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I <br /> Section 00 65 19 <br /> Certificate of Completion Form <br /> I CONTRACTOR: <br /> ADDRESS: <br /> CITY: STATE: WA DATE: <br /> PROJECT TITLE: Rotary Park Renovation <br /> PROJECT NO. PW 2021-072 <br /> DATE WORK COMPLETED: _ FINAL CONTRACT AMOUNT: $ <br /> CONTRACTOR'S CERTIFICATION <br /> I,the undersigned,having first been duly sworn,certify that the attached statement is a proper charge for work <br /> performed and material furnished to the City of Everett, that the same or any part thereof has not been paid, <br /> 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 correct <br /> statement showing all the moneys due me from the City of Everett under this contract; that I have carefully <br /> examined said final statement and understand the same and that I hereby release the City of Everett from any <br /> and all claims of whatsoever nature which I may have, arising out of the performance of said contract, which <br /> are not set forth in said statement. <br /> X X <br /> CONTRACTOR TITLE <br /> ISubscribed and sworn to before <br /> me this day of <br /> I X Notary Public <br /> in and for the State of Washington, <br /> residing at <br /> PARKS AND COMMUNITY SERVICES CERTIFICATION <br /> APPROVED Date: <br /> I Certify the attached final <br /> I statement to be true and <br /> correct to the best of my <br /> knowledge. <br /> Project Manager Director of Parks and Community Services <br /> Dean Shaughnessy Bob Leonard <br /> ADMINISTRATION USE ONLY <br /> Date of Acceptance By: X <br /> MAYOR Cassie Franklin <br /> Rotary Park Renovation 1 of 2 <br /> I <br />