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Contractor's Application for Payment <br />Owner: City of Elk River Dwner's Project No.: <br />Engineer: Bolton & Menk, Inc. Engineer's Project No.: OR1.129209 <br />Contractor: Northdale Constructlon Company Agency's Project No.: <br />Project: Rolling Hills Sewer Extenslon <br />Contract: <br />Applicatfon No.: 2 Application Date: 12/19/2023 <br />Application Period: From 1Q/30/2023 to 12/15/2023 <br />1. Origfnal Contract Price $ ; 1,71:1,92831:: <br />2. Net change by Change Orders $ ` <br />3. Curtent Contract Prfce (Line 1+ Line 2) �. ;: 1,711;923.$1 <br />4. Total Work completed and materials stored to date <br />{Sum of Column G Lump Sum Total and Column J Unit Price Total) $ 1,291;76173, <br />5. Retalnage <br />a. 5� X;$ 1,245;�51.33 : Work Completed $ 62�25��5'�. < <br />b. 5% X$.�46,610.40.'.Stored Materials $ 2,330 52:i <br />c. Total Retainage (Line S.a + Line 5.b) $ 64;588 09:=: <br />6. Amount eligible to date (Line 4- Line 5,c) $• :.. 1;227;17'3;64' <br />7. Less prevlous payments $ 1,070,681.23 <br />. 15b,492:41: <br />8. Amount due this application $. ''� ` ` ``'` � ` <br />Contractor's Certification <br />The undersigned Contractor �ertifles, to the best of Its knowledge, the following: <br />{1) All prevlous progress payments received from Owner on account of Work done under the Contract have been applled on <br />account to discharge Contractor's legitimate obligatlons incurred In connection with the Work covered by prior Applicatlons for <br />Payment; <br />(2) Title to all Work, materials and equipment incorporated in said Work, or otherwise Ilsted In or covered by this Application for <br />Payment, will pass to Owner at time of payment free and clear of all Ilens, security interests, and encumbrances (except such as <br />are c�vered hy a bond acceptable to Owner Indemnifying Owner against any such Ilens, security Interest, ar encumbrances); <br />and <br />(3) All the Work covered by this Application far Payment is in accordance with the Contract Documents and is not defective. <br />Contractor: ( <br />Signature, Date: %a —/�—���„� <br />' �'n�/�,� <br />Name: Title: <br />Recommended by Engineer Approved by Owner <br />By, ��.-� .✓�-- ey: �� <br />Name: lason Cook Name: Brandon Wisner <br />Title: Project Engineer Tltle: Engineering Project Manager <br />Date: 12/15/2023 Date: 12/18l2023 <br />�(�� �- ��{v-�S3a <br />EJCDC C-620 Contractor's Application for Payment <br />{c) 2018 National Soclety of Professlonal Englneers for EJCDC. All rlghts reserved. <br />