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<br />APPLICATION FOR PAYMENT <br />PAYMENT NO.1 - FINAL PAYMENT <br /> <br />. <br /> <br />Project: <br /> <br />2005 Seal Coating Project <br /> <br />Owner: <br />Owner No.: <br />Contractor: <br />URS Job No.: <br />Application Date: <br />For Period Ending: <br /> <br />City of Arden Hills <br /> <br />"fURS Copy <br />City Copy <br />Contractor Copy <br />Inspector Copy <br /> <br />Allied Blacktop Co. <br />31809831.00000 <br />91612005 <br />812612005 <br /> <br />Original Contract Amount: <br />Contract Amendments: <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 0.00% Retainage: <br />Amount Due To Date: <br />Less Previous Payments: <br />Total Due This Application: <br /> <br />$39,714.56 <br />$0.00 <br />$39,714.56 <br />$38,547.84 <br /> <br />$0.00 <br />$38,547.84 <br />$0.00 <br />$38,547.84 <br />$0.00 <br />$38,547.84 <br /> <br />. <br /> <br />I hereby certify that all items and amounts shown are correct for the work completed <br />to date. <br /> <br />Contractor: Allied Blacktop Co. <br />"'--. <br />By: Kk:- "Y'1 (l ~~ <br />, <br /> <br />Date: '1- "d- - c:J-~ <br /> <br />The work shown on this project and the application for payment have been reviewed <br />and the amount shown is recommended for payment. <br /> <br />By: <br /> <br /> <br />~ <br /> <br />Date:. 9-1 O~ <br /> <br />APPROVED FOR PAYMENT <br /> <br />Owner: City of Arden Hills <br /> <br />. <br /> <br />By: <br /> <br />Date: <br /> <br />Page 1 of4 <br />