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4.3 SR 09-18-2023
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4.3 SR 09-18-2023
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9/15/2023 9:29:08 AM
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Contractor's Application for Payment <br />Owner: City of Elk River Owner's Project No.: <br />Engineer: Bolton & Menk, Inc. Engineer's Project No.: OR1.128082 <br />Contractor: North Valley Inc. Agency's Project No.: <br />Project: 2023 Street improvements Project <br />Contract: <br />Application No.: 4 Application Date: 9/5/2023 <br />Application Period: From 7/31/2023 to 8/25/2023 <br />1. Origina) Contract Price $ 5,433,358.71 <br />2. Net change by Change Orders $ 75,713.40 <br />3. Current Contract Price (Line 1+ Line 2) $ 5,509,072.11 <br />4. Total Work completed and materials stored to date <br />(Sum of Column G Lump Sum Total and Column 1 Unit Price Total) $ 3,477,109.15 <br />5. Retainage <br />a. S% X$ 3,477,109.15 Work Completed $ 173,855.46 <br />b. X $ - Stored Materials $ - <br />c. Total Retainage (Line 5.a + Line 5.b) $ 173,855.46 <br />6. Amount eligible to date (Line 4- Line 5.c) $ 3,303,253.69 <br />7. less previous payments $ 2,693,430.93 <br />8. Amount due this application $ 609,822.76 <br />9. Balance to finish, including retainage (Line 3- Line 4) $ 2,031,962.96 <br />Contractor's Certitication <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 Contract have been applied on <br />account to discharge Contractor's legitimate obligations incurred in connection with the Work covered by prior Applications for <br />Payment; <br />(2) Title to all Work, materials and equipment incorporated in said Work, or otherwise listed in or covered by this Application for <br />Payment, will pass to Owner at time of payment free and clear of all liens, security interests, and encumbrances (except such as <br />are covered by a bond acceptable to Owner indemnifying Owner against any such liens, security interest, or encumbrances); and <br />(3) All the Work covered by this Application for Payment is in accordance with the Contract Documents and is not defective. <br />Contractor. North Valley Inc. <br />Signature: Date: September 6, 2023 <br />Name: Leslie A. Bloom Title: President <br />Recommended by Engineer Approved by Owner <br />gy; I�W�-- By: �ta%1?�LG�� <br />Name: Jason W. Cook, PE Name: Justin Femrite <br />Title: Project Manager Title: Chlef <br />Date: 9/5/2023 Date: 9-7-23 <br />Code: 401-4-8080-4530 <br />EJCDC C-620 Contractor's Application for Payment <br />(c) 2018 National Society of Professional Engineers for E1CDC. Aii rights reserved. <br />
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