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CITY OF EVERETT <br /> FINAL CONTRACT VOUCHER CERTIFICATION <br /> DATE: January 14,2014 ADDRESS: PO Box 3686 <br /> CONTRACTOR: Tri-State Construction Company CITY/STATE:Bellevue WA 98009 <br /> PROJECT TITLE: 41st St.Extension&Roundabout WORK ORDER NO. RD 3314 <br /> DATE WORK COMPLETE: December 7,2012 FINAL AMOUNT: $ 6,317,432.78 <br /> Exclusive of State Sales Tax <br /> CONTRACTOR'S CERTIFICATION <br /> I, the undersigned, having first been duly sworn, certify that the.attached bill 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, and <br /> that I am authorized to sign for the claimant; that I have not rented or purchased any equipment or materials <br /> from any employee of the City; I further certify that the attached final estimate is a.true and correct statement <br /> showing all the monies due me from the City of Everett under this contract; that I have carefully examined said <br /> fmal estimate and understand the same and that I hereby release the City of Everett from any and all claims of <br /> whatsoever nature which I may have, arising out of the performance of said contract, which are not set forth in <br /> said estimate. <br /> X �! X President <br /> CO RACT TITLE `++++:► i i�,,��� <br /> Tri-State Construction Company �, ��`�y,P S Q f ,II <br /> ��� <br /> Subscribed and sworn to before me thisday day of �:•ve,/,4s- -`f ::: v4 � St <br /> T . <br /> X % I": UB�c <br /> 3(lotary Public <br /> % ' a" „ <br /> moi•Qk•.h0-17,, `ee• <br /> in and for the State of Washington,residing at 5,09-77.4-e. . .r. iV,Qg4��1G�.' <br /> • <br /> PUBLIC WORKS DEPARTMENT CERTIFICATION <br /> I Certify the attached fmal estimate to be <br /> based upon actual measurements and to <br /> be true and correct. APPROVED Da <br /> /t-• <br /> � �� <br /> X goi, •G�t X "l <br /> Construction Manager Publi orks Director <br /> Tom Fuchs Dave Davis <br /> INSTRUCTIONS <br /> The Affidavit of Wages Paid must be prepared by the prime contractor, all,subcontractors, and all subcontractor's <br /> agents 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 <br /> attached. <br /> Revised 6/2012 <br /> . 99 <br />