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#03 - City Center Pay Request
STAFF REPORT DATE: November 15, 2022 CONSENT AGENDA ITEM: City Center-Public Works Addition Pay Request #10 SUBMITTED BY: Kristina Handt, City Administrator BACKGROUND: At the November 3, 2021 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 #10 for the City Center and Public Works Addition project? PROPOSAL: Pay request #10 is for $1,250,686.75. A copy is included in your packet. FISCAL IMPACT: With this pay request, the project remains within budget. OPTION: 1) Approve pay request #10 2) Don’t approve pay request #10 RECOMMENDATION: “Motion to approve Pay Request #10 for the New City Center and Public Works Addition.” ATTACHMENTS: • Pay Request #10 APPLICATION AND CERTIFICATE FOR PAYMENTTO (OWNER): PROJECT:LAKE ELMO CITY HALL, FIRE DEPARTMENT APPLICATION NO: 10Distribution to:City of Lake Elmo & PUBLIC WORKS FACILITIES REMODELXOWNER3880 Laverne Ave N PERIOD TO:10/31/2022Lake 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 $6,849,725.77NumberDate Approved (Column G on G703) 5. RETAINAGE:$0.00$0.00 a. _5_ % of Completed Work$342,486.33 (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)$342,486.33TOTALS$0.00$0.006. TOTAL EARNED LESS RETAINAGE$6,507,239.44Net 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)$5,256,552.69Payment has been completed in accordance with the Contract Documents, 8. CURRENT PAYMENT DUE$1,250,686.75and that current payments shown herein are now due.9. BALANCE TO FINISH, PLUS RETAINAGE $6,895,548.56 (Line 3 less Line 6)CONSTRUCTION MANAGER:HOFFMANN + UHLHORN CONSTRUCTION, INC.State of: MINNESOTACounty of:Anoka County Subscribed and sworn to before me this 11/2/2022Notary Public:By:Date:11/2/2022My Commission expires:31-Jan-23ARCHITECT'S CERTIFICATE FOR PAYMENTAMOUNT CERTIFIED$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 SUBSTATION2022-11-08 CITY OF LAKE ELMO - OVERALLAPPLIC. FOR PAYMENT NO.#10H+U CONSTRUCTION EDITION OF AIA DOCUMENT G703PERIOD ENDING 10/31/2022 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 Conditions243,080.000.00243,080.0066,126.1731,313.3597,439.5240%145,640.484,871.98ReimburseConstruction Management Reimbursables488,555.000.00488,555.00275,573.7536,397.50311,971.2564%176,583.7515,598.56FeeConstruction Management Fee82,595.000.0082,595.0035,733.638,502.0744,235.7054%38,359.302,211.79TrailerTemporary City Office Trailer53,170.000.0053,170.0035,852.552,458.8938,311.4472%14,858.561,915.57ContingencyConstruction Contingency588,330.00(389,374.00)198,956.000.000.000.000%198,956.000.00TestingTesting & Special Inspections28,000.000.0028,000.000.000.000.000%28,000.000.00#0330Cast-In-Place Concrete668,316.0042,542.00710,858.00481,008.0061,000.00542,008.0076%168,850.0027,100.40#0341Strutctural Precast1,755,999.00580.001,756,579.001,664,768.5028,390.601,693,159.1096%63,419.9084,657.96#0510Steel Erection93,400.0011,270.00104,670.0046,000.0018,000.0064,000.0061%40,670.003,200.00#0512Steel Supply485,000.009,215.00494,215.00427,778.880.00427,778.8887%66,436.1221,388.94#0610Carpentry & GC1,027,000.0027,818.001,054,818.00221,231.3218,502.95239,734.2723%815,083.7311,986.71#0750Roofing & Metal Panels1,113,300.00(60,415.00)1,052,885.00453,949.65268,793.55722,743.2069%330,141.8036,137.16#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 & Curtainwall400,410.0094,127.00494,537.00154,455.0060,310.00214,765.0043%279,772.0010,738.25#0920Drywall & Fireproofing543,770.0045,514.00589,284.00134,000.0045,000.00179,000.0030%410,284.008,950.00#0930Tile154,980.000.00154,980.000.000.000.000%154,980.000.00#0950Acoustical Ceilings & Panels126,000.000.00126,000.000.0025,000.0025,000.0020%101,000.001,250.00#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 & Heating854,000.000.00854,000.00393,343.9489,593.97482,937.9157%371,062.0924,146.90#2300HVAC & Controls962,000.00154,703.001,116,703.00114,028.50584,249.50698,278.0063%418,425.0034,913.90#2600Electrical1,454,170.0059,225.001,513,395.00324,610.0039,000.00363,610.0024%1,149,785.0018,180.50#3100Earthwork & Site Utilities575,790.004,795.00580,585.00426,603.500.00426,603.5073%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 AMOUNTS13,402,788.000.0013,402,788.005,533,213.391,316,512.386,849,725.7751%6,553,062.23342,486.33 APPLICATION