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I hereby certify that all items and amounts shown <br />are correct for the work completed to date. <br /> <br />Contractor <br /> <br />H & M Asphalt <br /> <br />By <br /> <br />(Name and Title) <br /> <br />By <br /> <br /> work on this pr~ct and the application for payment have been <br /> /~eviewe~[~ld tl~mol~lt ~hown is recommended for paymenL __ <br />~ ~ ~~~ Date ~~~~~ <br /> (P,oje~ne~r) ~ <br /> <br />APPROVED FORPAYMENT <br /> <br />Owner <br /> <br /> City of Ramsay <br /> <br />· ( a~],, and Title) <br /> / <br /> <br />Date <br /> <br />By <br /> <br />Page 2 ot' 5 <br /> <br /> <br />