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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 />1 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 />NET CHANGE BY $101,722.24 $808,078.63 <br />CHANGE ORDERS <br />(Engineer) <br />$1,794,420.48 <br />TOTALS $101,722.24 $0.00 $986,341.85 <br />$0.00 <br />$94,443.18 <br />$94,443.18 <br />Approved Change Orders $3,777,635.22 <br />Additions Deductions $101,722.24 <br />101,722.24 $3,879,357.46 <br />$1,888,863.66 <br />3 <br />City of Elk River June 1, 2017 thru <br />July 1, 2017 July 7, 2017 <br />2017 Street Improvements Hakanson AndersonNorth Valley, Inc. <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 <br />incurred 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 <br />in 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