AND CERTIFICATE FOR PAYMENTTO (OWNER): PROJECT:LAKE ELMO CITY HALL, FIRE DEPARTMENT APPLICATION NO: 10Distribution to:City of Lake Elmo & PUBLIC WORKS FACILITIES REMODELXOWNER3880 Laverne Ave N PERIOD TO:10/31/2022Lake 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 $2,650,127.28NumberDate Approved (Column G on G703) 5. RETAINAGE:$0.00$0.00 a. _5_ % of Completed Work$132,506.39 (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)$132,506.39TOTALS$0.00$0.006. TOTAL EARNED LESS RETAINAGE$2,517,620.89Net 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)$2,039,129.18Payment has been completed in accordance with the Contract Documents, 8. CURRENT PAYMENT DUE$478,491.71and that current payments shown herein are now due.9. BALANCE TO FINISH, PLUS RETAINAGE $3,974,920.11 (Line 3 less Line 6)CONSTRUCTION MANAGER:HOFFMANN + UHLHORN CONSTRUCTION, INC.State of: MINNESOTACounty of:Anoka County Subscribed and sworn to before me this 11/2/2022Notary Public:By:Date:11/2/2022My Commission expires:31-Jan-23ARCHITECT'S CERTIFICATE FOR PAYMENTAMOUNT CERTIFIED$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 SUBSTATION2022-11-08 CITY OF LAKE ELMO - LABOR & GENERAL CONDITIONSAPPLIC. FOR PAYMENT NO.#10H+U CONSTRUCTION EDITION OF AIA DOCUMENT G703PERIOD ENDING 10/31/2022 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 Conditions243,080.000.00243,080.0066,126.1731,313.3597,439.5240%145,640.484,871.98ReimburseConstruction Management Reimbursables488,555.000.00488,555.00275,573.7536,397.50311,971.2564%176,583.7515,598.56FeeConstruction Management Fee82,595.000.0082,595.0035,733.638,502.0744,235.7054%38,359.302,211.79TrailerTemporary City Office Trailer53,170.000.0053,170.0035,852.552,458.8938,311.4472%14,858.561,915.57ContingencyConstruction Contingency588,330.00(389,374.00)198,956.000.000.000.000%198,956.000.00TestingTesting & Special Inspections28,000.000.0028,000.000.000.000.000%28,000.000.00#0330Cast-In-Place Concrete428,316.0028,053.00456,369.00304,519.0038,000.00342,519.0075%113,850.0017,125.95#0341Strutctural Precast333,704.000.00333,704.00302,400.359,226.44311,626.7993%22,077.2115,581.34#0510Steel Erection93,400.0011,270.00104,670.0046,000.0018,000.0064,000.0061%40,670.003,200.00#0610Carpentry & GC459,000.006,684.00465,684.00188,831.328,302.95197,134.2742%268,549.739,856.71#0750Roofing & Metal Panels614,800.00(31,650.00)583,150.00155,766.40251,803.80407,570.2070%175,579.8020,378.51#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 & Curtainwall78,450.000.0078,450.0010,375.001,560.0011,935.0015%66,515.00596.75#0920Drywall & Fireproofing314,360.0026,906.00341,266.0064,000.0027,000.0091,000.0027%250,266.004,550.00#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 & Heating363,000.000.00363,000.00141,166.6238,407.99179,574.6149%183,425.398,978.73#2300HVAC & Controls300,000.0012,406.00312,406.0019,278.5015,202.5034,481.0011%277,925.001,724.05#2600Electrical646,070.0018,008.00664,078.0085,745.0017,500.00103,245.0016%560,833.005,162.25#3100Earthwork & Site Utilities366,400.004,245.00370,645.00259,067.500.00259,067.5070%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 AMOUNTS6,492,541.000.006,179,089.002,146,451.79503,675.492,650,127.2843%3,528,961.72132,506.39 INVOICE SUMMARY-PAYMENT APPLICATION NO. #10CITY OF LAKE ELMO - LABOR & GENERAL CONDITIONSPERIOD ENDING 10/31/2022ITEM NO# DESCRIPTION VENDORDATENUMBERAMOUNTRETAINAGEDUE1General ConditionsH+U Construction10/31/22Applic #10$31,313.35$1,565.67$29,747.68ReimburseConstruction Management ReimbursablesH+U Construction10/31/22Applic #10$36,397.50$1,819.88$34,577.62FeeConstruction Management FeeH+U Construction10/31/22Applic #10$8,502.07$425.10$8,076.97TrailerTemporary City Office TrailerH+U Construction10/31/22Applic #8$2,458.89$122.94$2,335.95#0330Cast-In-Place ConcreteAxel H. Ohman, Inc.10/31/22Applic #5$38,000.00$1,900.00$36,100.00#0341Strutctural PrecastWells Concrete10/31/22Applic #3$9,226.44$461.32$8,765.12#0510Steel ErectionA.M.E. Construction Corp10/31/22Applic #3$18,000.00$900.00$17,100.00#0610Carpentry & GCEbert Construction10/31/22Applic #10$8,302.95$415.15$7,887.80#0750Roofing & Metal PanelsPalmer West Construction10/31/22Applic #2$251,803.80$12,590.19$239,213.61#0840Aluminum Storefronts & CurtainwallEmpirehouse, Inc.10/31/22Applic #4$1,560.00$78.00$1,482.00#0920Drywall & FireproofingCommercial Drywall10/31/22Applic #7$27,000.00$1,350.00$25,650.00#2200Plumbing & HeatingPeterson Sheet Metal10/31/22Applic #5$38,407.99$1,920.40$36,487.59#2300HVAC & ControlsSt. Cloud Refrigeration10/31/22Applic #4$15,202.50$760.13$14,442.37#2600ElectricalVinco, Inc.10/31/22Applic #8$17,500.00$875.00$16,625.00SUBTOTAL AMOUNT DUE$503,675.49$25,183.78$478,491.71 TOTAL AMOUNT DUE $478,491.71 INVOICE : 220275 PROJECT: J21001 OCTOBER 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 October, 2022 CONSTRUCTION MANAGEMENT REIMBURSABLES Senior Project Manager 66.00 hrs. @ 125.00 $8,250.00 Project Manager 54.00 hrs. @ 105.00 $5,670.00 Project Administrator/Accountant 22.50 hrs. @ 65.00 $1,462.50 Project Superintendent 183.00 hrs. @ 105.00 $19,215.00 Truck, Travel, & Small Tools 1 mo. @ 1,400.00 $1,400.00 Field Office Equipment 1 mo. @ 400.00 $400.00 $36,397.50 GENERAL CONDITIONS Temporary City Office Trailer $2,458.89 Drinking Water $8.59 Temp Heaters/Fans $14,831.09 Temporary Toilets $421.99 Equipment Rental $1,747.60 Xcel Energy - Utility Service $135.04 Trash Removal $678.00 Scaffold Rental $236.23 Trailer $1,350.00 Skid Steer $1,800.00 Manhole Covers Direct $1,754.31 Braun Intertec Corporation $8,350.50 $33,772.24 $70,169.74 Subtotal Construction Management Reimbursables Subtotal Reimbursable Expenses Total INVOICE : 220275 PROJECT: J21001 OCTOBER 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 October 31, 2022 #0330-Labor Axel H. Ohman, Inc.$38,000.00 #0330-Material Axel H. Ohman, Inc.$23,000.00 #0341-Labor Wells Concrete $9,226.44 #0341-Material Wells Concrete $19,164.16 #0510-Labor A.M.E. Construction Corp $18,000.00 #0610-Labor Ebert Construction $8,302.95 #0610-Material Ebert Construction $10,200.00 #0750-Labor Palmer-West Construction $251,803.80 #0750-Material Palmer-West Construction $16,989.75 #0840-Labor Empirehouse Inc.$1,560.00 #0840-Material Empirehouse Inc.$58,750.00 #0920-Labor Commercial Drywall, Inc.$27,000.00 #0920-Material Commercial Drywall, Inc.$18,000.00 #0950-Material Acoustic Associates, Inc.$25,000.00 #2200-Labor Peterson Sheet Metal, Inc.$38,407.99 #2200-Material Peterson Sheet Metal, Inc.$51,185.98 #2300-Labor St.Cloud Refrigeration, Inc.$15,202.50 #2300-Material St.Cloud Refrigeration, Inc.$569,047.00 #2600-Labor Vinco, Inc.$17,500.00 #2600-Material Vinco, Inc.$21,500.00 $1,237,840.57 $8,502.07 $1,316,512.38 Retainage Current Retainge 65,825.63 Prior Retainage 276,660.70 Retainage-To-Date 342,486.33 Total Amount Due $1,250,686.75 CONSTRUCTION MANAGEMENT FEE Total Contractor's Pay Applications October 1 - October 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 11/24/2022 Due Date Customer PO No. RQ152297 Lake Elmo DW Trailer Invoice No.: Invoice Date:10/25/2022 INV613895 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 11/24/2022 Due Date Customer PO No. RQ152297 Lake Elmo DW Trailer Invoice No.: Invoice Date:10/25/2022 INV613895 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 11/24/2022 Due Date Customer PO No. RQ152297 Lake Elmo DW Trailer Invoice No.: Invoice Date:10/25/2022 INV613895 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 10/25/22 11/21/22 1 2,000.00 2,000.00 RR not utilized no need to winterize. STEPS Steps - Rental 10/25/22 11/21/22 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 131349453-0001 PO BOX 409211 ATLANTA, GA 30384-9211 661003 10/05/22 1 LAKE ELMO LAKE ELMO CITY CENTER 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 131349453 BURNSVILLE MN CC PC1171 3700 W PRESERVE BLVD BURNSVILLE, MN 55337 7746 952-707-5050 1171 H + U CONSTRUCTION 5555 WEST 78TH STREET, SUITE A MINNEAPOLIS, MN 55439 . QTY EQUIPMENT # Min Day Week 4 Week Amount . 