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I hereby certify that all items and amounts shown <br /> <br />Contractor <br /> <br /> -- {Name and Title) <br /> <br /> _ The work on thi., <br /> /1 ~=revi~and <br /> <br />Owner <br /> <br />are correct for the work completed to date. <br /> <br />H & M Asphalt <br /> <br />Date <br /> <br /> The work on this prp'~ect and the application for payment have been <br /> ~ =revi~and th/~Im~n~hown is recommended for payment. <br />~n~gineerl _ ~~' Date <br /> <br /> APPROVED FOR PAYMENT <br />City of Ramsay <br /> <br />Date '7 [ ~/~ <br /> <br />Page 2 of 5 <br /> <br /> <br />