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• <br /> City of Everett 00 65 19- 1 <br /> South Precinct Roof Replacement <br /> SECTION 00 65 19-CERTIFICATE OF COMPLETION FORM <br /> CONTRACTOR:Snyder Roofing of Washington,LLC <br /> ADDRESS: 20203 Broadway Ave. <br /> CITY: Snohomish STATE: WA 98296 DATE:March 23,2020 <br /> PROJECT TITLE South Precinct Roof Replacement PROJECT NO.342-522 <br /> DATE WORK COMPLETED:December 17,2020 FINAL CONTRACT AMOUNT:$449,242.31 (Including WSST) <br /> CONTRACTORS CERTIFICATION <br /> I,the undersigned,having first been duly sworn,certify that the attached statement is a proper charge for work performed <br /> and material furnished to the City of Everett,that the same or any part thereof has not been paid,and that I am authorized <br /> to sign for the claimant;that I have not rented or purchased any equipment or materials from any employee of the City;I <br /> further certify that the attached final statement is a true and correct statement showing all the moneys due me from the <br /> City of Everett under this contract;that I have carefully examined said final statement and understand the same and that I <br /> hereby release the City of Everett from any and all claims of whatsoever nature which I may have,arising out of the <br /> performance of said contract,which are not set forth in said statement. <br /> Iff ,, <br /> • <br /> X 1 �,- , N •., atta Albertson-Office Director <br /> .OfMt RACTOR -1 <br /> Subscribed and sworn to before +1OlI4 9, a <br /> m this2lyday of ' do 4 p <br /> Notary Public a OB L IC _ <br /> in andd7 or the tate of Washington,residing 7� cl' ''' <br /> c, <br /> at 4.01 nsr a 4 i:st,r }. CZ`•.`3.ra;e Zr4i2 �=^Q <br /> '' NI <br /> ' '€lrp.p.ntr± P,'.o. <br /> DEPARTMENT CERTIFICATION <br /> APPROVED Date: 4,4/ZxZc <br /> I Certify the attached final <br /> statement to be true and correct <br /> to the best of my knowledge. <br /> . e <br /> X C44PrZi X 1e/` <br /> Project Mafiager Director <br /> ADMINISTRATION USE ONLY <br /> Date.of Acceptance By: X <br /> Cassie Franklin,Mayor <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 subcontractor's 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 <br /> attached. <br /> Revised 11-03 <br /> END OF SECTION 00 6519 <br /> 00 65 19- 1 CERTIFICATE OF COMPLETION FORM • <br /> 6 <br />