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City of Everett. 00 41 1:3- 4.. <br /> 1.9 BED:FO:RM SIGNATORtS- <br /> A. By Submitting this Bid; Bidder• certifies that it has teVieWed the Insurance. <br /> requirements of Document 001200- GENERAL CONDITIONS and certifies that <br /> ooverage will be provided:as required. <br /> B. The undersigned also: hereby certifies that, Within the three-year period <br /> Immediately preceding the bid solicitation date:for this.Project,the Bidder has not <br /> been determined by a final and binding citation and notice of assessment issUed <br /> by the department of labor and industries or through a civil judgment aritered by <br /> a court.of limited or.general jurisdiction to have willfully violated, as defined in <br /> ROW 49':43,0$2, any provision of chapter 446, 49:43, or 49 52 RCW The.. <br /> undersigned declares under penalty of perjury under the laws of the State of <br /> Washington that the foregoing:WIWI0e is true and.oOrrebt: <br /> Signed this /4 day of <-3() Ni15 , 2022 <br /> Narne.of t(idder: /4 s7-41-) C2) S 774 c_ /u/ <br /> Signature of Bidd.erls.Authorized Agent: <br /> Cityand StateWhere S s LA-44- <br /> II tie: Oz.s,5 t.) <br /> Mate of Incorporation . LA/ces— Contractors License No. /A5-7;4c.r.9 73c,zc <br /> Washington State o 2. zlib <br /> Email.address of Biddefs:a.pthorized Agent. <br /> ./)Q; stc, c.,,is-trvc.tio. . c,,, <br /> 00 41 13 4. MD FORM <br /> Provided to Builders Exchange of WA, Inc. For usage Conditions Agreement see www.bxwa.com - Always Verify Scal <br />