1.00 550K BTU MA DIRECT FIRE LPNG HEATER W/HD 3285.00 3285.00 10362184 Make: PSW Model: THP-550 Ser #: PSW0878 5PSI NG (Will get Power) 1.00 550K BTU MA DIRECT FIRE LPNG HEATER W/HD 3285.00 3285.00 10362189 Make: PSW Model: THP-550 Ser #: PSW0882 5PSI NG (Will get Power) 1.00 1M BTU MA DIRECT FIRE LPNG HEATER W/HOOD 4491.00 4491.00 TA013133 Make: TEMP AIR Model: THP-1000 Ser #: 13133 5PSI NG 208/1/25a 10.00 GAS HOSE 1" X 50' 198.00 1980.00 (2) 1" Pipe Tees Rental Sub-total: 13041.00 SALES ITEMS: Qty Item number Unit Price 1 DLPKSRCHG EA 105.750 105.75 TRANSPORTATION SURCHARGE 1 ENVIRONMENTAL EA 215.670 215.67 ENVIRONMENTAL/HAZMAT FEE 2133XXX0000 DELIVERY CHARGE 225.00 PICKUP CHARGE 225.00 CONTINUED DEMAND BILL NET 30 THERESA CASBOLT theresa.casebolt@sunbeltrentals.com SCHOER, GABE Biffs, Inc6430 County Rd 101 EShakopee MN 55379-5202952.403.1221 Invoice #W886000 10/5/2022 W886000 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 $325.35 Balance Due $325.35 Due Date: 11/2/2022 Terms Due Date PO #Sales Rep Builders Club# Net 28 11/2/2022 -Jeff Foley Qty Item Days Sales Order #Service Level Rate Amount 1 RENTAL RegularUnit Sep 07-Oct 04 28 385563 -$4.00 $4.00 1 SERVICEService Sep 07-Oct 04 28 385563 1X/wk $70.00 $70.00 1 SERVICEClimateSvc Sep 07 to Oct 04 28 385563 1X/wk $16.00 $16.00 1 RENTAL HandSani Sep 07-Oct 04 28 385563 -$0.00 $0.00 1 RENTALRegularUnit Sep 07-Oct 04 28 386930 -$4.00 $4.00 1 SERVICE Service Sep 07-Oct 04 28 386930 1X/wk $70.00 $70.00 1 SERVICEClimateSvc Sep 07 to Oct 04 28 386930 1X/wk $16.00 $16.00 1 RENTAL HandSani Sep 07-Oct 04 28 386930 -$0.00 $0.00 1 DELIVERYDelivery Sep 07 1 398087 -$33.00 $33.00 1 RENTAL RegularUnit Sep 07-Oct 04 28 398087 -$4.00 $4.00 1 SERVICEService Sep 07-Oct 04 28 398087 1X/wk $70.00 $70.00 1 SERVICE ClimateSvc Sep 07 to Oct 04 28 398087 1X/wk $16.00 $16.00 1 DELIVERYDelivery Sep 07 1 398087 -$0.00 $0.00 1 RENTALHandSani Sep 07-Oct 04 28 398087 -$0.00 $0.00 0 TAX-MN Tax-MN ---$0.00 $20.83 0 TAX-WASHTax-WASH ---$0.00 $1.52 Biffs, Inc6430 County Rd 101 EShakopee MN 55379-5202952.403.1221 Invoice #W886000 10/5/2022 W886000 2 of 2 Subtotal $325.35 Invoice Total $325.35 Credits/Payments Applied $0.00 Balance Due $325.35 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 #W886000 Amount Due $325.35 Amount Paid ______________________ Biffs, Inc6430 County Rd 101 EShakopee MN 55379-5202952.403.1221 Invoice #W886001 10/5/2022 W886001 1 of 1 Bill To C57180Hoffman & Uhlhorn Const Inc5555 W 78th StSte AMinneapolis MN 55439United States Location L141353LEPW3445 Ideal Ave NLake Elmo MN 55042United States Invoice Total $96.64 Balance Due $96.64 Due Date: 11/2/2022 Terms Due Date PO #Sales Rep Builders Club# Net 28 11/2/2022 LEPW Jeff Foley Qty Item Days Sales Order #Service Level Rate Amount 1 RENTAL RegularUnit Sep 07-Oct 04 28 396954 -$4.00 $4.00 1 SERVICEService Sep 07-Oct 04 28 396954 1X/wk $70.00 $70.00 1 SERVICEClimateSvc Sep 07 to Oct 04 28 396954 1X/wk $16.00 $16.00 1 RENTAL HandSani Sep 07-Oct 04 28 396954 -$0.00 $0.00 0 TAX-WASHTax-WASH ---$0.00 $0.45 0 TAX-MN Tax-MN ---$0.00 $6.19 Subtotal $96.64 Invoice Total $96.64 Credits/Payments Applied $0.00 Balance Due $96.64 Biffs Inc.Remittance Slip Make Checks Payable To Customer L141353 Hoffman & Uhlhorn Const Inc : LEPW Biffs, Inc6430 County Rd 101 EShakopee MN 55379-5202 Please return this portion with your payment. Invoice #W886001 Amount Due $96.64 Amount Paid ______________________ 131349453-0001 PO BOX 409211 ATLANTA, GA 30384-9211 661003 10/05/22 2 LAKE ELMO LAKE ELMO CITY CENTER 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 131349453 BURNSVILLE MN CC PC1171 3700 W PRESERVE BLVD BURNSVILLE, MN 55337 7746 952-707-5050 1171 13812.42 1018.67 14831.09 H + U CONSTRUCTION 5555 WEST 78TH STREET, SUITE A MINNEAPOLIS, MN 55439 SALES ITEMS: Qty Item number Unit Price BILLED FOR 179 DAYS 10/04/22 THRU 4/29/23. . 13812.42. DEMAND BILL NET 30 THERESA CASBOLT theresa.casebolt@sunbeltrentals.com SCHOER, GABE 126521501-0005 PO BOX 409211 ATLANTA, GA 30384-9211 661003 10/05/22 1 LAKE ELMO LAKE ELMO CITY CENTER 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 9/20/22 THRU 10/17/22. . 984.55. 4 WEEK BILL NET 30 THERESA CASBOLT theresa.casebolt@sunbeltrentals.com DOMINIC, DOMINIC 131803378-0001 PO BOX 409211 ATLANTA, GA 30384-9211 661003 10/17/22 1 LAKE ELMO LAKE ELMO CITY CENTER 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 131803378 BURNSVILLE MN CC PC1171 3700 W PRESERVE BLVD BURNSVILLE, MN 55337 7746 952-707-5050 1171 643.00 47.44 690.44 H + U CONSTRUCTION 5555 WEST 78TH STREET, SUITE A MINNEAPOLIS, MN 55439 . QTY EQUIPMENT # Min Day Week 4 Week Amount . 2.00 GAS HOSE 1" X 50' 198.00 396.00 Rental Sub-total: 396.00 SALES ITEMS: Qty Item number Unit Price 1 DLPKSRCHG EA 47.000 47.00 TRANSPORTATION SURCHARGE DELIVERY CHARGE 100.00 PICKUP CHARGE 100.00 BILLED FOR 170 DAYS 10/14/22 THRU 4/29/23. . 