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#08 - City Center Pay Req 8
STAFF REPORT DATE: September 20, 2022 CONSENT AGENDA ITEM: City Center-Public Works Addition Pay Request #8 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 #8 for the City Center and Public Works Addition project? PROPOSAL: Pay request #8 is for $1,199,912.26. A copy is included in your packet. FISCAL IMPACT: With this pay request, the project remains within budget. OPTION: 1) Approve pay request #8 2) Don’t approve pay request #8 RECOMMENDATION: “Motion to approve Pay Request #8 for the New City Center and Public Works Addition.” ATTACHMENTS: • Pay Request #8 APPLICATION AND CERTIFICATE FOR PAYMENTTO (OWNER): PROJECT:LAKE ELMO CITY HALL, FIRE DEPARTMENT APPLICATION NO: 8Distribution to:City of Lake Elmo & PUBLIC WORKS FACILITIES REMODELXOWNER3880 Laverne Ave N PERIOD TO:8/31/2022Lake 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 $4,827,610.08NumberDate Approved (Column G on G703) 5. RETAINAGE:$0.00$0.00 a. _5_ % of Completed Work$241,380.52 (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)$241,380.52TOTALS$0.00$0.006. TOTAL EARNED LESS RETAINAGE$4,586,229.56Net 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)$3,386,317.30Payment has been completed in accordance with the Contract Documents, 8. CURRENT PAYMENT DUE$1,199,912.26and that current payments shown herein are now due.9. BALANCE TO FINISH, PLUS RETAINAGE $8,816,558.44 (Line 3 less Line 6)CONSTRUCTION MANAGER:HOFFMANN + UHLHORN CONSTRUCTION, INC.State of: MINNESOTACounty of:Anoka County Subscribed and sworn to before me this 9/6/2022Notary Public:By:Date:9/6/2022My Commission expires:31-Jan-23ARCHITECT'S CERTIFICATE FOR PAYMENTAMOUNT CERTIFIED$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 SUBSTATION2022-09-13 CITY OF LAKE ELMO - OVERALLAPPLIC. FOR PAYMENT NO.#8H+U CONSTRUCTION EDITION OF AIA DOCUMENT G703PERIOD ENDING 8/31/2022 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 Conditions243,080.000.00243,080.0039,928.9614,862.7154,791.6723%188,288.332,739.58ReimburseConstruction Management Reimbursables488,555.000.00488,555.00202,183.7536,332.50238,516.2549%250,038.7511,925.81FeeConstruction Management Fee82,595.000.0082,595.0023,019.928,156.9131,176.8338%51,418.171,558.84TrailerTemporary City Office Trailer53,170.000.0053,170.0028,475.884,917.7833,393.6663%19,776.341,669.68ContingencyConstruction Contingency588,330.00(48,499.34)539,830.660.000.000.000%539,830.660.00TestingTesting & Special Inspections28,000.000.0028,000.000.000.000.000%28,000.000.00#0330Cast-In-Place Concrete668,316.0011,438.00679,754.00323,038.0053,866.00376,904.0055%302,850.0018,845.20#0341Strutctural Precast1,755,999.00580.001,756,579.00724,998.55910,669.921,635,668.4793%120,910.5381,783.42#0510Steel Erection93,400.000.0093,400.0016,000.000.0016,000.0017%77,400.00800.00#0512Steel Supply485,000.009,215.00494,215.00258,784.180.00258,784.1852%235,430.8212,939.21#0610Carpentry & GC1,027,000.000.001,027,000.00208,436.540.00208,436.5420%818,563.4610,421.83#0750Roofing & Metal Panels1,113,300.000.001,113,300.00243,465.0054,718.25298,183.2527%815,116.7514,909.16#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 & Curtainwall400,410.000.00400,410.0021,205.0096,500.00117,705.0029%282,705.005,885.25#0920Drywall & Fireproofing543,770.0025,699.00569,469.00124,000.000.00124,000.0022%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 & Heating854,000.000.00854,000.00371,428.0918,060.49389,488.5846%464,511.4219,474.43#2300HVAC & Controls962,000.000.00962,000.00101,898.150.00101,898.1511%860,101.855,094.91#2600Electrical1,454,170.00(3,227.66)1,450,942.34177,560.0060,350.00237,910.0016%1,213,032.3411,895.50#3100Earthwork & Site Utilities575,790.004,795.00580,585.00421,972.504,631.00426,603.5073%153,981.5021,330.18#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 AMOUNTS13,402,788.000.0013,402,788.003,564,544.521,263,065.564,827,610.0836%8,575,177.92241,380.52 APPLICATION AND CERTIFICATE FOR PAYMENTTO (OWNER): PROJECT:LAKE ELMO CITY HALL, FIRE DEPARTMENT APPLICATION NO: 8Distribution to:City of Lake Elmo & PUBLIC WORKS FACILITIES REMODELXOWNER3880 Laverne Ave N PERIOD TO:8/31/2022Lake 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 $1,794,537.54NumberDate Approved (Column G on G703) 5. RETAINAGE:$0.00$0.00 a. _5_ % of Completed Work$89,726.89 (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)$89,726.89TOTALS$0.00$0.006. TOTAL EARNED LESS RETAINAGE$1,704,810.65Net 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)$1,322,772.24Payment has been completed in accordance with the Contract Documents, 8. CURRENT PAYMENT DUE$382,038.41and that current payments shown herein are now due.9. BALANCE TO FINISH, PLUS RETAINAGE $4,787,730.35 (Line 3 less Line 6)CONSTRUCTION MANAGER:HOFFMANN + UHLHORN CONSTRUCTION, INC.State of: MINNESOTACounty of:Anoka County Subscribed and sworn to before me this 9/6/2022Notary Public:By:Date:9/6/2022My Commission expires:31-Jan-23ARCHITECT'S CERTIFICATE FOR PAYMENTAMOUNT CERTIFIED$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 SUBSTATION CITY OF LAKE ELMO - LABOR & GENERAL CONDITIONSAPPLIC. FOR PAYMENT NO.