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EVE ETT <br />WASHINGTON <br />City of Everett <br />Construction IVianagement <br />Affidavit ®f A rinand DBE Participants <br />Contractor: <br />nDate: <br />In <br />C <br />(0 <br />it 1 <br />1(g/.QCC.oLnnscMa\oc\ deg <br />o <br />Address: <br />City: <br />State: <br />Zi995Q".70 <br />Code. <br />`� <br />Pc <br />`� <br />LO <br />VACK <br />.} <br />D <- <br />t <br />c <br />A <br />Project <br />Title: <br />Project <br />Work <br />Order <br />It: <br />7 <br />Kcac <br />bau\a\\ <br />uOcc\-fx <br />\v‘Nea <br />Q <br />C <br />UV <br />7LJ <br />0 <br />ci <br />.3 <br />Federal <br />Aid <br />Project <br />Number <br />(if <br />Federally <br />Funded) <br />0 iA <br />Contract <br />Bid <br />Price: <br />DBE <br />Condition <br />$ <br />ofAw <br />0 <br />I 1-1- <br />rd: <br />$ <br />\o5L\3\c(€ao <br />Name <br />DBE <br />Participant <br />and <br />Address <br />Ethnic <br />Code <br />Contract <br />Type <br />Bid <br />No.(s) <br />Item <br />Amount <br />(Including <br />Paid <br />retainage <br />Participants <br />held) <br />Ethnic <br />B <br />H <br />A <br />= <br />= <br />= <br />Black <br />Hispanic <br />Asian <br />Code: <br />American <br />I <br />0 <br />= American <br />Alaskan <br />= <br />Other <br />Native <br />Indian <br />and <br />Contract <br />S <br />M <br />JV <br />= Subcontractor <br />= <br />= <br />Joint <br />Material <br />Type: <br />Venture <br />Supplier <br />Total <br />DBE <br />$ <br />Participation <br />Achieved <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 />``\������ N 11{I III ./ <br />s\o e ,,,'QSi nature <br />-120729 'Subscribed and sworn before <br />1 <br />%�Votatto B�`�' = �O <br />1 <br />ii ,9� �III����� <br />,! Foy 1IV Pcl\A <br />!l l r ,\ ,� <br />I ►1t\\\\\\'`"~' residing at VA0LAATA-- \LP Yv _c \ <br />Title Pr.OSta g Int <br />1' <br />me this: (P day of Jovjt Zort <br />et_Sh...0..reerC u� <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 />