or organization be added as an additional insured on your policy. Workers Compensation (Form WC 000313) Blanket Waiver of Subrogation when required by written agreement of contact.Umbrella (Form CU 92) Blanket Waiver of Subrogation (Form CU 100) Blanket Additional Insureds Primary and Noncontributory Pollution Blanket AI and WOS for any clients of the named insured ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD © 2008 ACORD CORPORATION. All rights reserved. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER:FORM TITLE: ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE Page of AGENCY CUSTOMER ID: LOC #: AGENCY CARRIER NAIC CODE POLICY NUMBER NAMED INSURED EFFECTIVE DATE: Named Insured/Mailing Address: Agency Name/Address/Code Number: Policy Number:Mod: Effective Date of Change: at 12:01 AM Standard Time Authorized Representative IK968 (08-97) Named Insured/Mailing Address: Agency Name/Address/Code Number: Policy Number:Mod: Effective Date of Change: at 12:01 AM Standard Time Authorized Representative IK968 (08-97) Named Insured/Mailing Address: Agency Name/Address/Code Number: Policy Number:Mod: Effective Date of Change: at 12:01 AM Standard Time Authorized Representative IK968 (08-97) Named Insured/Mailing Address: Agency Name/Address/Code Number: Policy Number:Mod: Effective Date of Change: at 12:01 AM Standard Time Authorized Representative IK968 (08-97) Named Insured/Mailing Address: Agency Name/Address/Code Number: Policy Number:Mod: Effective Date of Change: at 12:01 AM Standard Time Authorized Representative IK968 (08-97) by any utility provider,but only where such failure or interruption of service impacts a Computer System owned or controlled by the Assured or any other party acting on behalf of the Assured. b. This contract excludes any loss,damage,liability,claim,costs,expense,fines,penalties, mitigation costs or any other amount for actual or alleged breach of Data Protection Law by the Assured or any other party acting on behalf of the Assured. 5. Any cover for costs of reconstituting or recovering lost,inaccessible or damaged documents owned or controlled by the Assured or any other party acting on behalf of the Assured in this contract shall not apply to Data. 6. For the purposes of this endorsement the following definitions apply: Computer System means any computer,hardware,software,communications system,electronic device (including,but not limited to,smart phone,laptop,tablet,wearable device),server,cloud or microcontroller including any similar system or any configuration of the aforementioned and including any associated input,output,data storage device,networking equipment or back up facility. Cyber Act means an unauthorised,malicious or criminal act or series of related unauthorised,malicious or criminal acts,regardless of time and place,or the threat or hoax thereof,involving access to, processing of,use of or operation of any Computer System. Data means information,facts,concepts,code or any other information of any kind that is recorded or transmitted in a form to be used,accessed,processed,transmitted or stored by a Computer System. Data Protection Law means any applicable data protection and privacy legislation or regulations in any country,province,state,territory or jurisdiction which govern the use,confidentiality,integrity, security and protection of personal data or any guidance or codes of practice relating to personal data issued by any data protection regulator or authority from time to time (all as amended,updated or re-enacted from time to time). IUA 04-017 27.11.2020 (Amended) MILLERPIUS0065 V.RISK MANAGEMENT SERVICES PROVIDER Risk management services are to be provided