#8H+U CONSTRUCTION EDITION OF AIA DOCUMENT G703PERIOD ENDING 8/31/2022 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 Conditions243,080.000.00243,080.0039,928.9614,862.7154,791.6723%188,288.332,739.58ReimburseConstruction Management Reimbursables488,555.000.00488,555.00202,183.7536,332.50238,516.2549%250,038.7511,925.81FeeConstruction Management Fee82,595.000.0082,595.0023,019.928,156.9131,176.8338%51,418.171,558.84TrailerTemporary City Office Trailer53,170.000.0053,170.0028,475.884,917.7833,393.6663%19,776.341,669.68ContingencyConstruction Contingency588,330.00(48,499.34)539,830.660.000.000.000%539,830.660.00TestingTesting & Special Inspections28,000.000.0028,000.000.000.000.000%28,000.000.00#0330Cast-In-Place Concrete428,316.0011,438.00439,754.00203,038.0036,866.00239,904.0055%199,850.0011,995.20#0341Strutctural Precast333,704.000.00333,704.000.00273,300.32273,300.3282%60,403.6813,665.02#0510Steel Erection93,400.000.0093,400.0016,000.000.0016,000.0017%77,400.00800.00#0610Carpentry & GC459,000.000.00459,000.00184,636.540.00184,636.5440%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 & Fireproofing314,360.0016,224.00330,584.0059,000.000.0059,000.0018%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 & Heating363,000.000.00363,000.00132,657.128,509.50141,166.6239%221,833.387,058.33#2300HVAC & Controls300,000.000.00300,000.0012,148.150.0012,148.154%287,851.85607.41#2600Electrical646,070.00(2,100.00)643,970.0069,945.0015,100.0085,045.0013%558,925.004,252.25#3100Earthwork & Site Utilities366,400.004,245.00370,645.00254,967.504,100.00259,067.5070%111,577.5012,953.38#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 AMOUNTS6,492,541.000.006,473,848.661,392,391.82402,145.721,794,537.5428%4,679,311.1289,726.89 INVOICE SUMMARY-PAYMENT APPLICATION NO. #8CITY OF LAKE ELMO - LABOR & GENERAL CONDITIONSPERIOD ENDING 8/31/2022ITEM NO# DESCRIPTION VENDORDATENUMBERAMOUNTRETAINAGEDUE1General ConditionsH+U Construction8/31/22Applic #8$14,862.71$743.14$14,119.57ReimburseConstruction Management ReimbursablesH+U Construction8/31/22Applic #8$36,332.50$1,816.63$34,515.87FeeConstruction Management FeeH+U Construction8/31/22Applic #8$8,156.91$407.85$7,749.06TrailerTemporary City Office TrailerH+U Construction8/31/22Applic #6$4,917.78$245.89$4,671.89#0330Cast-In-Place ConcreteAxel H. Ohman, Inc.8/31/22Applic #3$36,866.00$1,843.30$35,022.70#0341Strutctural PrecastWells Concrete8/31/22Applic #1$273,300.32$13,665.02$259,635.30#2200Plumbing & HeatingPeterson Sheet Metal8/31/22Applic #4$8,509.50$425.48$8,084.02#2600ElectricalVinco, Inc.8/31/22Applic #6$15,100.00$755.00$14,345.00#3100Earthwork & Site UtilitiesPark Construction Company8/31/22Applic #5$4,100.00$205.00$3,895.00SUBTOTAL AMOUNT DUE$402,145.72$20,107.31$382,038.41 TOTAL AMOUNT DUE $382,038.41 INVOICE : 220240 PROJECT: J21001 AUGUST 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 August, 2022 CONSTRUCTION MANAGEMENT REIMBURSABLES Senior Project Manager 35.00 hrs. @ 125.00 $4,375.00 Project Manager 86.00 hrs. @ 105.00 $9,030.00 Project Administrator/Accountant 16.50 hrs. @ 65.00 $1,072.50 Project Superintendent 191.00 hrs. @ 105.00 $20,055.00 Truck, Travel, & Small Tools 1 mo. @ 1,400.00 $1,400.00 Field Office Equipment 1 mo. @ 400.00 $400.00 $36,332.50 GENERAL CONDITIONS Temporary City Office Trailer $4,917.78 Plan Prints/Shipping $148.08 Expendable Supplies $1,138.38 Drinking Water $31.68 Temporary Toilets $193.28 Construction Fencing $680.00 Safety & OSHA $2,630.34 Equipment Rental $1,057.16 Xcel Energy - Utility Service $101.68 Trash Removal $290.88 Scaffold Rental $236.23 Trailer $1,350.00 Skid Steer $1,800.00 Braun Intertec Corporation $5,205.00 $19,780.49 $56,112.99 Subtotal Construction Management Reimbursables Subtotal Reimbursable Expenses Total INVOICE : 220240 PROJECT: J21001 AUGUST 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 August 31, 2022 #0330-Labor Axel H. Ohman, Inc.