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DocuSign Envelope ID: B9AC738B-C9E0-4A2C-8C7E-396B7E4554CA <br />City of Everett <br />E V E R E T T Construction Management <br />WA SHIN GTON <br />Affidavit of Amounts Paid DBE Participants <br />Contractor: Northwest Construction, Inc. <br />Date: 9/1/2022 <br />Address: 2353 130th Ave, NE, Suite 100 <br />City: Bellevue <br />State: WA <br />Zip Code: 98005 <br />Project Title: Port of Everett Combined Sewer Main Improvements <br />Project Work Order #: <br />U P-3768 <br />Federal Aid Project Number (if Federally Funded) <br />Contract Bid Price: <br />$4,551,566.85 <br />DBE Condition of Award: <br />$ <br />DBE Participant <br />Name and Address <br />Ethnic <br />Code <br />Contract <br />Type <br />Bid Item <br />No.(s) <br />Amount Paid Participants <br />(Including retainage held) <br />Magna LLC, dba Magna Services <br />DBE/MBE <br />S <br />1, 25 <br />$181,000.00 <br />Ethnic Code: <br />B = Black I = American Indian and <br />H = Hispanic Alaskan Native <br />A = Asian American 0 = Other <br />Contract Type: <br />S = Subcontractor <br />M = Material Supplier <br />JV = Joint Venture <br />Total DBE Participation Achieved <br />$181,000.00 <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 ota ry <br />Seal <br />Signature <br />- DocuSigned by: <br />�E65D360EAA324DC... <br />Title <br />Project Manager <br />1/18/2023 1 9:24 AM PST <br />Subscribed and sworn before me this: day of <br />- DocuSigned by: <br />N1eL.nie -Pidvon <br />'-C90C7ASA96B04BF <br />residing at <br />Edmonds, WA <br />Notary Public : ".." +" _C`, ` "� <br />MELANIE PIDGEON <br />Notary Public <br />State of Washington <br />License Number 206920 <br />My Commission Expires <br />March 25, 2023 <br />THIS FORM IS REQUIRED WITH THE FINAL ESTIMA <br />FROM THE PRIME CONTRACTOR ON ALL PROJECTS <br />