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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.: 5 Application Date: 5/31/2024 <br />Application Period: From 5/1/2024 to 5/31/2024 <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) $ 1,438,415.02 <br />5. Retainage <br />a. 5% X $ 1,438,415.02 Work Completed $ 71,920.75 <br />b. X $ Stored Materials $ - <br />c. Total Retainage (Line 5.a + Line 5.b) $ 71,920.75 <br />6. Amount eligible to date (Line 4 - Line 5.c) $ 1,366,494.27 <br />7. Less previous payments $ 1,289,602.86 <br />8. Amount due this application $ 76,891,41 <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 />Contractor: Nb(�(llciGl(� ('�hStYUc�'or> 1L>G <br />Signature: Date: LP S 1202A <br />Name: �} hilip �f1Gt! Title: c%nt <br />Recommended by Engineer Approved by Owner <br />By: I ono 'jt�(/ By: <br />Name: Jason Cook Name: 4ustin Femrite <br />Title: Project Engineer Title: Chief <br />Date: 5/31/2024 Date: 6-6-24 <br />Code: Rolling Hills <br />EJCDC C-620 Contractor's Application for Payment <br />(c) 2018 National Society of Professional Engineers for EJCDC. All rights reserved. <br />Page 32 of 372 <br />