Premier Field Development Inc. 10/15/2021

Section 00 65 19 Certificate of Completion Form CONTRACTOR:Qt,t .7,0,r��+ �``r c t ' dela f7/'r Tt �G ADDRESS: :�41 (_t .r �. ClTY:Sre��inwts c.fj. STATE:WA DATE: f 2`Z, 20Z-/ PROJECT TITLE:Phil Johnson Balifields Renovation PROJECT NO.PW 2019-054 DATE WORK COMPLETED:419,1,/.30 2bil FINAL CONTRACT AMOUNT:$ �l-013r CONTRACTOR'S CERTIFICATION I, the undersigned, having first been duly sworn, certify that the attached statement is a proper charge for work performed and material furnished to the City of Everett,that the same or any part thereof has not been paid,and that I am authorized to sign for the claimant;that I have not rented or purchased any equipment or materials from any employee of the City; I further certify that the attached final statement Is a true and correct statement showing all the moneys due me from the City of Everett under this contract; that I have carefully examined said final statement and understand the same and that I hereby release the City of Everett from any and all claims of whatsoever nature which I may have, arising out of the performance of said contract,which are not set forth in said statement. X X t,Dore�7de.�ra�rr f+ary CO RACTOR � TITLEoil I it io, J Subscribed and sworn to before �0 QN•°O( 4r;„ me this"*day of o,. 2��a\ v;•�5� 0. X � ry Public 'J o�� in an for the State `ash�ng�t© � Et-) �� 1 O residing at t PV , PARKS AND COMM Uff41 1 (II .MlitICATION �FFIf ,llii O APPROVED Date: iJy' I Certify the attached final statement to be true and correct to the best of my knowledge. 4 , t.. X X Project Manager Director of Parks and Community Services Dean Shaughnessy Lori Cummings ADMINISTRATION USE ON V Date of Acceptance /054/ By: X MAYOR in Phil Johnson Balifields Renovation 1 of 2 ` q ST. City Jerk