by DWF Claims. MILLERPIUS0005 VI.ADDITIONAL INSURED ENDORSEMENT (BLANKET)-AS EXPIRING Enter text here VII.INSURING CLAUSE I.A.3 SUBLIMITED ENDORSEMENT -AS EXPIRING Enter text here VIII.MINNESOTA SURPLUS LINES NOTICE THIS INSURANCE IS ISSUED PURSUANT TO THE MINNESOTA SURPLUS LINES INSURANCE ACT.THE INSURER IS AN ELIGIBLE SURPLUS LINES INSURER BUT IS NOT OTHERWISE LICENSED BY THE STATE OF MINNESOTA.IN CASE OF INSOLVENCY,PAYMENT OF CLAIMS IS NOT GUARANTEED. LMA9056 01 September 2013 ALL OTHER TERMS AND CONDITIONS OF THIS CERTIFICATE REMAIN UNCHANGED Page 39 of 39B0621PPETE002122 B0621PPETE002122 Page 1 of 45 Lloyd’s Certificate This Insurance is effected with certain Underwriters at Lloyd’s, London. This Certificate is issued in accordance with the limited authorization granted to the Correspondent by certain Underwriters at Lloyd's, London whose syndicate numbers and the proportions underwritten by them can be ascertained from the office of the said Correspondent (such Underwriters being hereinafter called "Underwriters") and in consideration of the premium specified herein, Underwriters hereby bind themselves severally and not jointly, each for his own part and not one for another, their Executors and Administrators. The Assured is requested to read this Certificate, and if it is not correct, return it immediately to the Correspondent for appropriate alteration. All inquiries regarding this Certificate should be addressed to the following Correspondent: Miller Insurance Services LLP 70 Mark Lane, London EC3R 7NQ. SLC-3 (USA) NMA2868 (24/08/00) amended. B0621PPETE002122 Page 2 of 45 This Declaration Page is attached to and forms part of Certificate provisions (SLC-3 USA amended) Previous No: Authority Ref. No: Certificate No: Insurance is effective with: B0621PPETE002121 B0621PFDO11522 B0621PPETE002122 Certain UNDERWRITERS AT LLOYD'S, LONDON 100% Scheduled as follows: HAM 4000 55.0000% BRT 2987 7.0000% MOS 1609 7.0000% AUW 0609 5.0000% AFB 2623 5.7400% AFB 0623 1.2600% CSL 1084 5.0000% CGM 2488 7.0000% ARG 2121 7.0000% Signed <<ESIGN01>> Signed <<ESIGN02>> Dated <<DATE01>> Dated <<DATE02>> By <<NAME01>> By <<NAME02>> CERTIFICATE PROVISIONS 1. Signature Required. This Certificate shall not be valid unless signed by the Correspondent. 2. Correspondent Not Insurer. The Correspondent is not an Insurer hereunder and neither is nor shall be liable for any loss or claim whatsoever. The Insurers hereunder are those Underwriters at Lloyd's, London whose syndicate numbers can be ascertained as hereinbefore set forth. As used in this Certificate "Underwriters" shall be deemed to include incorporated as well as unincorporated persons or entities that are Underwriters at Lloyd's, London. 3. Assignment. This Certificate shall not be assigned either in whole or in part without the written consent of the Correspondent endorsed hereon. Cecilia Yanez 21 June 2022 Eleanor Lloyd 21 June 2022 B0621PPETE002122 Page 3 of 45 4. Attached Conditions Incorporated. This Certificate is made and accepted subject to all the provisions, conditions and warranties set forth herein, attached or endorsed, all of which are to be considered as incorporated herein. 