4.2 SR 11-20-2023 - Laserfiche WebLink

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Contractor's Application for Payment Owner: City of Elk River Owner's Project No.: Engineer: Bolton & Menk, inc. Engineer's Project No.: OR1.129209 Contractor. Northdale Construction Company Agency's Project No.: Projed: Rolling Hilis Sewer Extension Contract: Application No.: 1 Application Date: 10/27/2023 Application Period: From 9/25/2023 to 10/27/2023 1. Original Contract Price $ :I,:Z11,923:51:; 2. Net change by Change Orders $ - 3. Current Contract Price (Line 1+ Line 2) � $ 1;7iY;923:51 ; 4. Total Work completed and materials stored to date (Sum of Column G Lump Sum Total and Column J Unit Price Total) $ 1;127,032Y$�;; ! 5. Retainage . _ . . __ ____ a. 5% X$:1;127;032;87;;. Work Completed $ . ;56,351;5z4; b. X $ ._ ': > Stored Materials $ c. Total Retainage (Line 5.a + Line 5.b) $ `;;56,35L:64::: 6. Amount eligible to date (Line 4- Line 5.c) $ 1;070;681:23:" 7. Less previous payments S. Amount due this application $:;;= :, r:1;070;681:23::;i 9. Balance to finish, including retainage (Line 3- Line 4) $ 554,84Q;G4:; Contractar's Certification 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 besn 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: . - Signature: �a�� Y —� �%i "a-✓ Name: , �p/,�� p�s�} Title: ��j�� Recommended by Engineer Approved by Ow�er i � � �� By: � By: Name: Jason Cook Tlame: Brandon Wisner Title: Project Engineer Title: Engineering Project Manager Date: 10/27/2023 Date: 10/31 /2023 Code:4a6-4-8040-4530 E1CDC Gfi20 Contrac[or's Application for Payment (c) 2018 National Society of Professional Engineers for EICDC. All rightr resenred.