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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 /> WASHINGTON <br /> Affidavit of Amounts Paid DBE Participants <br /> Contractor: Northwest Construction, Inc. Date: 9/1/2022 <br /> Address: 2353 130th Ave, NE,Suite 100 City: Bellevue State: WA Zip Code: 98005 <br /> Project Title: Port of Everett Combined Sewer Main Improvements Project Work Order#: <br /> UP-3768 <br /> Federal Aid Project Number(if Federally Funded) <br /> Contract Bid Price: DBE Condition of Award: <br /> $4,551,566.85 $ <br /> DBE Participant Ethnic Contract Bid Item Amount Paid Participants <br /> Name and Address Code Type No.(s) (Including retainage held) <br /> Magna LLC, dba Magna Services DBE/MBE S 1, 25 $181,000.00 <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 $181,000.00 <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 /> , —DocuSigned by: Title Project Manager <br /> Signature <br /> \--E65D360EAA324DC... 1/18/2023 I 9:24 AM PST <br /> Subscribed and sworn before me this: day of <br /> Notary r—DoeuSignedby: <br /> Seal µei"eit tik5ew Notary Public c+^+,. r"1^,.1"—+,. <br /> '--c90c7ABA96B04BF... MELANIE P I D G E O N <br /> residing at Edmonds, WA Notary Public <br /> State of Washington <br /> License Number 206920 <br /> My Commission Expires <br /> THIS FORM IS REQUIRED WITH THE FINAL ESTIM? March 25, 2023 <br /> FROM THE PRIME CONTRACTOR ON ALL PROJECTS <br />