F D Thomas Inc 9/9/2019 - Laserfiche WebLink

111 City of Everett 00 65 19 - 1 Everpark Garage Repairs 2018-034 ISECTION 00 65 19 -CERTIFICATE OF COMPLETION FORM I CONTRACTOR: ADDRESS: CITY: STATE: WA DATE:_ PROJECT TITLE: Everpark Garage—Repairs PROJECT NO. 2018-034 IDATE WORK COMPLETED: FINAL CONTRACT AMOUNT: $ CONTRACTOR'S CERTIFICATION I,the undersigned, having first been duly sworn, certify that the attached statement is a proper charge for work performed and material furnished to the City of Everett,that the same or any part thereof has not been paid, and that I am authorized to sign for the claimant;that I have not rented or purchased any equipment or materials from any employee of the City; I further certify that the attached final statement is a true and correct statement showing all the moneys due me from the I City of Everett under this contract;that I have carefully examined said final statement and understand the same and that I hereby release the City of Everett from any and all claims of whatsoever nature which I may have, arising out of the performance of said contract,which are not set forth in said statement. I X X CONTRACTOR TITLE I Subscribed and sworn to before me this day of X Notary Public in and for the State of Washington, residing I at . I DEPARTMENT CERTIFICATION APPROVED Date: Certify the attached finalII statement to be true and correct to the best of my knowledge. XIx Project Manager Director ADMINISTRATION USE ONLY I Date of Acceptance By: X Cassie Franklin, Mayor IApproved as to Form X City Attorney INSTRUCTIONS IThe Affidavit of Wages Paid must be prepared by the prime contractor, all subcontractors, and all subcontractor's agents and forwarded with the Final Contract Voucher Certification. I Contractor's Claims, if any, must be included and the Contractor's Certification must be labeled indicating a claim attached. Revised 11-03 END OF SECTION 00 65 19 I I00 65 19 - 1 CERTIFICATE OF COMPLETION FORM