IMCO General Construction 12/13/2022

I City of Everett 00 65 19 - 1 Water Filter Plant Portal 4 Improvements WO# 3755 SECTION 00 65 19 - CERTIFICATE OF COMPLETION FORM CONTRACTOR: ' ADDRESS: CITY: STATE: WA PROJECT TITLE: Water Filter Plant Portal 4 Improvements PROJECT NO. WO# 3755 DATE WORK COMPLETED: FINAL CONTRACT SUM: $ CONTRACTOR'S CERTIFICATION I, the undersigned, certify and declare, under penalty of perjury under the laws of the State of Washington, that the foregoing is true and correct: I am authorized to sign for the claimant; that in connection with the work performed and, to the best of my knowledge, no loan, gratuity or gift in any form whatsoever has been extended to any employee of the City Everett, nor have I rented or purchased any equipment or materials from any employee of the City of Everett; that the attached final statement is a true and correct statement showing all the monies due the claimant from the City of Everett for work performed and material furnished under this Contract; that I have carefully examined said final statement and understand the same and; that I, on behalf of the claimant, hereby release and forever discharge the City of Everett from any and all claims of whatsoever nature which I or the claimant may have, arising out of the performance of said Contract, which are not set forth in the attached statement. DATED at this day of , 20 . (City, State) X X CONTRACTOR AUTHORIZED TITLE SIGNATURE DEPARTMENT CERTIFICATION APPROVED DATE: I certify the attached final statement to be true and correct to the best of my knowledge. X X Project Manager Director I i 00 65 19 - 1 CERTIFICATE OF COMPLETION FORM