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Section 00 65 19 <br />Certificate of Completion Form <br />CONTRACTOR: `Wien .c/' J`%e a ade4ADDRESS: <br />2D1 <br />CITY°S;zp4brn "f / STATE: WA DATE: f fay 22 '24V( <br />PROJECT TITLE: Phil Johnson Ballfields Renovation <br />PROJECT NO. PW 2019 - 054 <br />DATE WORK COMPLETED: lief 17 3q 2202-( FINAL CONTRACT AMOUNT: $ y O 414_013,. O ' <br />CONTRACTOR'S CERTIFICATION <br />I, the undersigned, having first been duly sworn, certify that the attached statement is a proper charge for <br />work performed and material furnished to the City of Everett, that the same or any part thereof has not been <br />paid, and that I am authorized to sign for the claimant; that I have not rented or purchased any equipment or <br />materials from any employee of the City; I further certify that the attached final statement is a true and <br />correct statement showing all the moneys due me from the City of Everett under this contract; that ! have <br />carefully examined said final statement and understand the same and that I hereby release the City of Everett <br />from any and all claims of whatsoever nature which I may have, arising out of the performance of said <br />contract, which are not set forth in said statement. <br />Subscribed and sworn to before <br />� C]-at, \ <br />Wary Public <br />me this day of <br />in antilc. for the State of Washington, <br />residing at ���k` <br />x COrpJra*Secn i� <br />TITLE <br />��Qb04U��dp00 <br />g00%%��C1Do e,, <br />D goopOQq ' <br />c-‘4 .\104";°0 .)‘?() -`2) <br />-. o c> jam' �� 0 en, �y �Y o �' <br />o ° Y�� v1� o �¢i <br />C� ° tj <br />a7 O /'\ <br />® its ° . lio•i a C? <br />4 e°•A !%\ <br />PARKS AND COIVIIVIU41 *is% <br />V" ;CATION <br />R <br />APPROVED Date: ?»312 / <br />Certify the attached final <br />statement to be true and <br />correct to the best of my <br />knowledge. <br />X N, / / X <br />Proje Manager Director of Parks and mmunity Services <br />Lori Cummings <br />'Y <br />Dean Shaughnessy <br />ADMINISTRATION USE ONLY <br />Date of Acceptance By: X <br />MAYOR Cassie Franklin <br />Phil Johnson Ballfields Renovation 1 of 2 <br />