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<br />. <br /> <br />. <br /> <br />. <br /> <br />APPLICATION FOR PAYMENT <br />PAYMENT NO.4 <br /> <br />URS Copy <br />City Copy <br />Contractor Copy <br />Inspoolor Copy <br /> <br />Project: <br /> <br />2004 Pavement Management Program <br />Edgewater Avenue Neighborhood <br />ADDENDUM NO.1 <br />City of Arden Hills <br /> <br />Owner: <br />Owner No.: <br />Contractor: <br /> <br />ARNT CONSTRUCTION <br />COMPANY, INC. <br />31809367.00101 <br /> <br />BRW Job No.: <br /> <br />Application Date: <br />For Period Ending: <br /> <br />11/23/2004 <br />10/30/2004 <br /> <br />Original Contract Amount: <br /> <br />Contract Amendments: <br />Contract Amount To Date: <br /> <br />Total Amount of Work Complete To Date: <br /> <br />Material Suitably Stored On-Site but not <br />Incorporated into Work: <br /> <br />Gross Amount Due To-Date: <br /> <br />Less 5.00% Reiainage: <br />Amount Due To-Date: <br /> <br />Less Previous Payments: <br /> <br />Total Due This Application: <br /> <br />By: <br /> <br /> <br />I hereby certify that a Items and amoun <br />date. <br /> <br />Con <br /> <br />$1,059,189.76 <br />($825.00) <br />$1,058,364.76 <br />$1,011,724.31 <br /> <br />$0.00 <br /> <br />$1,011,724.31 <br />$50,586.22 <br />$961,138.09 <br />$915,414.64 <br /> <br />$45,723.45 <br /> <br />orrect for the work completed to- <br /> <br />Date: / J- - rif-oy <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 />By: <br /> <br />APPROVED FOR PAYMENT <br />Owner: City of Arden Hills <br /> <br />By: <br /> <br />Date: <br /> <br />J,} - f/~Ol( <br /> <br />Date: <br /> <br />Page 1 of 9 <br />