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' Department of Labor and Industries Request for Contract Release <br /> Contract Releasef <br /> t <br /> PO Box 44274 <br /> Olympia,WA 98504-4272 <br /> NOTICE OF COMPLETION OF PUBLIC WORKS CONTRACT <br /> Do not pay retained funds until you have Department of Labor and Industries approval <br /> Contractor's Tax Registration No. (UBI No.) Date: <br /> From: <br /> Name&Address of Public Agency Department Use Only <br /> ' Assumed To <br /> Date Assigned: <br /> Notice is hereby given relative to the completion of contract or project described below <br /> Project Name/Description of Project: Contract Number: <br /> IContract Amount: <br /> Retained Amount: <br /> ' Contractor's Name: Telephone Number: <br /> Contractor's Address: <br /> Date Contract Awarded: Date Work Commenced: Date Work Completed: Date Work Accepted: <br /> Surety or Bonding Company: <br /> Agent's Address: <br /> ' Please list Subcontractors below: Continue Subcontractors list on other side. <br /> Subcontractor's Name UBI Number: <br /> Disbursing Officer Comments: <br /> Contact Name: <br /> Phone Number: <br /> Email Address: <br /> The Disbursing Officer must complete and submit this notice to the Department of Labor and Industries immediately after <br /> acceptance of the work done under this contract. Mail this notice to Department of Labor and Industries, Contract <br /> ' Release,PO Box 44274,Olympia,WA 98504-4274,or fax to(360)902-6897 or e-mail to ContractReleasena,lni.wa.gov. <br /> NO PAYMENT SHALL BE MADE FROM RETAINED FUNDS until receipt of the Department's certificate of release, <br /> and then only in accordance with the certificate. <br /> For assistance contact Contract Release at(360)902-5360. <br /> F215-038-000 Request for Contract Release 09-2009 <br />