$36,866.00 #0330-Material Axel H. Ohman, Inc.$17,000.00 #0341-Labor Wells Concrete $273,300.32 #0341-Material Wells Concrete $637,369.60 #0750-Material Palmer-West Construction $54,718.25 #0840-Material Empirehouse Inc.$96,500.00 #2200-Labor Peterson Sheet Metal, Inc.$8,509.50 #2200-Material Peterson Sheet Metal, Inc.$9,550.99 #2600-Labor Vinco, Inc.$15,100.00 #2600-Material Vinco, Inc.$45,250.00 #3100-Labor Park Construction Company $4,100.00 #3100-Material Park Construction Company $531.00 $1,198,795.66 $8,156.91 $1,263,065.56 Retainage Current Retainge 63,153.30 Prior Retainage 178,227.22 Retainage-To-Date 241,380.52 Total Amount Due $1,199,912.26 CONSTRUCTION MANAGEMENT FEE Total Contractor's Pay Applications August 1 - August 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 09/01/2022 Due Date Customer PO No. RQ152297 Lake Elmo DW Trailer Invoice No.: Invoice Date:08/02/2022 INV591666 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 09/01/2022 Due Date Customer PO No. RQ152297 Lake Elmo DW Trailer Invoice No.: Invoice Date:08/02/2022 INV591666 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 09/01/2022 Due Date Customer PO No. RQ152297 Lake Elmo DW Trailer Invoice No.: Invoice Date:08/02/2022 INV591666 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 08/02/22 08/29/22 1 2,000.00 2,000.00 RR not utilized no need to winterize. STEPS Steps - Rental 08/02/22 08/29/22 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 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 09/29/2022 Due Date Customer PO No. RQ152297 Lake Elmo DW Trailer Invoice No.: Invoice Date:08/30/2022 INV598958 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 09/29/2022 Due Date Customer PO No. RQ152297 Lake Elmo DW Trailer Invoice No.: Invoice Date:08/30/2022 INV598958 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 09/29/2022 Due Date Customer PO No. RQ152297 Lake Elmo DW Trailer Invoice No.: Invoice Date:08/30/2022 INV598958 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 08/30/22 09/26/22 1 2,000.00 2,000.00 RR not utilized no need to winterize. STEPS Steps - Rental 08/30/22 09/26/22 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 54MNI90526928/3/2022 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 54MNO90487457/29/2022NET30ARC DELIVERY1016013ASI #24 Stair 2 Revisions 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: $47.288/3/202254MNI90526921016013 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/9B93E538-4FC2-4904-94C0-4E66CD7A8848 QuickPay Online Payment Scan or Click ARC DOCUMENT SOLUTIONS LLC 4730 PARK GLEN RD SAINT LOUIS PARK MN 55416-5701 54MNI90528578/12/2022 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 54MNO90490488/16/2022NET30ARC DELIVERY1016013 OrderOrder Due DatePayment TermsShipping MethodCustomer IDPurchase Order # ASI 25 Security Camera RevisionsJ21001Lisa Knox Project NameProject NumberOrdered By Extended PricePriceDescriptionItem NumberUOM Quantity BO Quantity Shipped Quantity Ordered 1 set of 3 (30.00x42.00) $2.97$0.10989Bond Prints - First Set1600SQFT0.0027.0027.00 1 set of 1 $1.93$1.92918Stapling Sets1624EACH011 1 set of 1 $35.00$35.00Courier Charge5202EACH011 $5.00$5.00Energy / Fuel Surcharge5205EACH011 $48.27Total Due Amount Received $48.27Total $0.00Trade Discount $0.00Freight $3.37Tax $0.00Misc $44.90SubtotalllakotasBiller: $48.278/12/202254MNI90528571016013 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/7AE21DBB-02B1-41C9-8A46-2E3F8F6991DA QuickPay Online Payment Scan or Click ARC DOCUMENT SOLUTIONS LLC 4730 PARK GLEN RD SAINT LOUIS PARK MN 55416-5701 54MNI90529628/18/2022 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 54MNO90491588/22/2022NET30ARC DELIVERY1016013R2 FA Shops 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 1 set of 1 $1.93$1.92918Stapling Sets1624EACH011 $35.00$35.00Supply / Delivery Charge5201EACH011 $5.00$5.00Energy / Fuel Surcharge5205EACH011 $52.53Total Due Amount Received $52.53Total $0.00Trade Discount $0.00Freight $3.68Tax $0.00Misc $48.85SubtotalllakotasBiller: $52.538/18/202254MNI90529621016013 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/33AF1787-4106-42D4-8F4A-BF939DB79979 QuickPay Online Payment Scan or Click U1WRKINV Invoice Amount: $420.68 Terms: Due Upon Receipt Payment options: Contact our credit office 212-333-6600 Ext. 8 REMIT TO: UNITED RENTALS (NORTH AMERICA),INC. PO BOX 840514 DALLAS TX 75284-0514 INVOICE Page 1 EQUIP # Make Model Serial # Description COE223964 BOBCAT S650 ALJ811152 SKID STEER TRACK LOA CustEqp#: 1152 Hr