5. Complaints. All complaints must be referred in the first instance to the Coverholder and, if no satisfaction is obtained, complaints can be referred to the Complaints Department, Lloyd’s whose address is: Complaints Department, Lloyd’s, One Lime Street, London EC3M 7HA, UK. Tel. +44 (0)20 7327 1000 www.lloyds.com Lloyd’s is Authorised under the Financial Services and Markets Act 2000 and regulated by the Financial Conduct Authority and the Prudential Regulation Authority, whose addresses are as follows: Financial Conduct Authority, 12 Endeavour Square, London E20 1JN. Tel. +44 (0)20 7066 1000 www.fca.org.uk Prudential Regulation, 20 Moorgate, London, EC2R 6DA Tel. +44 (0)20 3461 7000 www.pra.org.uk B0621PPETE002122 Page 4 of 45 DECLARATIONS DESIGN BUILD AND CONTRACTORS PROFESSIONAL LIABILITY, CONTRACTORS POLLUTION LIABILITY, CONTRACTORS MICROBIAL CONDITION LIABILITY, TRANSPORTATION POLLUTION LIABILITY, NON-OWNED DISPOSAL SITE TECHNOLOGY BASED SERVICES, TECHNOLOGY PRODUCTS, COMPUTER NETWORK SECURITY, AND MULTIMEDIA AND ADVERTISING AND PRIVACY LIABILITY INSURANCE INSURING CLAUSE I.A. OF THIS CERTIFICATE PROVIDES COVERAGE ON A CLAIMS MADE AND REPORTED BASIS AND APPLIES ONLY TO ANY CLAIM FIRST MADE AGAINST THE ASSUREDS DURING THE CERTIFICATE PERIOD OR OPTIONAL EXTENSION PERIOD, IF APPLICABLE, AND REPORTED IN WRITING TO THE UNDERWRITERS EITHER DURING THE CERTIFICATE PERIOD, WITHIN SIXTY (60) DAYS AFTER THE EXPIRATION OF THE CERTIFICATE PERIOD OR DURING THE OPTIONAL EXTENSION PERIOD, IF APPLICABLE. AMOUNTS INCURRED AS CLAIMS EXPENSES SHALL REDUCE AND MAY EXHAUST THE LIMIT OF LIABILITY AND ARE SUBJECT TO THE DEDUCTIBLE. THE UNDERWRITERS SHALL NOT BE LIABLE FOR ANY DEFENSE COSTS OR FOR ANY JUDGMENT OR SETTLEMENT AFTER THE LIMIT OF LIABILITY HAS BEEN EXHAUSTED. PLEASE READ THIS CERTIFICATE CAREFULLY. INSURING CLAUSE I.B. OF THIS CERTIFICATE PROVIDES FIRST PARTY COVERAGE ON AN INCIDENT DISCOVERED AND REPORTED BASIS AND APPLIES ONLY TO INCIDENTS FIRST DISCOVERED BY THE ASSURED AND REPORTED TO THE UNDERWRITERS DURING THE CERTIFICATE PERIOD. These Declarations and the Certificate with endorsements shall constitute the contract between the Assureds and the Underwriters. Certificate Number: B0621PPETE002122 1. Named Assured: Peterson Sheet Metal, Inc Address: 3728 Bemidji Ave N Suite 300 Bemidji Minnesota 56601 United States of America 2. Certificate Period: From: 21st June 2022 To: 21st June 2023 Both dates at 12:01 a.m. Local Standard Time at the address stated in Item 1. RPSMIN/SC/2022.06.23 To Report a Loss • Dial toll-free #1 (844)777-8323 or visit our • Website: https://my.rpsins.com/claimsfnol • Contact Insurer directly (see policy section) THIS INSURANCE IS ISSUED PURSUANT TO THE MINNESOTATHIS INSURANCE IS ISSUED PURSUANT TO THE MINNESOTATHIS INSURANCE IS ISSUED PURSUANT TO THE MINNESOTATHIS INSURANCE IS ISSUED PURSUANT TO THE MINNESOTA SURPLUS LINES INSURANCE ACT. THE INSURER IS ANSURPLUS LINES INSURANCE ACT. THE INSURER IS ANSURPLUS LINES INSURANCE ACT. THE INSURER IS ANSURPLUS LINES INSURANCE ACT. THE INSURER IS AN ELIGIBLE SURPLUS LINES INSURER BUT IS NOT OTHERWISEELIGIBLE SURPLUS LINES INSURER BUT IS NOT OTHERWISEELIGIBLE SURPLUS LINES INSURER BUT IS NOT OTHERWISEELIGIBLE SURPLUS LINES INSURER BUT IS NOT OTHERWISE LICENSED BY THE STATE OF MINNESOTA. IN CASE OFLICENSED BY THE STATE OF MINNESOTA. IN CASE OFLICENSED BY THE STATE OF MINNESOTA. IN CASE OFLICENSED BY THE STATE OF MINNESOTA. IN CASE OF INSOLVENCY, PAYMENT OF CLAIMS IS NOT GUARANTEED.INSOLVENCY, PAYMENT OF CLAIMS IS NOT GUARANTEED.INSOLVENCY, PAYMENT OF CLAIMS IS NOT GUARANTEED.INSOLVENCY, PAYMENT OF CLAIMS IS NOT GUARANTEED. B0621PPETE002122 Page 5 of 45 3. Limit of Liability: (a) USD 2,000,000 Each Claim – includes Claims Expenses (b) USD 0 Each Incident, or related Incidents giving rise to an obligation to pay Privacy Breach Response Services (c) USD 2,000,000 Aggregate for the Certificate Period –includes Claims Expenses The Privacy Breach Response Services sublimit stated in Item 3.(b) is part of, and not in addition to, the “Aggregate for the Certificate Period” stated in Item 3.(c) of the Declarations. 