643.00. DEMAND BILL NET 30 THERESA CASBOLT theresa.casebolt@sunbeltrentals.com SCHOER, GABE Invoice Date 10/6/2022 Invoice # 356739Customer 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 10/3/2022 30 Yard Container742252 1Each 371.00 371.00 10/3/2022 Solid Waste Management Tax calculated at $0.60/yard. This ticket includes $18.00 of solid waste disposal tax. 742252 30Yards 0.60 18.00 $389.00 $389.00 $0.00 Invoice Date 10/28/2022 Invoice # 359050Customer 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 We've moved! Please update our address and mail payments to: 315 27th Ave NE, Minneapolis, MN 55418 Service Date DescriptionTicket QtyUnit of Measure Rate Amount 10/25/2022 10 Yard Container743431 1Each 283.00 283.00 10/25/2022 Solid Waste Management Tax calculated at $0.60/yard. This ticket includes $6.00 of solid waste disposal tax. 743431 10Yards 0.60 6.00 $289.00 $289.00 $0.00 Invoice A121176 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 10/27/2022Date Job Site Shipping Address: 3880 LAVERNE AVE N LAKE ELMO, MN 55042-9627 Created: 10/27/2022 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 9/29/2022 10/26/2022 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: October 27, 2022 6:49:18 AM Page 1 of 1A121176 1 Zach Green From:Manhole Covers Direct <sales@manholecoversdirect.com> Sent:Wednesday, October 5, 2022 9:36 AM To:Lucas Nelson Subject:[External] Your Manhole Covers Direct order has been received! [CAUTION: This email originated outside the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe.] The linked image cannot be displayed. The file may hav e been mov ed, renamed, or deleted. Verify that the link points to the correct file and location. Thank you for your order Hi Luke, Just to let you know — we've received your order #W1844, and it is now being processed: [Order #W1844] (October 5, 2022) Product Quantity Price Composite Manhole Frame and Cover · Manhole Size O.D.: 40" Round · Cover Style: Standard Lay In Style (with handle) 1 $1,547.06 2 · Skirt Length / Depth: 12" Subtotal: $1,547.06 Shipping: $207.25 via Freight Tax: $0.00 Payment method: Authorize.net Payment Total: $1,754.31 Note: Please contact Gabe upon delivery, 651-395-0055. Manhole can be brought to jobsite trailer. Billing address Luke Nelson H+U Construction 5555 West 78th Street, Suite A Minneapolis, MN 55439 763-355-8882 lnelson@hu-construction.com Shipping address Gabe Schoer H+U Construction 3880 Laverne Avenue North Lake Elmo, MN 55042 Thanks for using manholecoversdirect.com! Manhole Covers Direct — Custom Engineered Manholes 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 B312906Invoice number Date 10/12/2022 Project ID B2203298.00 Customer account 27053 Customer PO For Professional Services rendered through 10/8/2022 Lake Elmo Public Facilities - Storm Shelter Storm Shelter Structural Observations 3800 Laverne Avenue North Lake Elmo, MN 55042 1 - Onsite Structural Observations and Project Management 1.1 - Onsite Structural Observations and Project Management $2,970.00 $2,970.00 Total Fees $2,970.00 Amount Previously Invoiced: $0.00 Amount Invoiced to Date: $2,970.00 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: B2203298.00 - Lake Elmo Public Facilities - Storm Shelter Invoice number: B312906 Qty/Hours Rate Amount 1 - Onsite Structural Observations and Project Management 1.1 - Onsite Structural Observations and Project Management Non-Salary Detail Site Observation and Report (by P.E.)2.00 1,110.00 2,220.00 Submittal Review and Pre-Construction Meeting 1.00 750.00 750.00 Total 1.1 - Onsite Structural Observations and Project Management $2,970.00 Total 1 - Onsite Structural Observations and Project Management $2,970.00 Total Project $2,970.00 Page 2 of 2 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 B314003Invoice number Date 10/18/2022 Project ID B2203298 Customer account 27053 Customer PO For Professional Services rendered through 10/8/2022 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 $1,142.00 1.2 - Concrete Observations and Testing $2,517.00 1.4 - Structural Steel Observations $1,023.00 1.6 - Project Management $698.50 $5,380.50 Total Fees $5,380.50 Amount Previously Invoiced: $11,477.00 Amount Invoiced to Date: $16,857.50 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: B314003 Qty/Hours Rate Amount 1 - Construction and Materials Testing 1.1 - Soil Observations and Testing Consulting Services Detail Staff Engineer 1.50 132.00 198.00 Excavation Observations 3.75 92.00 345.00 Compaction Testing - Nuclear 4.50 82.00 369.00 Non-Salary Detail Nuclear moisture-density meter charge, per hour 4.50 20.00 90.00 CMT Trip Charge 4.00 35.00 140.00 Total 1.1 - Soil Observations and Testing $1,142.00 1.2 - Concrete Observations and Testing Consulting Services Detail Concrete Observations 8.50 92.00 782.00 Concrete Testing 8.75 82.00 717.50 Concrete Cylinder Pick up 1.25 82.00 102.50 Non-Salary Detail Compressive strength of concrete cylinders (ASTM C 39),per specimen 20.00 30.00 600.00 CMT Trip Charge 9.00 35.00 315.00 Total 1.2 - Concrete Observations and Testing $2,517.00 1.4 - Structural Steel Observations Consulting Services Detail ICC Structural Steel Technician 9.00 102.00 918.00 Non-Salary Detail NDE Trip charge 3.00 35.00 105.00 Total 1.4 - Structural Steel Observations $1,023.00 1.6 - Project Management Consulting Services Detail Staff Engineer 3.75 132.00 495.00 Project Control Specialist 0.50 120.00 60.00 Project Assistant 1.75 82.00 143.50 Total 1.6 - Project Management $698.50 Total 1 - Construction and Materials Testing $5,380.50 Total Project $5,380.50 Page 2 of 2 36,100.0010/26/22 $ 17,100.0010/26/22 7,887.8010/26/22 10/27/22 1,482.00 78,450.00 45,349.00 123,799.00 11,935.00 596.75 11,338.25 9,856.25 0.00 0.00 11,935.00 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 Amount of this request Stored material (as per attached breakdown) Total completed and stored to date Subtotal 1,482.00 Empirehouse Inc. 5200 Quincy StreetMounds View, MN 55112 To: From: Phone: Project:Lake Elmo City Center (L)3880 Laverne Avenue N. Lake Elmo, MN 55042 Application No: 4 Date: 10/01/22 Period To: 10/31/22 Contract For: Contract Date: Contractor Job Number:21152 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: ___________________________________ 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: ___________________________________ 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: ___________________________________ October 20, 2022 20 October 2022 January 31, 2025 Kristine Hutera, CEO 010500 010600 020550 020551 020552 021050 021550 029050 029051 031050 040550 041050 042050 059000 CO #001-1 CO #001-2 1,115.00 1,115.00 0.00 0.00 1,115.00 100.00 55.750.00 9,260.00 9,260.00 0.00 0.00 9,260.00 100.00 463.000.00 12,085.00 0.00 0.00 0.00 0.00 0.00 0.0012,085.00 6,820.00 0.00 0.00 0.00 0.00 0.00 0.006,820.00 2,225.00 0.00 0.00 0.00 0.00 0.00 0.002,225.00 18,906.00 0.00 0.00 0.00 0.00 0.00 0.0018,906.00 5,962.00 0.00 1,560.00 0.00 1,560.00 26.17 78.004,402.00 6,820.00 0.00 0.00 0.00 0.00 0.00 0.006,820.00 2,146.00 0.00 0.00 0.00 0.00 0.00 0.002,146.00 2,146.00 0.00 0.00 0.00 0.00 0.00 0.002,146.00 1,560.00 0.00 0.00 0.00 0.00 0.00 0.001,560.00 2,340.00 0.00 0.00 0.00 0.00 0.00 0.002,340.00 195.00 0.00 0.00 0.00 0.00 0.00 0.00195.00 6,870.00 0.00 0.00 0.00 0.00 0.00 0.006,870.00 1,360.00 0.00 0.00 0.00 0.00 0.00 0.001,360.00 43,989.00 0.00 0.00 0.00 0.00 0.00 0.0043,989.00 123,799.00 10,375.00 1,560.00 0.00 11,935.00 9.64 596.75111,864.00 To:H+U Construction From (Subcontractor):Empirehouse Inc. Project:Lake Elmo City Center (L) Application and Certificate For Payment -- page 2 Application No: 4 Date: 10/01/22 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 Installation CW Installation Housekeeping Window Installation Skylight Installation Ballistic Window Install Hurricane Window Install Mock-up Installation Borrowed Lite Installati Heavy Wall Installation Mirrors Installation Equipment All Glass Door 205A Billing Total Add Curtainwall Billing Total Application Total Period To: 10/31/22 Contractor's Job Number: 21152 10/26/22 14,442.3787 10/26/22 APPLICATION AND CERTIFICATE FOR PAYMENTTO (OWNER): PROJECT:LAKE ELMO CITY HALL, FIRE DEPARTMENT APPLICATION NO: 10Distribution to:City of Lake Elmo & PUBLIC WORKS FACILITIES REMODELXOWNER3880 Laverne Ave N PERIOD TO:10/31/2022Lake 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 $4,199,598.49NumberDate Approved (Column G on G703) 5. RETAINAGE:$0.00$0.00 a. _5_ % of