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I <br /> 1112 This form must be submitted with the Bid Proposal or as a Supplement to the Bid <br /> E V E R E T T no later than 24 hours after the time for delivery of the Bid Proposal,as provided <br /> for in Section 1-02.9 of the Contract Provisions. <br /> WASHINGTON <br /> Certification of Compliance with Wage Payment Statutes <br /> The bidder hereby certifies that, within the three-year period immediately preceding the bid <br /> solicitation date (APRIL 4, 2023), the bidder is not a "willful" violator, as defined in RCW <br /> 49.48.082, of any provision of chapters 49.46, 49.48, or 49.52 RCW, as determined by a final <br /> and binding citation and notice of assessment issued by the Department of Labor and Industries <br /> or through a civil judgment entered by a court of limited or general jurisdiction. I <br /> I certify under penalty of perjury under the laws of the State of Washington that the foregoing <br /> is true and correct. I <br /> HM Pacific Northwest,Inc. <br /> Bidder's Business me <br /> Signatur Authorized Official* I <br /> Jamie remain <br /> Printed Name I <br /> VP/GM <br /> Title <br /> 4/04/2023 Redmond WA <br /> Date City State <br /> Check One: <br /> Sole Proprietorship ❑ Partnership ❑ Joint Venture ❑ Corporation a <br /> State of Incorporation, or if not a corporation, State where business entity was formed: <br /> Washington <br /> If a co-partnership, give firm name under which business is transacted: ' <br /> *If a corporation,proposal must be executed in the corporate name by the president or vice-president U <br /> (or any other corporate officer accompanied by evidence of authority to sign). If a co-partnership, <br /> proposal must be executed by a partner. <br /> 2023 FEDERAL OVERLAY <br /> FEDERAL AID*STBGUL-2715(011) <br /> WO#3788 March 2,2023 136 <br /> Provided to Builders Exchange of WA, Inc. For usage Conditions Agreement see www.bxwa.com - Always Verify Scal <br />