4.3 SR 10-18-2021 - Laserfiche WebLink

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Contractor's Application for Payment Owner: City of Elk River Owner's Project No.: R13.121582 Engineer: Jason W. Cook, P.E. Engineer's Project No.: R13.121582 Contractor: North Valley Inc. Other Project No.: Project: 2021 Street Improvements Contract: Application No.: 5 Application Date: 9/30/2021 Application Period: From 9/1/2021 to 9/30/2021 1. Original Contract Price $ 4,764,032.23 2. Net change by Change Orders $ 410,387.05 3. Current Contract Price (Line 1 + Line 2) $ 5,174,419.28 4. Total Work completed and materials stored to date (Sum of Column G Lump Sum Total and Column J Unit Price Total) $ 4,046,956.42 5. Retainage a. 5% X $ 4,046,956.42 Work Completed $ 202,347.82 b. X $ - Stored Materials $ - c. Total Retainage (Line 5.a + Line 5.b) $ 202,347.82 6. Amount eligible to date (Line 4 - Line 5.c) $ 3,844,608.60 7. Less previous payments (Line 6 from prior application) $ 3,220,822.27 8. Amount due this application $ 623,786.33 9. Balance to finish, including retainage (Line 3 - Line 4) $ 1,127,462.86 3220822.27 The undersigned Contractor certifies, to the best of its knowledge, the following: (1) All previous progress payments received from Owner on account of Work done under the Contract have been applied on account to discharge Contractor's legitimate obligations incurred in connection with the Work covered by prior Applications for Payment; (2) Title to all Work, materials and equipment incorporated in said Work, or otherwise listed in or covered by this Application for Payment, will pass to Owner at time of payment free and clear of all liens, security interests, and encumbrances (except such as are covered by a bond acceptable to Owner indemnifying Owner against any such liens, security interest, or encumbrances); and (3) All the Work covered by this Application for Payment is in accordance with the Contract Documents and is not defective. Contractor: North Valley, Inc._-7 Signature: Date: October 8, 2021 Name: Leslie A. Bloom Title: Vice President Recommended by Engineer Approved by Owner By: I �✓( By: Name: Jason W. Cook, PE Name: Justin Femrite Title: Project Manager Title: Chief Date: 10/11 /2021 Date: 10-11-21 Code: 401-4-8080-4530 EJCDC C-620 Contractor's Application for Payment (c) 2018 National Society of Professional Engineers for EJCDC. All rights reserved.