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City of Everett 00 65 19 - 1 <br /> Fire Administration Building Tenant Improvements 18-1080 <br /> SECTION 00 65 19 -CERTIFICATE OF COMPLETION FORM <br /> CONTRACTOR: Kirtley-Cole Associates, LLC <br /> ADDRESS:_2820 Oakes Avenue, Suite B <br /> CITY: Everett STATE: WA DATE: 4/26/2021 <br /> PROJECT TITLE: Fire Administration Building Tenant Improvements PROJECT NO. 18-1080 <br /> DATE WORK COMPLETED: 3/1/2021 FINAL CONTRACT AMOUNT: $1,315,406.55 <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 contra t, which are not set forth in said statement. <br /> x IfZ- , R <br /> \,•'' '...." <br /> CONTRACTOR TITLE ' '' <br /> ° PF %Og <br /> Subscribed and sworn to before cNOTARY <br /> me his2,V t of S! it 202/ - N • i <br /> o • Notary Public 7." N : PUBLIC <br /> if nd sr th State of Washington, residing s •. ✓ ;OZ <br /> a /er�eff 1,�1l4 `Ii�t .,,'9 ••. (y25,?5ti:G.� <br /> •,,,Op WAzi,\'\\ , <br /> �,,,,4u u u U ddI"`,,` <br /> DEPARTMENT CERTIFICATION <br /> APPROVED Date: <br /> I Certify the attached final <br /> statement to be true and correct <br /> to th best of my knowledge. <br /> X u l,' FX <br /> /c7t- 'VII V24 <br /> Project Manager Director <br /> /- r ADMINISTRATION USE ON <br /> (JJ <br /> Date of Acceptance —r�- 4P--/ By: X <br /> Cassie , Mayor <br /> Approved as to Form <br /> .: i�ce of the City AttOPrie}+ ���T. <br /> APPROVED A TO Pry 4M <br /> X r)a„Pa C.Well,laity 'rot,,,City Attorney -W�- 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 />