Meter: 1485.500 Cat/Class 903-0585 PARTS: Qty Part Number Description StkCl Bin Loc Unit of Measure Price Extended 1 TIRE REPAIR-CES TIRE REPAIR - CUSTOM MCI EACH 385.000 385.00 1 ENV ENVIRONMENTAL SERVIC MCI EACH 7.700 7.70 ISSUE: FLAT TIRE CAUSE: FLAT TIRE CORRECTION: DISPATCHED POMPS TIRE REPAIRED TIRE DISMOUNT RESEAL MOUNT TIRE Total Parts & Materials 392.70 Tax 27.98 Total Amount 420.68 JOBSITE 3880 LAVERNE AVE N LAKE ELMO MN 55042-9627 Office: 612-438-0258 Cell: 651-395-0055 H U CONSTRUCTION 5555 W 78TH ST, SUITE A MINNEAPOLIS MN 55439 BRANCH J23 3750 HIGHWAY 13 W BURNSVILLE MN 55337-1717 952-895-8005 952-895-5085 FAX # 209524102-001 Job Site Job Site Job Site Job Site Job Site Job Site Job Site Job Site Job Site Job Site Job Site Job Site Job Site Job Site Job Site Job Site Customer # : Work Order Date: Invoice date : UR Job Loc : UR Job # : Customer Job ID: P.O. # : Authorized : Written by : 5527178 08/11/22 08/11/22 3880 LAVERNE AVE N, LAKE 4 - GABE DAREN WALTER Where permitted by law, United Rentals may impose a surcharge of 1.8% for credit card payments on charge accounts. This surcharge is not greater than our merchant discount rate for credit card transactions and is subject to sales tax in some jurisdictions. Due to the hazardous nature of some waste and other products, to comply with federal and state environmental regulations, and to promote a clean environment, United charges an Environmental Service Charge for certain services. This is not a government-mandated charge. The Environmental Service Charge is not designated for any particular use and is used at United's discretion. The Environmental Service Charge is 2.0% of the fees charged for items listed and will not exceed $99. Customer acknowledges the items indicated above are subject to the Environmental Service Charge and Customer agrees to pay that Charge. The total labor amount indicated above is subject to a charge which represents the costs and profits to United Rentals for the use of miscellaneous shop supplies in connection with the labor and other services provided to Customer (the "Shop Supplies Charge"). The Shop Supplies Charge is four percent (4%) of the total amount for labor and will not exceed $75.00 per Work Order. Fuel charges do not include federal, state, or local excise taxes. THIS INVOICE IS ISSUED SUBJECT TO THE TERMS AND CONDITIONS OF THE WORK ORDER TERMS, which are updated from time to time and posted online at www.unitedrentals.com/legal/workorder and incorporated herein by reference. Customer must read and agree to the online terms. By agreeing to the Work Order Terms, Customer will agree (1) to indemnify United for losses relating to this transaction; (2) that United's liabilities to Customer and any other person are limited, and (3) that United makes no warranties, express or implied, including without limitation, warranties of merchantability, quality or fitness for a particular purpose. Los Términos de la Orden de Trabajo están disponsibles en español en línea en http://www.unitedrentals.com/legal/ workorder-es. A PAPER COPY OF THE WORK ORDER TERMS OR MAINTENANCE & INSPECTION TERMS IS AVAILABLE UPON REQUEST. Biffs, Inc6430 County Rd 101 EShakopee MN 55379-5202952.403.1221 Invoice #W876015 8/10/2022 W876015 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: 9/7/2022 Terms Due Date PO #Sales Rep Builders Club# Net 28 9/7/2022 -Jeff Foley Qty Item Days Sales Order #Service Level Rate Amount 1 RENTAL RegularUnit Jul 13-Aug 09 28 385563 -$4.00 $4.00 1 SERVICEService Jul 13-Aug 09 28 385563 1X/wk $70.00 $70.00 1 SERVICEClimateSvc Jul 13 to Aug 09 28 385563 1X/wk $16.00 $16.00 1 RENTAL HandSani Jul 13-Aug 09 28 385563 -$0.00 $0.00 1 RENTALRegularUnit Jul 13-Aug 09 28 386930 -$4.00 $4.00 1 SERVICE Service Jul 13-Aug 09 28 386930 1X/wk $70.00 $70.00 1 SERVICEClimateSvc Jul 13 to Aug 09 28 386930 1X/wk $16.00 $16.00 1 RENTAL HandSani Jul 13-Aug 09 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 #W876015 8/10/2022 W876015 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 #W876015 Amount Due $193.28 Amount Paid ______________________ OECS OECS - 170064 PO Box 9201 Minneapolis, MN 55480 763-417-9599 accounting@oecscomply.com Invoice 36885 BILL TO H+U Construction 5555 West 78th Street, Suite A Minneapolis, MN 55439 DATE 07/15/2022 PLEASE PAY $11,500.00 DUE DATE 07/30/2022 DATE DESCRIPTION QTY RATE AMOUNT March - June Monthly Safety Services 4 2,875.00 11,500.00 TOTAL DUE $11,500.00 THANK YOU. Branch:100 St. Paul 1368956 Invoice Date Page INVOICE 3247103 ORDER