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CITY OF EVERETT <br /> FINAL CONTRACT VOUCHER CERTIFICATION <br /> CONTRACTOR: Tri State Construction ADDRESS: PO Box 3686 <br /> CITY: Bellevue STATE: WA 98009 DATE: June 20, 2011 <br /> PROJECT TITLE: Replacement of Water WORK ORDER NO.: UP 3141 <br /> Transmission Lines 2&3,Phase 6 FINAL AMOUNT: $ 23,801,315.49 <br /> DATE WORK COMPLETE: December 13, 2010 excluding Washington 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 performed <br /> and material furnished to the City of Everett, that the same or any part thereof has not been paid, and that I am <br /> authorized to sign for the claimant; that I have not rented or purchased any equipment or materials from any <br /> employee of the City; I further certify that the attached final estimate is a true and correct statement showing all the <br /> monies due me from the City of Everett under this contract; that I have carefully examined said final estimate and <br /> understand the same and that I hereby release the City of Everett from any and all claims of whatsoever nature <br /> which I may have, arising out of the performance of said contract,which are not set forth in said estimate. <br /> X c � , • <br /> x P- 2Sl dint <br /> CONTRACTOR TITLE <br /> Tri State Construction �`%(o 14AEMI4 10,0 <br /> Subscribed and sworn to before =cc <br /> me this ' day of +II _1tI Or- <br /> 2.. <br /> Xn► .0 r11A A .i. _ I. 061 otary Public i pU3V"' o <br /> in a d for the State of Washington, residing at l7Ul,V0..4ostoireI N,►�: A• <br /> ti ? <br /> 'Immo% <br /> PUBLIC WORKS DEPART ENT CERTIFICATION <br /> I Certify the attached final APPROVED Date: r <br /> estimate to be based upon actual <br /> - measurements and to be true and correct. <br /> X .� i X d' <br /> Construction Manager Public Works r irector <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 /> • <br /> 44 <br />