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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.: OR1.129209 <br />Contractor: Northdale Construction Company Agency's Project No.: <br />Project: Rolling Hills Sewer Extension <br />Contract: <br />Application No.: 3 Application Date: 3/31/2024 <br />Application Period: From 12/16/2023 to 3/31/2024 <br />1. Original Contract Price $ 1,711,923.51 <br />2. Net change by Change Orders $ - <br />3. Current Contract Price (Line 1 + Line 2) $ 1,711,923.51 <br />4. Total Work completed and materials stored to date <br />(Sum of Column G Lump Sum Total and Column J Unit Price Total) $ 1,305,101.73 <br />5. Retainage <br />a. 5% X $ 1,245,151.33 Work Completed $ 62,257.57 <br />b. 5% X $ 59,950.40 Stored Materials $ 2,997.52 <br />c. Total Retainage (Line 5.a + Line 5.b) $ 65,255.09 <br />6. Amount eligible to date (Line 4 - Line 5.c) $ 1,239,846.64 <br />7. Less previous payments $ 1,227,173.64 <br />8. Amount due this application $ 12,673.00 <br />Contractor's Certification <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 />i <br />Contractor: <br />Signature: Date: <br />Name: Title: A-[5 <br />Recommended by Engineer Approved by Owner <br />�I / <br />By: w By: <br />Name: Jason Cook Name: Justin Femrite <br />Title: Project Engineer Title: Chief <br />Date: 3/31/2024 Date: 6-7-24 <br />Code- Rolling Hills Sewer <br />EJCDC C-620 Contractor's Application for Payment <br />(c) 2018 National Society of Professional Engineers for EJCDC. All rights reserved. <br />Page 30 of 372 <br />