NUMBER Columbus, MN 55025 9205 Lake Drive NE Viking Industrial Center 1 of 1651-646-6141 INVOICE 08/05/2022 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 15913657Tracking #:Carrier: Net Due Date Discount AmountDisc Due DateTerm DescriptionPO Number Lake Elmo Net 30 09/04/2022 09/04/2022 0.00 Primary Salesrep NameOrder Date Pick Ticket No Taker 08/04/2022 10:53:41 2275681 Douglas P. Geist TWOODBURY Item ID Item DescriptionOrderedShippedRemaining Quantities UOM Disp.Unit Size Pricing UOM Unit PriceUnit Size PriceExtended 2.00 0.00 EA V0J-SCT2-1H-5Y EA 173.968000 347.94 1.0 1.0000 2.00 TYPE2 SFTY CAN FLAM 1X9 FLEX HS 5GAL YW Type 2 Safety Can for Flammables with 1x 9 Flexible Hose - 5 Gallon Yellow (7250230) Ordered As:7250230 SUB-TOTAL:Total Lines:1 347.94 Total Freight In:TOTAL FREIGHT:Total Freight Out:48.190.00 48.19 MN STATE TAX 27.23: MN SPECIAL TAX 1.98: 425.34AMOUNT 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 126521501-0003 PO BOX 409211 ATLANTA, GA 30384-9211 661003 8/10/22 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 7/26/22 THRU 8/22/22. . 984.55. 4 WEEK BILL NET 30 ANNA CLARK anna.clark@sunbeltrentals.com DOMINIC, DOMINIC Invoice Date 8/15/2022 Invoice # 351266Customer 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 8/10/2022 Clean Recycled Concrete/Masonry @ $225.00734386 1Each 225.00 225.00 8/10/2022 Disposal Fee @ $65.88734386 1Each 65.88 65.88 $290.88 $290.88 $0.00 Invoice A118778 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 8/3/2022Date Job Site Shipping Address: 3880 LAVERNE AVE N LAKE ELMO, MN 55042-9627 Created: 8/4/2022 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 7/7/2022 8/3/2022 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: August 04, 2022 6:47:51 AM Page 1 of 1A118778 INVOICE Braun Intertec Corporation Lockbox #446035 PO BOX 64384 Saint Paul, MN 55164-0384 (952) 995-2000 (952) 995-2020 Telephone Fax PLEASE REMIT TO Tax I.D.41-1684205 Hoffmann + Uhlhorn Construction, Inc. (H+U Construction) 5555 West 78th Street, Suite A Minneapolis, MN 55439 Luke Nelson B304004Invoice number Date 8/3/2022 Project ID B2203298 Customer account 27053 Customer PO For Professional Services rendered through 7/29/2022 Lake Elmo Public Facilities Special Inspections & Materials Testing 3800 Laverne Avenue North Lake Elmo, MN 55042 1 - Construction and Materials Testing 1.1 - Soil Observations and Testing $1,007.50 1.2 - Concrete Observations and Testing $3,259.50 1.6 - Project Management $938.00 $5,205.00 Total Fees $5,205.00 Amount Previously Invoiced: $5,212.00 Amount Invoiced to Date: $10,417.00 Please pay from this invoice. Terms: Due on receipt, 1 1/2% per month after 30 days, 18% annual percentage rate, unless otherwise specified by written agreement. Page 1 of 2 Projects: B2203298 - Lake Elmo Public Facilities Invoice number: B304004 Qty/Hours Rate Amount 1 - Construction and Materials Testing 1.1 - Soil Observations and Testing Consulting Services Detail Staff Engineer 2.00 132.00 264.00 Project Engineer 0.25 162.00 40.50 Senior Engineer 1.00 182.00 182.00 Compaction Testing - Nuclear 3.00 82.00 246.00 Non-Salary Detail Nuclear moisture-density meter charge, per hour 3.00 20.00 60.00 Moisture Density Relationship (Standard), per sample 1.00 180.00 180.00 CMT Trip Charge 1.00 35.00 35.00 Total 1.1 - Soil Observations and Testing $1,007.50 1.2 - Concrete Observations and Testing Consulting Services Detail Concrete Observations 11.25 92.00 1,035.00 Concrete Testing 8.50 82.00 697.00 Concrete Testing 1.00 103.00 103.00 OT Concrete Cylinder Pick up 2.25 82.00 184.50 Non-Salary Detail Compressive strength of concrete cylinders (ASTM C 39),per specimen 25.00 30.00 750.00 CMT Trip Charge 14.00 35.00 490.00 Total 1.2 - Concrete Observations and Testing $3,259.50 1.6 - Project Management Consulting Services Detail Staff Engineer 5.00 132.00 660.00 Project Control Specialist 0.50 120.00 60.00 Project Engineer 0.25 162.00 40.50 Senior Engineer 0.75 182.00 136.50 Project Assistant 0.50 82.00 41.00 Total 1.6 - Project Management $938.00 Total 1 - Construction and Materials Testing $5,205.00 Total Project $5,205.00 Page 2 of 2 35,022.708/29/22 7228/29/22 8/29/22 3,895.008/29/22 APPLICATION AND CERTIFICATE FOR PAYMENTTO (OWNER): PROJECT:LAKE ELMO CITY HALL, FIRE DEPARTMENT APPLICATION NO: 8Distribution to:City of Lake Elmo & PUBLIC WORKS FACILITIES REMODELXOWNER3880 Laverne Ave N PERIOD TO:8/31/2022Lake 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 $3,033,072.54NumberDate Approved (Column G on G703) 