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CONTRACTOR'S PAY REQUEST <br />DISTRIBUTION: <br />CONTRACTOR (1) <br />2015 STREET IMPROVEMENTS <br />OWNER (1) <br />CITY OF ELK RIVER <br />ENGINEER (1) <br />SAP 204-135-001, 204-107-007, 204-114-003, 204-116-002 <br />BONDING CO. (1) <br />BMI PROJECT NO. N15.108340 <br />TOTAL AMOUNT BID PLUS APPROVED CHANGE ORDERS <br />$3,953,239.73 <br />TOTAL, COMPLETED WORK TO DATE <br />$3,076,449.03 <br />TOTAL, STORED MATERIALS TO DATE <br />$0.00 <br />DEDUCTION FOR STORED MATERIALS USED IN WORK COMPLETED <br />$0.00 <br />TOTAL, COMPLETED WORK & STORED MATERIALS <br />$3,076,449.03 <br />RETAINED PERCENTAGE ( 5%) <br />$153,822.45 <br />TOTAL AMOUNT OF OTHER PAYMENTS OR (DEDUCTIONS) <br />$0.00 <br />NET AMOUNT DUE TO CONTRACTOR TO DATE <br />$2,922,626.58 <br />TOTAL AMOUNT PAID ON PREVIOUS ESTIMATES <br />$2,201,998.77 <br />PAY CONTRACTOR AS ESTIMATE NO. 5 <br />$720,627.81 <br />Certificate for Partial Payment <br />I hereby certify that, to the best of my knowledge and belief, all items quantities and prices <br />of work and material shown on this Estimate are correct and that all work has been <br />performed in full accordance with the terms and conditions of the Contract for this project <br />between the Owner and the undersigned Contractor, and as amended by any <br />authorized changes, and that the foregoing is a true and correct statement of the <br />contract amount for the period covered by this Estimate. <br />Contractor: North Valley, Inc. <br />20015 Iguana St NW OD <br />owthen, N 553,30, <br />By <br />Name Title <br />Date 0 cd <br />CHECKED AND APPROVED AS TO QUANTITIES AND AMOUNT: <br />ENGINEER: POLTON 4 MENK, INC., 7533 Sunwood Drive NW, Suite 206, Ramsey, MN 55303 <br />By PROJECT ENGINEER <br />Cody olmes, P.E11. <br />Date `� t <br />APPROVED FOR PAYMENT: <br />OWNER: <br />By <br />Name Title Date <br />And <br />Name Title Date <br />