2009/12/16 Council Agenda Packet

• 3 CITY OF EVERETT FINAL CONTRACT VOUCHER CERTIFICATION CONTRACTOR:Tri State Construction ADDRESS: PO Box 3686 CITY:Bellevue STATE: WA 98009 DATE: October 15,2009 PROJECT HALE: BNSF Delta Yard Sewer Protection WORK ORDER NO. 3372 DATE WORK COMPLETE: September 22,2009 FINAL AMOUNT: $ 962,541.15 CONTRACTOR'S CERTIFICATION I, the undersigned, having first been duly sworn, certify that the attached bill 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 estimate is a true and correct statement showing all the monies due me from the City of Everett under this contract; that I have carefully examined said final estimate 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 estimate. • X Prvl QX l,S C.�Pn CONTRACTOTITLE 6 Mq � ,��.� Tri State Construction �.` �S •Viii• *' 'e Subscribed and sworn to before : I NOTARY me this `' `day f ,� 1�X (2.01)°I o • X .I -aottary Public sly; �9`�.ys oe�so� ,.•'rf in and for the State of Washington,residing at 1)ua,I, p j�WAN • 01°�` PUBLIC WORKS DEPARTMENT CERTIFICATION • y I Certify the attached final APPROVED Date: • estimate to be based upon actual measurements and to be true and correct. X01.nstruction Maner Public Wor. ,.' i2li4k rector Tom Fuchs Dave Davis 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. 6