5. RETAINAGE:$0.00$0.00 a. _5_ % of Completed Work$151,653.63 (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)$151,653.63TOTALS$0.00$0.006. TOTAL EARNED LESS RETAINAGE$2,881,418.91Net 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)$2,063,545.06Payment has been completed in accordance with the Contract Documents, 8. CURRENT PAYMENT DUE$817,873.85and that current payments shown herein are now due.9. BALANCE TO FINISH, PLUS RETAINAGE $4,028,828.09 (Line 3 less Line 6)CONSTRUCTION MANAGER:HOFFMANN + UHLHORN CONSTRUCTION, INC.State of: MINNESOTACounty of:Anoka County Subscribed and sworn to before me this 9/6/2022Notary Public:By:Date:9/6/2022My Commission expires:31-Jan-23ARCHITECT'S CERTIFICATE FOR PAYMENTAMOUNT CERTIFIED$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 SUBSTATION CITY OF LAKE ELMO - MATERIALAPPLIC. FOR PAYMENT NO.#8H+U CONSTRUCTION EDITION OF AIA DOCUMENT G703PERIOD ENDING 8/31/2022 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 Concrete240,000.000.00240,000.00120,000.0017,000.00137,000.0057%103,000.006,850.00#0341Strutctural Precast1,422,295.00580.001,422,875.00724,998.55637,369.601,362,368.1596%60,506.8568,118.41#0512Steel Supply485,000.009,215.00494,215.00258,784.180.00258,784.1852%235,430.8212,939.21#0610Carpentry & GC568,000.000.00568,000.0023,800.000.0023,800.004%544,200.001,190.00#0750Roofing & Metal Panels498,500.000.00498,500.00243,465.0054,718.25298,183.2560%200,316.7514,909.16#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 & Curtainwall321,960.000.00321,960.0010,830.0096,500.00107,330.0033%214,630.005,366.50#0920Drywall & Fireproofing229,410.009,475.00238,885.0065,000.000.0065,000.0027%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 & Heating491,000.000.00491,000.00238,770.979,550.99248,321.9651%242,678.0412,416.10#2300HVAC & Controls662,000.000.00662,000.0089,750.000.0089,750.0014%572,250.004,487.50#2600Electrical808,100.00(1,127.66)806,972.34107,615.0045,250.00152,865.0019%654,107.347,643.25#3100Earthwork & Site Utilities209,390.00550.00209,940.00167,005.00531.00167,536.0080%42,404.008,376.80#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 AMOUNTS6,910,247.000.006,928,939.342,172,152.70860,919.843,033,072.5444%3,895,866.80151,653.63 INVOICE SUMMARY-PAYMENT APPLICATION NO. #8CITY OF NEWPORT - MATERIALPERIOD ENDING 8/31/2022ITEM NO# DESCRIPTION VENDORDATENUMBERAMOUNTRETAINAGEDUE#0330Cast-In-Place ConcreteAxel H. Ohman, Inc.8/31/22Applic #3$17,000.00$850.00$16,150.00#0341Strutctural PrecastWells Concrete8/31/22Applic #5$637,369.60$31,868.48$605,501.12#0750Roofing & Metal PanelsPalmer West Construction8/31/22Applic #2$54,718.25$2,735.91$51,982.34#0840Aluminum Storefronts & CurtainwallEmpirehouse, Inc.8/31/22Applic #3$96,500.00$4,825.00$91,675.00#2200Plumbing & HeatingPeterson Sheet Metal8/31/22Applic #5$9,550.99$477.55$9,073.44#2600ElectricalVinco, Inc.8/31/22Applic #6$45,250.00$2,262.50$42,987.50#3100Earthwork & Site UtilitiesPark Construction Company8/31/22Applic #5$531.00$26.55$504.45SUBTOTAL AMOUNT DUE$860,919.84$43,045.99$817,873.85 TOTAL AMOUNT DUE $817,873.85 16,150.008/29/22 ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? INSR ADDL SUBRLTR INSD WVD PRODUCER CONTACTNAME:FAXPHONE(A/C, No):(A/C, No, Ext): E-MAILADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER: $ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH-STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A(Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS. 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. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THISCERTIFICATE 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), AUTHORIZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. 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 onthis certificate does not confer rights to the certificate holder in lieu of such endorsement(s). COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 8/22/2022 (507) 373-6446 (507) 373-8424 19038 The Wells Companies, IncPO Box 656 Albany, MN 56307-0656 10677 A 1,000,000 VTC2K-CO-3L210289-IND-22 4/1/2022 4/1/2023 500,000 10,000 1,000,000 2,000,000 2,000,000 X Contractual Liability 1,000,000A VTC2J-CAP-3L210265-TIL-22 4/1/2022 4/1/2023 5,000,000A CUP-3L210290-22-25 4/1/2022 4/1/2023 5,000,000 10,000 A UB-9R415762-22-25-H 4/1/2022 4/1/2023 1,000,000N1,000,000 1,000,000 A Leased/Rented Equip QT-660-8A135732-TIL-22 4/1/2022 Leased/Rented Equip 1,798,000 B Excess Umbrella EXS 0379319 4/1/2022 4/1/2023 Excess Umbrella 5,000,000 WC Job# 7509. Project Lake Elmo Fire Station, 