McClure and Sons Inc. 7/25/2016 - Laserfiche WebLink

ICITY OF EVERETT PUBLIC WORKS DOCUMENT 00 65 19 SPECIAL PROVISIONS CERTIFICATE OF COMPLETION FORM 1 DOCUMENT 00 65 19—CERTIFICATE OF COMPLETION FORM ICONTRACTOR: ADDRESS: CITY: STATE: WA DATE: PROJECT TITLE: UP 3583 DATE WORK COMPLETED:PSO6 REROUTE PROJECT NO. FINAL CONTRACT AMOUNT: $ CONTRACTOR'S CERTIFICATION I, the undersigned, having first been duly sworn, certify that the attached statement is a proper charge for work performed and material furnished to the City of Everett, that the same or any part thereof has not been paid, I and that I am authorized to sign for the claimant; that I have not rented or purchased any equipment or materials from any employee of the City; I further certify that the attached final statement is a true and correct statement showing all the moneys due me from the City of Everett under this contract; that I have carefully examined said final statement and understand the same and that I hereby release the City of Everett from any I and all claims of whatsoever nature which I may have, arising out of the performance of said contract, which are not set forth in said statement. X x ICONTRACTOR TITLE Subscribed and sworn to before I me this day of X Notary Public in and for the State of Washington, residing at i DEPARTMENT CERTIFICATION I APPROVED Date: I Certify the attached final statement to be true and correct . to the best of my knowledge. I x X Project Manager Director IADMINISTRATION USE ONLY Date of Acceptance By: X IMAYOR Ray Stephanson Approved as to Form I X City Attorney IINSTRUCTIONS The Affidavit of Wages Paid must be prepared by the prime contractor,all subcontractors,and all subcontractor's agents and forwarded with the Final Contract Voucher Certification. I Contractor's Claims, if any, must be included and the Contractor's Certification must be labeled indicating a claim attached. Revised 11-03 END OF DOCUMENT 00 65 19 tPSO6 REROUTE 006510 - 1 WO NO.—UP3583 MAY 2016 1