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Page 2 <br />September 14, 1987 <br /> <br />Please verify the amount of previous payments, if any, and the receipt by <br />the city of the following items from the contractor prior to making payment. <br /> <br />1. Certificate of Claims Payment (Lien Waiver), <br />2. Affidavit for Payment of State Taxes (Minn. State Tax Form 134), <br />3. Letter of Consent from surety firm. <br /> <br />APPROVALS: <br /> <br />CONTRACTOR: <br /> <br />ENGINEER: <br /> <br />OWNER: <br /> <br />Certification by Contractor: I certify that all items and amounts <br />shown are correct for the work completed to date. <br /> <br />FOREST LAKE CONTRACTING <br /> <br />Signed: <br /> <br />Title: <br /> <br />Date: <br /> <br />HAKANSON ANDERSON ASSOCIATES, INC. <br />Signed: <br /> <br />Title: <br /> <br />Date: <br /> <br />CITY OF RA/~SEY <br /> <br />Signed: <br /> <br />Title: <br /> <br />Date: <br /> <br />File: RA8:15-5 <br /> <br /> <br />