3880 Laverne Ave North, Lake Elmo, MN 55042. The certificate and all parties per written contract are additional insureds on the General Liability and Auto Liability policy on a primary, non-contributory basis per written contract. The Umbrella coverage follows form. Should the insurance company cancel the above insurance for any other reason than non-payment of premium 30 day notice will be mailed. The Work Comp coverage is for the following states Iowa, South Dakota, Colorado, and Wisconsin. Minnesota is self- insured. Stored materials in the amount of $177,583.02. City of Lake Elmo 3880 Laverne Ave North, Ste 100 Lake Elmo, MN 55042 WELLCOM-01 DERSH1 Heartman Insurance1606 E. Main StreetAlbert Lea, MN 56007 info@heartman.com Travelers Cincinnati Insurance Company Aggregate Limit X 4/1/2023 X X X X X X X X X 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 8/29/22 08/22/2022 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 $290,583.85 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 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 91,675.00 321,960.00 0.00 321,960.00 107,330.00 5,366.50 101,963.50 10,288.50 0.00 91,750.00 15,580.00 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 91,675.00 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: 3 Date: 08/01/22 Period To: 08/31/22 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 Date: __________________________________ Subscribed and sworn to before me this _____ day of ____________, _________ (year). Notary public: _____________________________ My commission expires ____________________. Contractor: Empirehouse Inc. By: ____________________________________ Title: ___________________________________ Date: __________________________________ Subscribed and sworn to before me this _____ day of ____________, _________ (year). Notary public: _____________________________ My commission expires ____________________. Contractor: Empirehouse Inc. By: ____________________________________ Title: ___________________________________ August 18, 2022 18 August 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 6,250.00 4,750.00 0.00 11,000.00 42.15 550.0015,100.00 49,080.00 0.00 0.00 49,080.00 49,080.00 100.00 2,454.000.00 17,575.00 0.00 0.00 17,575.00 17,575.00 100.00 878.750.00 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 17,565.00 17,565.00 100.00 878.250.00 7,530.00 0.00 0.00 7,530.00 7,530.00 100.00 376.500.00 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 10,830.00 4,750.00 91,750.00 107,330.00 33.34 5,366.50214,630.00 To:H+U Construction From (Subcontractor):Empirehouse Inc. Project:Lake Elmo City Center (M) Application and Certificate For Payment -- page 2 Application No: 3 Date: 08/01/22 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: 08/31/22 Contractor's Job Number: 21153 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 THISCERTIFICATE 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 OCCURRENCE DAMAGE 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 8/24/2022 Marsh &McLennan Agency LLC6150GoldenHillsDriveMinneapolisMN55416 Centralized Accounts Service Team CAST@MarshMMA.com Lloyds of London 55555 EMPIREHOUSE National Union Fire Ins Co PittsburghPA 19445EmpirehouseInc.5200 Quincy StreetMoundsViewMN55112 Burlington Insurance Company 23620 Charter Oak Fire Insurance Company 25615 New Hampshire Insurance Company 23841 393489347 B X 2,000,000 X 100,000 25,000 2,000,000 4,000,000 X GL3118632 3/1/2022 3/1/2023 4,000,000 B 2,000,000 X CA5425627 3/1/2022 3/1/2023 C X X 6,000,000370BE01163023/1/2022 3/1/2023 6,000,000 X 0 E X N WC011326667 3/1/2022 3/1/2023 1,000,000 1,000,000 1,000,000 AD Professional&PollutionBusinessPersonalProperty B0621PEMPI001022QT6608A140858COF22 3/1/20223/1/2022 3/1/20233/1/2023 Per Claim /AggregateLimit 2,000,0002,000,000 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 bytheStateofMinnesota.In case of insolvency,payment of claims is not guaranteed.Company A and Company C are subject to statutes and regulations ofsurpluslinescarriers.Re:Job #J21001,Lake Elmo Public Facilities,Lake Elmo City Center -3880 Laverne Avenue North,Lake Elmo,MN 55042;Lake Elmo Public Works Addition -3445 Ideal Avenue North,Lake Elmo,MN 55042. August 2022 pay applicationStoredamount$91,750.00SeeAttached... H+U Construction5555West78thStreet,Suite AMinneapolis,MN 55439 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: EMPIREHOUSE 1 1 Marsh &McLennan Agency LLC Empirehouse Inc.5200 Quincy StreetMoundsViewMN55112 25 CERTIFICATE OF LIABILITY