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NOIll <br /> n. City of Everett <br /> EVER E T T Construction Management <br /> wAs"I"°T°" Affidavit of Amounts Paid DBE Participants <br /> Contractor: Date: <br /> (A o.c r r //// <br /> Addreess: r �,�L(t. City, ��� State: Zipq�de: <br /> _Il6fr2V <br /> Project Title: Project Work Order#: <br /> 20Z0 TAL lM V/ V ",,, �, 3 7yZ <br /> Federal Aid Project Number(if Federally Funded) <br /> Contract Bid Price: DBE Condition of Award: <br /> $ ?95- S' Od,d0 $ 0, <br /> i. <br /> DBE Participant Ethnic Contract Bid Item Amount Paid Participants <br /> Name and Address Code Type No.(s) (Including retainage held) <br /> Ethnic Code: Contract Type: Total DBE Participation Achieved <br /> B=Black I=American Indian and S=Subcontractor <br /> H=Hispanic Alaskan Native M=Material Supplier $ �. �O <br /> A=Asian American 0=Other JV=Joint 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 been paid the amounts shown for bid items,or portions thereof,listed. <br /> `��•��`•9,41.hi tAUK•�iy� Title /1-13 ee/ , <br /> `��et:•;iiMEHTe:C," nature V / <br /> s .QQ .O T44 to. . <br /> Q *= m Stascribed worn f e me this: ( day of TJ to V cV2r1' , 2021 <br /> W.. <br /> t.t ..�p.':� jAk :A.,,,,, <br /> Notary Public in and for the State of Washington <br /> •, oFrWA,SH,N�` residing <br /> at Vlit54 [LW6 , ( J <br /> THIS FORM IS REQUIRED WITH THE FINAL ESTIMATE <br /> FROM THE PRIME CONTRACTOR ON ALL PROJECTS <br />