4. Deductible: (a) USD 25,000 Each Claim Deductible – includes Claims Expenses (b) USD 0 Each Incident, or related Incidents giving rise to an obligation to pay Privacy Breach Response Services 5. Premium: USD 13,500.00 6. Retroactive Date: 21st June 2013 7. Contractors Pollution Liability, Contractors Microbial Condition Liability, Transportation Pollution Liability, Non-Owned Disposal Site Pollution Liability, Technology Based Services, Technology Products, Computer Network Security and Privacy Liability, Multimedia and Advertising, and Privacy Breach Response Services Coverage Option: Purchased ✓ if this box is checked then Insuring Clauses I.A.2. of this Certificate shall apply. Not Purchased if this box is checked then Insuring Clauses I.A.2. of this Certificate shall not apply. Purchased ✓ if this box is checked then Insuring Clauses I.A.3. of this Certificate shall apply. Not Purchased if this box is checked then Insuring Clauses I.A.3. of this Certificate shall not apply. Purchased if this box is checked then Insuring Clauses I.A.4. of this Certificate shall apply. Not Purchased ✓ if this box is checked then Insuring Clauses I.A.4. of this Certificate shall not apply. Purchased if this box is checked then Insuring Clauses I.A.5. of this Certificate shall apply. Premium Broker Fee - RPS MN Surplus Lines Tax MN Stamping Office Fee Total Charges $13,500.00 $300.00 $414.00 $5.52 $14,219.52 B0621PPETE002122 Page 6 of 45 Not Purchased ✓ if this box is checked then Insuring Clauses I.A.5. of this Certificate shall not apply. Purchased ✓ if this box is checked then Insuring Clauses I.A.6., I.A.7., I.A.8., and I.A.9. of this Certificate shall apply. Not Purchased if this box is checked then Insuring Clauses I.A.6., I.A.7., I.A.8., and I.A.9. of this Certificate shall not apply. Purchased if this box is checked then Insuring Clause I.B. of this Certificate shall apply. Not Purchased ✓ if this box is checked then Insuring Clause I.B. of this Certificate shall not apply. If no box is checked, then Insuring Clauses I.A.2., I.A.3., I.A.4., I.A.5., I.A.6., I.A.7.. I.A.8., I.A.9. and I.B. of this Certificate shall not apply. 8. Optional Extension Period: Premium for Optional Extension Period: 12 months at 100% of the total premium for this Certificate 24 Months at 175% of the total premium for this Certificate 36 Months at 225% of the total premium for this Certificate 9. Notification under this Certificate: (a) Notification (except Privacy Breaches under Insuring Agreement B.) pursuant to Clause XI. shall be given to: DWF Claims 740 Waukegan Road, Suite 340 Deerfield, IL 60015 USA FNOLUS@dwfclaims.com (b) Notification for Privacy Breaches under Insuring Agreement B. pursuant to Clause XI. shall be given to: Email: FNOLUS@dwfclaims.com Toll-Free 24-Hour Hotline: (866) 569-9097 – select Option 5 (c) All other notices under this Certificate shall be given to: DWF Claims 740 Waukegan Road, Suite 340 Deerfield, IL 60015 USA FNOLUS@dwfclaims.com B0621PPETE002122 Page 7 of 45 10. Service of process in any suit shall be made upon: Lloyd's America, Inc. Attention: Legal Department 280 Park Avenue, East Tower, 25th Floor New York, NY 10017 11. Notice of Election Risk Placement Services, Inc 7300 Metro Boulevard Suite 355 Minneapolis Minnesota 55349 United States of America 12. Choice of Law: New York 13. Endorsements Effective at Inception: I. Application Endorsement II. Several Liability Notice III. LSW541 RICO Exclusion IV. Professional Indemnity Cyber and Data Protection Law Endorsement V. Risk Management Services Provider VI. Blanket Additional Insured Endorsement VII. Insuring Clause I.A.3 Sublimit VIII. LMA9056 Minnesota Surplus Lines Notice 7/27/22 2,185.007/27/2270