Snyder Roofing of Washington LLC South Precinct Roof Replacement

City of Everett 00 65 19 1 ' South Precinct Roof Replacement SECTION 00 65 19 - CERTIFICATE OF COMPLETION FORM ' CONTRACTOR: ADDRESS: CITY: STATE: WA DATE: PROJECT TITLE: South Precinct Roof Replacement PROJECT NO. 342-522 DATE 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 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. X X CONTRACTOR TITLE ' Subscribed and sworn to before me this day of X Notary Public ' in and for the State of Washington, residing at DEPARTMENT CERTIFICATION APPROVED Date: ' I Certify the attached final statement to be true and correct to the best of my knowledge. X X Project Manager Director ADMINISTRATION USE ONLY Date of Acceptance By: X Cassie Franklin, Mayor Approved as to Form X City Attorney ' INSTRUCTIONS The 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. ' 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 ' 00 65 19 - 1 CERTIFICATE OF COMPLETION FORM