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i . . cry oPogRETT
<br /> MAL CONTRACT VOUCHER CERTIFICATION
<br /> CONTRACTOR: ICU Construction ADDAP4S; Pa PO( 1% 3
<br /> crry: Muletheo STATE: WA 98.275 DATE; arob 6;7008
<br /> pgamcr TITLE: South End Interceptor North Segment WORK ORDER NO, UP1203
<br /> PATE WOItt COMPLETE: January 31,2008 MAL.AMOUNTt S40.14014
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<br /> corrlitTors CtRTIFICATION 1
<br /> IT the:undersigned,having first been duly sworn,certify'that the fataabod bill is a pPaltor chair tot work firmed
<br /> and material furnished to the City of Everett, that the same or any part thereof has not been paid, and that I ant
<br /> 4utholized to sign for the claimant, that I have not rented or pumbased any quipment or mater...1* from any
<br /> employee of the City, I further certify that the attached final ostimate Jaz'mod mutat Ottawa showing all the i
<br /> inonies due me from the City of Everett under this contract that I have carotid:1y exatratied said final estimate and I
<br /> -understand the same and that I hereby release the City of Everett from any and. all claimof whatsoever nature 1
<br /> wit 6' Is ay h hi,arlsis:; out of the performance of said contract,which ate not set forth in said eetirnm,
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<br /> C071 ' !.,Co , 0 ' TITLE
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<br /> Subscribed and sworn to before
<br /> me ka,A.,day of 4pAf? Asr - - • :IA:A- \
<br /> "Nbtolty .,,,/ ow ,,,1 ,,e, -
<br /> in and forthe"state'of Washington,residing at,45 7.;26# ,prioALs 442_, me, m.,4 fol flk, , F:,...
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<br /> PWILIC WORKS DEPARTMENT CIPRTIKCATION
<br /> 14-1'60
<br /> I Certify the attached final APPROVED Date:
<br /> estimate to be based upon actual i
<br /> measurements and to be true and correct.
<br /> X . '
<br /> Construction Manager Utilities Director. ' I
<br /> Tom*Fuchs Torn Thetford
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<br /> iNSTIWCT,TON$ I
<br /> The Affidavit of Wars Paid must:be prepared by the prime•coritoictor,all subcontractors, and all subcontractor's
<br /> agents and forwarded with the final Contract Voucher Certification,
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<br /> Contractor's Claims, if any, must be included and the Contractor's Certification must be labeled indleatin$ a claim
<br /> attached. ,
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<br /> Revised 9194 . , 1
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