Completed Work$209,979.94 (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)$209,979.94TOTALS$0.00$0.006. TOTAL EARNED LESS RETAINAGE$3,989,618.55Net 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)$3,217,423.51Payment has been completed in accordance with the Contract Documents, 8. CURRENT PAYMENT DUE$772,195.04and that current payments shown herein are now due.9. BALANCE TO FINISH, PLUS RETAINAGE $2,920,628.45 (Line 3 less Line 6)CONSTRUCTION MANAGER:HOFFMANN + UHLHORN CONSTRUCTION, INC.State of: MINNESOTACounty of:Anoka County Subscribed and sworn to before me this 11/2/2022Notary Public:By:Date:11/2/2022My Commission expires:31-Jan-23ARCHITECT'S CERTIFICATE FOR PAYMENTAMOUNT CERTIFIED$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 SUBSTATION2022-11-08 CITY OF LAKE ELMO - MATERIALAPPLIC. FOR PAYMENT NO.#10H+U CONSTRUCTION EDITION OF AIA DOCUMENT G703PERIOD ENDING 10/31/2022 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 Concrete240,000.0014,489.00254,489.00176,489.0023,000.00199,489.0078%55,000.009,974.45#0341Strutctural Precast1,422,295.00580.001,422,875.001,362,368.1519,164.161,381,532.3197%41,342.6969,076.62#0512Steel Supply485,000.009,215.00494,215.00427,778.880.00427,778.8887%66,436.1221,388.94#0610Carpentry & GC568,000.0021,134.00589,134.0032,400.0010,200.0042,600.007%546,534.002,130.00#0750Roofing & Metal Panels498,500.00(28,765.00)469,735.00298,183.2516,989.75315,173.0067%154,562.0015,758.65#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 & Curtainwall321,960.0094,127.00416,087.00144,080.0058,750.00202,830.0049%213,257.0010,141.50#0920Drywall & Fireproofing229,410.0018,608.00248,018.0070,000.0018,000.0088,000.0035%160,018.004,400.00#0930Tile68,100.000.0068,100.000.000.000.000%68,100.000.00#0950Acoustical Ceilings & Panels75,000.000.0075,000.000.0025,000.0025,000.0033%50,000.001,250.00#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 & Heating491,000.000.00491,000.00252,177.3251,185.98303,363.3062%187,636.7015,168.17#2300HVAC & Controls662,000.00142,297.00804,297.0094,750.00569,047.00663,797.0083%140,500.0033,189.85#2600Electrical808,100.0041,217.00849,317.00238,865.0021,500.00260,365.0031%588,952.0013,018.25#3100Earthwork & Site Utilities209,390.00550.00209,940.00167,536.000.00167,536.0080%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 AMOUNTS6,910,247.00(0.00)7,223,699.003,386,761.60812,836.894,199,598.4958%3,024,100.51209,979.94 INVOICE SUMMARY-PAYMENT APPLICATION NO. #10CITY OF NEWPORT - MATERIALPERIOD ENDING 10/31/2022ITEM NO# DESCRIPTION VENDORDATENUMBERAMOUNTRETAINAGEDUE#0330Cast-In-Place ConcreteAxel H. Ohman, Inc.10/31/22Applic #5$23,000.00$1,150.00$21,850.00#0341Strutctural PrecastWells Concrete10/31/22Applic #6$19,164.16$958.21$18,205.95#0610Carpentry & GCEbert Construction10/31/22Applic #8$10,200.00$510.00$9,690.00#0750Roofing & Metal PanelsPalmer West Construction10/31/22Applic #3$16,989.75$849.49$16,140.26#0840Aluminum Storefronts & CurtainwallEmpirehouse, Inc.10/31/22Applic #5$58,750.00$2,937.50$55,812.50#0920Drywall & FireproofingCommercial Drywall10/31/22Applic #5$18,000.00$900.00$17,100.00#0950Acoustical Ceilings & PanelsAcoustics Associates10/31/22Applic #1$25,000.00$1,250.00$23,750.00#2200Plumbing & HeatingPeterson Sheet Metal10/31/22Applic #7$51,185.98$2,559.30$48,626.68#2300HVAC & ControlsSt. Cloud Refrigeration10/31/22Applic #5$569,047.00$28,452.35$540,594.65#2600ElectricalVinco, Inc.10/31/22Applic #8$21,500.00$1,075.00$20,425.00SUBTOTAL AMOUNT DUE$812,836.89$40,641.85$772,195.04 TOTAL AMOUNT DUE $772,195.04 21,850.0010/26/22 9,690.0010/26/22 10/27/22 55,812.50 321,960.00 94,127.00 416,087.00 202,830.00 10,141.50 192,688.50 136,876.00 0.00 54,750.00 148,080.00 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 55,812.50 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: 5 Date: 10/01/22 Period To: 10/31/22 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: ___________________________________ Date: __________________________________ Subscribed and sworn to before me this _____ day of ____________, _________ (year). Notary public: _____________________________ My commission expires ____________________. Contractor: Empirehouse Inc. By: ____________________________________ Title: ___________________________________ October 20, 