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Contractor's Application for Payment No. <br />To Application Application Date: <br />(Owner):Period: <br />Project:From (Contractor):Via (Engineer): <br />Application For Payment <br />Change Order Summary <br />1. ORIGINAL CONTRACT PRICE..................................$ <br />Number 2. Net change by Change Orders........................................$ <br />3. Current Contract Price (Line 1 ± 2)...............................$ <br />4. TOTAL COMPLETED AND STORED TO DATE $ <br />5. RETAINAGE:$ <br />a.5%X Work Completed............................$ <br />b.0%X Stored Material..............................$ <br />c.Total Retainage (Line 5.a + Line 5.b)..................$ <br />6. AMOUNT ELIGIBLE TO DATE (Line 4 - Line 5.c)....$ <br />7. LESS PREVIOUS PAYMENTS.....................................$ <br />8. AMOUNT DUE THIS APPLICATION.........................$ <br />Contractor's Certification ENGINEER: HAKANSON ANDERSON <br /> Certification: We recommend payment for work and quantites shown. <br />(Date) <br />OWNER: CITY OF ELK RIVER <br />Contractor Signature <br />By:Date:(Date)(Owner) <br />(Engineer) <br />$0.00 <br />Deductions <br />CHANGE ORDERS <br />$229,809.60 <br />$12,095.24 <br />$241,904.84 <br />$0.00 <br />$3,777,635.22 <br />$0.00 <br />NET CHANGE BY <br />$0.00TOTALS <br />Approved Change Orders <br />Additions <br />$229,809.60 <br />1 <br />May 5, 2017 <br />Hakanson Anderson <br />April 6, 2017 thru <br />May 1, 2017 <br />2017 Street Improvements <br />City of Elk River <br />North Valley, Inc. <br />$3,777,635.22 <br />$0.00 <br />$12,095.24 <br />The undersigned Contractor certifies, to the best of its knowledge, the following: <br />(1) All previous progress payments received from Owner on account of Work done under the <br />Contract have been applied on account to discharge Contractor's legitimate obligations incurred <br />in connection with the Work covered by prior Applications for Payment; <br />(2) Title to all Work, materials and equipment incorporated in said Work, or otherwise listed in <br />or covered by this Application for Payment, will pass to Owner at time of payment free and <br />clear of all Liens, security interests, and encumbrances (except such as are covered by a bond <br />acceptable to Owner indemnifying Owner against any such Liens, security interest, or <br />encumbrances); and <br />(3) All the Work covered by this Application for Payment is in accordance with the Contract <br />Documents and is not defective.