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<br />. <br /> <br />. <br /> <br />. <br /> <br />APPLICATION FOR PAYMENT <br />PAYMENT NO.4 <br /> <br />Project: <br /> <br />Lift Station #7 Rehabilitation / <br />Karth Lake Pumping Station <br />City of Arden Hills <br /> <br />URS Copy <br />X cay Copy <br />CcnIractor Copy <br />Inspector Copy <br /> <br />Owner: <br />Owner No.: <br />Contractor: <br />BRW Job No.: <br /> <br />JAY BROS., INC. <br />37951-028-0101 <br /> <br />Application Date: <br />For Period Ending: <br /> <br />6/15/D4 <br />6/11/04 <br /> <br />Original Contract Amount: <br />Contract Amendmenfs: <br />Contract Amount To Date: <br />Total Amount of Work Complete To Date: <br />Material Suitably Stored On-Site but not <br />Incorporated into Work: <br />Gross Amount Due To-Date: <br />Less 2.00% Retainage: <br />Amount Due To-Date: <br />Less Previous Payments: <br /> <br />Total Due This Application: <br /> <br />$232,772.50 <br />$D.OD <br />$232,772.50 <br />$206,116.00 <br /> <br />$0.00 <br /> <br />$2D6,116.DO <br />$4,122.32 <br />$201,993.68 <br />$164,738.07 <br /> <br />$37,255.61 <br /> <br />I hereby certify that all items and amounts shown are correct for the work completed to- <br />date, <br /> <br />Contractor: JAY BROS., INC, <br /> <br />By: ~~.~ <br /> <br />Date: l-d-'1 ~~ ~\ <br /> <br />The work on this project and the application for payment have been reviewed and the <br />amount shown is recommended for payment. <br /> <br /> <br />Date: <br /> <br />7- ;< 7-0'-/ <br />, <br /> <br />By: <br /> <br />APPROVED FOR PAYMENT <br />Owner: City of Arden Hills <br /> <br />By: <br /> <br />Date: <br /> <br />Page 1 of 5 <br />