2022 20 October 2022 January 31, 2025 Kristine Hutera, CEO 010500 010600 020500 020502 021000 021001 021002 030500 030501 030502 040500 041000 042000 055000 CO #001-1 CO #001-2 CO #001-3 CO #001-4 4,580.00 4,580.00 0.00 0.00 4,580.00 100.00 229.000.00 26,100.00 16,000.00 4,000.00 0.00 20,000.00 76.63 1,000.006,100.00 49,080.00 49,080.00 0.00 0.00 49,080.00 100.00 2,454.000.00 17,575.00 17,575.00 0.00 0.00 17,575.00 100.00 878.750.00 57,775.00 0.00 0.00 23,000.00 23,000.00 39.81 1,150.0034,775.00 47,640.00 0.00 0.00 0.00 0.00 0.00 0.0047,640.00 63,500.00 31,750.00 0.00 31,750.00 63,500.00 100.00 3,175.000.00 17,565.00 17,565.00 0.00 0.00 17,565.00 100.00 878.250.00 7,530.00 7,530.00 0.00 0.00 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 0.008,020.00 648.00 0.00 0.00 0.00 0.00 0.00 0.00648.00 468.00 0.00 0.00 0.00 0.00 0.00 0.00468.00 1,529.00 0.00 0.00 0.00 0.00 0.00 0.001,529.00 91,482.00 0.00 0.00 0.00 0.00 0.00 0.0091,482.00 416,087.00 144,080.00 4,000.00 54,750.00 202,830.00 48.75 10,141.50213,257.00 To:H+U Construction From (Subcontractor):Empirehouse Inc. Project:Lake Elmo City Center (M) Application and Certificate For Payment -- page 2 Application No: 5 Date: 10/01/22 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 StormDefend Windows Bullet Resistant Windows SF Glass Materials CW Glass Materials Skyligtht Glass Material Interior Glass Materials Heavy Wall Glass Materia Mirror Materials Testing Precast Revisions Billing Total Change Door 110 to All Glass Billing Total All Glass Door 205A Billing Total Add Curtainwall Billing Total Application Total Period To: 10/31/22 Contractor's Job Number: 21153 SF Window Materials 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 10/18/2022 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 1178620780 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&PollutionBusinessPersonalPropertyInstallationFloater B0621PEMPI001022QT6608A140858COF22 3/1/20223/1/2022 3/1/20233/1/2023 Per Claim /AggregateLimitLimit-AnyOneSite 2,000,0002,000,0005,000,000 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:Re:Job #J21001,Lake Elmo Public Facilities,Lake Elmo City Center -3880 Laverne Avenue North,Lake Elmo,MN 55042;Lake Elmo Public WorksAddition-3445 Ideal Avenue North,Lake Elmo,MN 55042. October 2022 pay applicationStoredamount$54,750.00SeeAttached... 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 and automobile liability,on a primary and non-contributory basis,for work performed by thenamedinsured,if required by written contract.Umbrella follows form over the General Liability,Automobile Liability and Employers Liability subject to policyterms,conditions and exclusions. $ 23,750.00$1,250.00$1,250.00$23,750.00$23,750.00 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 02/07/2022 Hays Companies Inc. a divsion of Brown & Brown Insurance 80 South Eighth Street Suite 700 Minneapolis MN 55402 Bev Schwagerl (612) 333-3323 (612) 373-7270 Bev.Schwagerl@bbrown.com Acoustics Associates, Inc 1250 Zane Ave N Golden Valley MN 55422 Union Insurance Company of Providence 21423 EMCASCO Insurance Company 21407 Employers Mutual Casualty Co 21415 Construction Services Group Self-Insurance Self-Insured Berkley Insurance Co. (AM Best 003630)32603 22-23 All STD Renewal A Contractual Liability XCU Y 5D45909 01/01/2022 01/01/2023 1,000,000 500,000 10,000 1,000,000 2,000,000 2,000,000 B 5E45909 01/01/2022 01/01/2023 1,000,000 C 10,000 5J45909 01/01/2022 01/01/2023 5,000,000 5,000,000 D N Self-Insured - WG-1269 01/01/2022 01/01/2023 1,000,000 1,000,000 1,000,000 E Workers Compensation and EmployersLiability WCB200022 AM Best # 003630 01/01/2022 01/01/2023 E.L. Each Accident 1,000,000 E.L. Disease Ea Employe 1,000,000 E.L. Disease Policy Limit 1,000,000 Re: Lake Elmo City Center. 3880 Laverne Ave N, Lake Elmo, MN 55042.Project includes $25,000 for inventory owned by others.The City of Lake Elmo, Architect andH+U Construction are additional insureds as respects the general liability policy where required by written contract, subject to the policy terms andconditions. H+U Construction 5555 West 78th Street, Suite A Minneapolis MN 55439 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 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 10/26/22 540,594.65 10/26/22