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5 <br /> CITY OF EVERETT <br /> FINAL CONTRACT VOUCHER CERTIFICATION <br /> DA FE: October 25, 2016 ADDRESS: 13036 Beverly Park Road <br /> CONTRACTOR: Pellco Construction, Inc. CITY/STAlE: Mukilteo WA 98275 <br /> PROJECT TITLE: Hawthorne Elementary Safe Routes to School WORK ORDER NO. PW 3540. <br /> DAl'E WORK COMPLETE: September 16,2016 FINAL AMOUNT: $ 330,356.86 <br /> Exclusive of State Sales Tax <br /> CONTRACTOR'S CERTIFICATION <br /> I, the undersigned, having first been duly sworn, certify that the attached bill is a proper charge for work <br /> performed and material furnished to the City of Everett,that the same or any part thereof has not been paid, and <br /> that I am authorized to sign for the claimant; that I have not rented or purchased any equipment or materials <br /> from any employee of the City; I further certify that the attached final estimate is a true and correct statement <br /> showing all the monies due me from the City of Everett under this contract; that I have carefully examined said <br /> final estimate and understand the same and that I hereby release the City of Everett from any and all claims of <br /> whatsoever nature which I may have, arising out of the performance of said contract, which are not set forth in <br /> said estimate. <br /> X .� X <br /> C• CTC� �l% TIT E \'RE Se <br /> Pellco Construction,Inc. Cdr` 10 // 'EXPIRL. <br /> 4\ - °S' <br /> Subscribed and sworn to before me this BB day of 9� ay (�,_,/ , 49+5 w *-) <br /> a tNQ� O <br /> ?N3 ®�9 : <br /> NsPublic ,s> <br /> in and for the State of Washington,residing at As \ OF 4° <br /> PUBLIC WORKS DEPARTMENT CERTIFICATION <br /> I Certify the attached final estimate to be <br /> based upon actual measurements and to <br /> be true and correct. APPROVED Date: J, 0 ;t <br /> X X iu/ 4 Amor, <br /> Construction Manager Public/= 11,7DTre for <br /> Tom Fuchs Dave Davis <br /> INSTRUCTIONS <br /> The Affidavit of Wages Paid must be prepared by the prime contractor, all subcontractors, and all subcontractor's <br /> agents and forwarded with the Final Contract Voucher Certification. <br /> Contractor's Claims, if any, must be included and the Contractor's Certification must be labeled indicating a claim <br /> attached. <br /> Revised 6/2012 26 <br />