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1 <br /> e <br /> Section 006519 <br /> Certificate of Completion Form <br /> a <br /> I <br /> CONTRACTOR: Faker Construction I <br /> ADDRESS: 131 East Grover St. i <br /> CITY: Lynden STATE: WA DATE: 7/11/2016 <br /> PROJECT TITLE: Senator Henry M.Jackson Park Renovation PROJECT NO. PW#2014-43 1 <br /> DATE WORK COMPLETED:7/6/2016 FINAL CONTRACT AMOUNT: $ 1.906.801 12 <br /> CONTRACTOR'S CERTIFICATION <br /> I, the undersigned, having first been duly sworn, certify that the attached statement is a proper charge for work I <br /> performed and material furnished to the City of Everett, that the same or any part thereof has not been paid, <br /> and that I am authorized to sign for the claimant: that I have not rented or purchased any equipment or <br /> materials from any employee of the City; I further certify that the attached final statement is a true and correct <br /> statement showing all the moneys due me from the City of Everett under this contract; that I have carefully <br /> examined said final statement and understand the same and that I hereby release the City of Everett from any ! <br /> and all claims of whatsoever nature which I may have, arising out of the performance of said contract, which r <br /> are not set forth in said statement. <br /> X 4---- X Project Manager,, mili iri„it g <br /> R TO� TITLE ��" IT P4.4i� I <br /> �i`� Gni <br /> Subscribe and sworn to before $S' NOTARY y 1 <br /> m this l ay of DECFNeet, �t6 :7-, PUBLIC 1 <br /> it Y4nur( Notary Public _ • • = <br /> in and�or the State of Washington, residing = MYrg�ZI * r <br /> g � COMMISSION Z� 1 <br /> at 62o2 Nide e6 . rE T,reauor�u6 IAA•4824$ .. , Expires O� 1 <br /> -i�`;), 06/2771020 V e <br /> ''/,;,9F WAS��••`- <br /> PARKS AND RECREATION DEPARTMENT CERTIFICATION <br /> APPROVED Date: <br /> I Certify the attached final <br /> statement to be true and corr.-0, <br /> o the best of my knowledge. <br /> Projectxciii <br /> N na er . Di or of Parks and R- - n <br /> g <br /> Mark Harris.• Lori Cummings <br /> ADMINISTRATION USE ONLY <br /> / I <br /> Date of Acceptance 16 By: X , ,; ak dem / <br /> , <br /> MAYOR iip Stepha'son <br /> 1 <br /> 1 a <br /> 'E <br /> Approved as to Form <br /> ATTEST: <br /> x De .-.21611 <br /> 44-. P0070-l-✓i°-- <br /> ity Attorney ,/-y City Clerk <br /> INSTRUCTIONS <br /> The Affidavit of Wages Paid must be prepared by the prime contractor, all subcontractors, and all subcontractor's agents 3 <br /> 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 attached. <br /> Revised 11.03 <br /> Senator Henry M.Jackson Park Renovation 1 of 1 <br /> i <br /> Provided to Builders Exchange of WA, Inc. For usage Conditions Agreement see www.bxwa.com-Always Verify Scale <br /> I <br /> 1 <br />