INSURANCE City of Lake Elmo (Owner),Leo A.Daly (Architect),H+U Construction (Construction Manager)and the Architect’s consultants are included as additional insuredsforgeneralliability,including ongoing and completed operations,automobile liability,and umbrella liability,on a primary and non-contributory basis,for workperformedbythenamedinsured,if required by written contract. POLICY NUMBER: ADDITIONAL INSURED - OWNERS, LESSEES ORCONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s)Location And Description Of Completed Operations COMMERCIAL GENERAL LIABILITYCG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 37 04 13 Page 1 of 1Insurance Services Office, Inc., 2012 A. Section II - Who Is An Insured is amended toinclude as an additional insured the person(s) or organization(s) shown in the Schedule, but onlywith respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". However: 1.The insurance afforded to such additional insured only applies to the extent permitted by law; and 2.If coverage provided to the additional insured is required by a contract or agree- ment, the insurance afforded to such addi- tional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B.With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1.Required by the contract or agreement; or 2.Available under the applicable Limits of Insu- rance shown in the Declarations; whichever is less. This endorsement shall not increase the appli- cable Limits of Insurance shown in the Decla- rations. GL 311-86-32 ANY PERSON OR ORGANIZATION WHOM YOU BECOME OBLIGATED TO INCLUDE AS AN ADDITIONAL INSURED AS A RESULT OF ANY WRITTEN CONTRACT OR AGREEMENT YOU HAVE ENTERED INTO THAT REQUIRES SUCH ADDITIONAL INSURED COVERAGE. PER THE WRITTEN CONTRACT OR AGREEMENT. POLICY NUMBER: ADDITIONAL INSURED - OWNERS, LESSEES ORCONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE COMMERCIAL GENERAL LIABILITYCG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Insurance Services Office, Inc., 2012 CG 20 10 04 13 Page 1 of 2 A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1.Your acts or omissions; or 2.The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1.The insurance afforded to such additionalinsured only applies to the extent permitted by law; and 2.If coverage provided to the additional insured is required by a contract oragreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B.With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury"or "property damage" occurring after: 1.All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations hasbeen completed; or 2. That portion of "your work" out of whichthe injury or damage arises has been put to its intended use by any person ororganization other than another contractor or subcontractor engaged in performingoperations for a principal as a part of the same project. GL 311-86-32 Name Of Additional Insured Person(s)Or Organization(s)Location(s) Of Covered Operations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. ANY PERSON OR ORGANIZATION WHOM YOU BECOME OBLIGATED TO INCLUDE AS AN ADDITIONAL INSURED AS A RESULT OF ANY WRITTEN CONTRACT OR AGREEMENT YOU HAVE ENTERED INTO THAT REQUIRES SUCH ADDITIONAL INSURED COVERAGE. PER THE WRITTEN CONTRACT OR AGREEMENT. Insurance Services Office, Inc., 2012 Page 2 of 2 CG 20 10 04 13 C.With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured isrequired by a contract or agreement, the most we will pay on behalf of the additional insuredis the amount of insurance: 1.Required by the contract or agreement; or 2.Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. 8/29/22 8/29/22 08/18/2022 AssuredPartners of Minnesota LLC 2361 Hwy 36 W St. Paul MN 55113 Sheryl Davison (651) 644-7200 (651) 644-9137 sheryl.davison@assuredpartners.com Vinco, Inc. P. O. Box 907 Forest Lake MN 55025-0907 Continental Cas Co 20443 National Fire Ins Co of Hartford 20478 Continental Ins Co 35289 Starr Indemnity 22-23 Master A Contractual Included XCU Included GL 7015723122 05/01/2022 05/01/2023 1,000,000 100,000 15,000 1,000,000 2,000,000 2,000,000 B BUA 7015723119 05/01/2022 05/01/2023 1,000,000 Uninsured motorist combined single limit 1,000,000 C 0 CUE 7015723136 05/01/2022 05/01/2023 10,000,000 10,000,000 C N WC 7 15723105 05/01/2022 05/01/2023 1,000,000 1,000,000 1,000,000 D Stored Material-$42,296.00 ITC100065179022 05/01/2022 05/01/2023 Project: Lake Elmo City Center - Switchgear City of Lake Elmo 3880 Laverne Ave N, 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. 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