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Section 00651.9 <br /> Certificate of Completion!Form <br /> CONTRACTOR:_Bates Roofing <br /> ADDRESS:_5607 South Durango Street <br /> CITY:Tacoma STATE:WA DATE: 12/13/2013 <br /> PROJECT TITLE: Park Roofing and Repairs—Multiple Bldgs PROJECT NO. PW2013-0223-52 <br /> DATE WORK COMPLETED:_12/13/2013_ FINAL CONTRACT AMOUNT:$68 42=- 2, 1q L(•7, <br /> CONTRACTOR'S CERTIFICATION <br /> I,the undersigned, having first been duly sworn, certify that the attached statement is a proper charge for work <br /> performed and material furnished to the City of Everett, that the same or any part thereof has not been paid, <br /> and that I am authorized to sign for the claimant; that I have not rented or purchased any equipment or <br /> materials from any employee of the City; I further certify that the attached final statement is a true and correct <br /> statement showing all the moneys due me from the City of Everett under this contract; that I have carefully <br /> examined said final statement and understand the same and that I hereby release the City of Everett from any <br /> and all claims of whatsoever nature which I may have, arising out of the performance of said contract, which <br /> are not set forth in said statement. <br /> 1 .1X bt � % -� , X �xxkEi rc' <br /> j� t/lGl/ <br /> • COMRAC-101:VIT/1- .0.Si <br /> oma kA�. <br /> Subscribed and sworn to before MAY �? o <br /> me this f day of /)&2ZD/i a*7.9 19 o: '' <br /> X /1s?/1.41/tah=; Notary Public ��� 2015 . <br /> in and for the Siatendf Washington, residing <br /> r5t`� <br /> 0°� <br /> at L i /1/0 & TA �t• <br /> .•sv4-111Y <br /> PARKS AND RECREATIOIVDEPA TIUIENT CERTIFICATION <br /> APPROVED Date: <br /> I Certify the attached;inial • <br /> statement to be true and correct • <br /> to the <br /> best of my knowledge. <br /> irtv4444.16, <br /> X .t' A �JoX go- I <br /> Project Manager / Director of Parks-'f Recreation <br /> Russell Dance • Paul Kaftanski <br /> • <br /> ADMINISTRATION USE ONLY <br /> Date of Acceptance By: X <br /> MAYOR Ray Stephanson 411 <br /> Approved as to Form <br /> X <br /> City Attorney <br /> INSTRUCTIONS <br /> The Affidavit of Wages Paid must be prepared by the prime contractor,all subcontractors,and all subcontractors agents <br /> and forwarded with the Final Contract Voucher Certification. <br /> Contractor's Claims,if any,must be included and the Contractor's Certification must be labeled indicating a claim attached. <br /> Revised 11-03 <br /> of <br /> 122 <br />