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Y <br />City of Everett 00 65 19 - 1 <br />3600 Smith Street Clean Up <br />SECTION 00 6519 - CERTIFICATE OF COMPLETION FORM <br />CONTRACTOR: 10 Environmental &InfrastructUlu, Inc. <br />ADDRESS: 14734 NE 951h Street <br />CITY: Redmond STATE: WA DATE: 02/13/2020 <br />PROJECT TITLE: 3600 Smith Street Clean Up <br />DATE WORK COMPLETED: 12109/2019 FINAL CONTRACT AMOUNT: $406,371.88 <br />CONTRACTOR'S 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 />X Y11x, h� X <br />CO T RACTOR u TITLE <br />Subscrib d and sworn to before <br />me this day of U4et2 :Zd2.� <br />7 otary Public <br />in and for the State of Wa to , r� , ding <br />at --- <br />a ��"`°''� MARISELA HI�UERA <br />N COUNTY <br />wtnmo� <br />= CVFW # 2289501 <br />BtIC&CAUFOW <br />lr Go �. EXPPJu 8, 2023 <br />DEPARTMENT CERTIFICATION <br />APPROVED Date: <br />I Certify the attached final <br />statement to be true and correct <br />to the es Hof my k owledge. <br />Project Manager <br />Date of Acceptance, <br />Approved as to Form <br />City Attorney <br />X <br />ADMINISTRATION USE ONLY <br />By: X <br />Cassie Franklin, Mayor <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 65 19 <br />00 65 19 - 1 CERTIFICATE OF COMPLETION FORM <br />