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1. <br />EVERETT <br />WASHINGTON <br />City of Everett <br />Construction Management <br />Affidavit of Amounts Paid DBE Participants <br />Contractor: <br />Jansen <br />Inc. <br />Date: <br />4/5/21 <br />Address: <br />1215 <br />W <br />Holly <br />Downtown <br />Street <br />to <br />City: <br />Bellingham <br />State: <br />WA <br />Zip <br />Code: <br />98225 <br />Project <br />Rucker <br />Ave <br />Title: <br />(Pacific <br />Everett <br />Ave <br />Everett <br />Streetscape <br />Ave <br />& <br />Hoyt <br />Improvement <br />Ave <br />(Pacific <br />Ave <br />to Wall <br />St) <br />1 <br />Project <br />PW3640/UP3648/PW3553 <br />Work <br />Order <br />#: <br />Federal <br />Aid <br />Project <br />Number <br />(if <br />Federally <br />Funded) <br />N/A <br />Contract <br />Bid <br />Price: <br />DBE <br />Condition <br />of <br />Award: <br />$9,577,841.02 <br />$0.00 <br />DBE <br />Participant <br />Ethnic <br />Contract <br />Bid <br />Item <br />Amount <br />__ <br />Paid <br />Participants <br />Name <br />and <br />Address <br />Code <br />Type <br />No.(s) <br />(Including <br />retainage <br />held) <br />His <br />Hands <br />Lawn <br />Care <br />& Services <br />0 <br />S <br />A7, <br />$331,193.44 <br />P.O. <br />Box 3750 <br />A38toA41, <br />Silverdale, <br />WA 98383 <br />A44toA57, <br />C48toC51, <br />C54toC65, <br />C67toC71 <br />OMA <br />Construction <br />0 <br />S <br />A15toA17, <br />$743,536.81 <br />22412 <br />SE 2315t <br />St <br />A20,A43, <br />Maple <br />Valley, <br />WA 98038 <br />B4,B6,C17, <br />C18,C22, <br />C23,C53,D3, <br />D4,DS,ES <br />Ethnic <br />Code: <br />Contract <br />Total <br />DBE <br />Participation <br />Achieved <br />Type: <br />B = Black <br />I = American Indian and <br />S - Subcontractor <br />H = Hispanic <br />Alaskan <br />Native <br />M <br />= Material <br />Supplier <br />$1,074,730.25 <br />A= Asian American <br />0= Other <br />JV= <br />Joint <br />Venture <br />Affidavit <br />I, the undersigned, do hereby certify that in connection with all work on the project for which this statement is submitted, <br />each DBE participant contracted by me has ten paid the amounts shown for bid items, or portions thereof, listed. <br />\\votk► 111 III, <br />lOPHF '114 <br />V* ,.��esioN r'',n,i ture <br />r ,�o Tq,�eo �4 eI <br />199939 a ubgribed and sworn before me this: 5th day of April , 2021 <br />j -4 %NotitaTiie L,c, - f C.- <br />- <br />� <o r,,r��9`2`G <br />�,II11 WASH#��$ <br />11%%"\\\‘‘� residing at: Bellingham Washington <br />Title Grant Jansen; President <br />Notary Public in and for the State of Washington <br />THIS FORM IS REQUIRED WITH THE FINAL ESTIMATE <br />FROM THE PRIME CONTRACTOR ON ALL PROJECTS <br />