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CITY OF EVERETT PUBLIC WORKS SPECIAL PROVISIONS DOCUMENT 006510—CERTIFICATE OF COMPLETION FORM CONTRACTOR: ADDRESS: CITY: STATE: WA DATE: PROJECT TITLE: WFP Operations Building Seismic Retrofit PROJECT NO. UP3600 DATE WORK COMPLETED: 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, 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 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 CONTRACTOR TITLE Subscribed and sworn to before me this day of X Notary Public in and for the State of Washington, residing at DEPARTMENT CERTIFICATION APPROVED Date: I Certify the attached final statement to be true and correct to the best of my knowledge. X X Project Manager Director ADMINISTRATION USE ONLY Date of Acceptance By: X MAYOR Ray Stephanson Approved as to Form X City Attorney INSTRUCTIONS 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. 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 006510 WFP Operations Building Seismic Retrofit- Rebid January 6, 2017 WO# UP3600 006510 - 1