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mis <br /> Lei City of Everett <br /> EVE R E T T Construction Management <br /> WASHINGTON Affidavit of Amounts Paid DBE Participants <br /> Contractor: Shearer&Associates Date: 31a3(ota-- <br /> Address: 19300 NE 112th City: Battle Ground State:WA Zip Code: 98604 <br /> Project Title:WFP East Clearwell Roof Replacement Design Build Project Project Work Order#: <br /> UP 3662 <br /> Federal Aid Project Number(if Federally Funded) <br /> N/A <br /> Contract Bid Price: DBE Condition of Award: <br /> $3,368,386.91 $ N/A <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 /> Title Vre.5\ <br /> Signature <br /> ,,00r" 1"�"',,,, Subscribed and sworn bef re me this: 023 day of Piirtk. , tap2a--- <br /> ��' al e.'R''' <'� <br /> Fs •� Notary Public in and for the State of Washington <br /> �45APY <br /> �` residing at Po � �.n� c.7J,- arc j1. <br /> PUB <br /> OF WPS; �` THIS FORM IS REQUIRED WITH THE FINAL ESTIMATE <br /> t"""" FROM THE PRIME CONTRACTOR ON ALL PROJECTS <br />