Laserfiche WebLink
ECity of Everett <br /> E V E R E T T Construction Management <br /> WASHINOTON Affidavit of Amounts Paid DBE Participants <br /> Contractor: Date: I���0�� <br /> �2�CC. Co(\S"i C c£ C c On Co (.D <br /> Address: \ City: � State:`J ZiLi9 Q--/O <br /> \-00X �31 �5()`,\,1�_ r)) <br /> Project Title: Project Work Order it: <br /> na---V-vAa\\ 2%?-eNA\-e, KcAc.c 'epc:.;c UT' :377LI <br /> Federal Aid Project Number(if Federally Funded) 011(31 <br /> Contract Bid Price: DBE Condition of Aw rd: <br /> $ \ \ C)5L\ , 5\c1 .ao $ ,vrA <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 $ <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 /> \\\\\\\" "tttiIiI <br /> �•-,,,,F• CONN��'�r/ _77 Title Pr'.�5 Tt <br /> y-�G';`yON fi;\ .i-A�,7, Si/ ature <br /> y ,-;-0 A70129 ;SSbscribed and sworn before me this: L0 day of -.JOV\il , 20Z 2 <br /> i %4VotaryVuv> = O <br /> � A / I„`` ;• \` `��� Notary Public in and for the State of Washington <br /> //,gillF Op W P ' aS�0. C uv,v�2_1. <br /> lilimm\...\," residing at \-&l(7un—V 1Le v'vtoN/\ <br /> THIS FORM IS REQUIRED WITH THE FINAL ESTIMATE <br /> FROM THE PRIME CONTRACTOR ON ALL PROJECTS <br />