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tee , APPLICATION FOR PAYMENT NO. 4 To: City of St. Anthony, Minnesota (OWNER) From: Forest Lake Contracting, Inc. (CONTRACTOR) Contract: City of St. Anthony Project: 1998 Watermain, Street and Storm Sewer Improvements - OWNER's Contract No. -- ENGINEER's Project No. 10408.03 For Work accomplished through the date of 9/5/98 1. Original Contract Price: S 533,674.45 2. Net change by Change'Orders and Written Amendments(+or-): S , 0.00 3. Current Contract Price(I plus 2): s 533,674.45 4. Total completed and stored to date: S 5730684-94 5. Retainage(per Agreement): 5 %of completed Work: S 28,684.25 %of stored material: S Total Retainage: S 28,684.25 6. Total completed and stored to date less retainage(4 minus S): S 545,000.69 7. Less previous Application for Payments: s 538,306.52 8. DUE THIS APPLICATION(6 MINUS 7): S F;,6g4.17 Accompanying Documentation: CONTRACTOR'S Certification: The undersigned CONTRACTOR certifies that(1)all previous progress payments received from OWNER on account of Work done under.the Contract referred to above have been applied on account to discharge CONTRACTOR's legitimate obligations incurred in connection with Work covered by prior Applications for Payment numbered 1 through 3 inclusive;(2)title of all Work,materials and equipment incorporated in said Work or otherwise listed in or covered by this Application for Payment will pass to OWNER at time of payment free and clear of all Liens,security interests and encumbrances(except such as are covered by a Bond acceptable to OWNER indemnifying OWNER against any such Lien,security interest or encumbrance);and(3)all Work covered by this Application for Payment is in accordance with the Contract Documents and not defective. Dated Forest Lake Contracting. Inc. CONTRACTOR B State of County of Subscribed and sworn to before me this day of , Notary Public My Commission expires: Payment of the above AMOUNT DUE THIS APPLICATION is recommended. DatedI;pntamhar 15T998 R By: EJCDC No.1910-8-E (1996 Edition) Prepared by the Engineers Joint Contract Documents Committee and endorsed by'rbe Associated General Contractors of America and the Construction Specification Institute.