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Estimate Number: 4 <br />Pay Estimate Summary Sheet <br />Partial <br />Project Number: 21-05 <br />Project Name: 2021 'VISA Pavement Overlay Improvements <br />Period Ending October 31, 2021 <br />Contractor: North Valley, Inc. <br />Address: 20015 Iguana Street NW, Suite 100, Nowthen, MN 55330 <br />1 Original Contract Amount <br />2 Change Order(s) No, Thru No. <br />3 Total Funds Encumbered <br />4 Value of Work Completed <br />Value of Work Remaining $ 30,865.91 <br />Percent Complete 85% <br />5 Retainage 5 % <br />6 Previous Payment(s) <br />7 Deductions or Charges <br />8 Total Retainage, Payments & Deductions (Lines 5+6+7) <br />Payment Due (Lines 4-8) <br />$ 206, 395.58 <br />206, 395.58 <br />$ 175,529.67 <br />8,776.48 <br />$ 161,172.54 <br />$ 169,949.02 <br />$ 5,580,65 <br />Certification of Partial Payment <br />l hereby certify that, to the best of my knowledge and belief, all items, quantities and prices of work and material shown on <br />this Estimate are correct and that all work has been performed in full accordance with the terms and conditions of the <br />Contract for this project between owner and the undersigned Contractor, and as amended by any authorized changes and <br />the foregoing is a true and correct statement of the contract amount for the period covered by this estimate. <br />Nmai\-\ \\A <br />Contractor Name <br />Tv-\c, --c-&\00{n <br />\c\ fes\ct-ef-\--Ir' <br />Title Signature <br />LliS (W)al <br />Print Name <br />Date <br />City of Ramsey Approval <br />Signature (Project Engineer) Date <br />Signature (City Engineer) <br />Date <br />Pay Estimate Page 1 of 2 <br />