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City of Everett 00 65 19 - 1 <br /> 3600 Smith Street Clean Up <br /> SECTION 00 65 19 -CERTIFICATE OF COMPLETION FORM <br /> CONTRACTOR: 10 Environmental& Infrastructure, Inc. <br /> ADDRESS: 14734 NE 95th Street <br /> CITY: Redmond STATE: WA DATE: 02/13/2020 <br /> PROJECT TITLE: 3600 Smith Street Clean Up <br /> DATE WORK COMPLETED: 12/09/2019 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 �� XCj/lk"..„RACTOR TITLE <br /> Subscrib d and sworn to before <br /> me this day of JtGLei �2-010 MARISELA HI6UET <br /> �+ � �p f�otary Public r- CoYY.x 2289 E <br /> -/r EY1 L� g N A in and or the State of res din 4 S NOTARY p6BlIC•CA(1FOR� V7 <br /> at SAN Dim CouNTr — <br /> Yr Con.EXP.Jun is,2023" <br /> AVW C4 • <br /> DEPARTMENT CERTIFICATION <br /> APPROVED Date: <br /> I Certify the attached final <br /> statement to be true and correct <br /> to the bes of m k owledge. <br /> X X <br /> Project Manager irector <br /> ADMINISTRATION USE 0 <br /> Q e \ <br /> Date of Acceptance 0 e 0 - By: X <br /> Cass nklin, <br /> Approved as to Form <br /> Office of the City Attorney <br /> David <br /> C. horn <br /> X C.Hail,City Attorney <br /> City Attorney City Clerk <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 />