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CITY OF EVERETT <br /> FINAL CONTRACT VOUCHER CERTIFICATION <br /> CONTRACTOR: Tri State Construction,Inc. ADDRESS: PO Box 3686 <br /> CITY: Bellevue STATE: WA 98009-3686 . DATE: September 21,2011 <br /> PROJECT TITLE: Replacement of Water Transmission Line 2, Phase 8B WORK ORDER NO. UP 3333 <br /> DATE WORK COMPLETE: January 7, 2011 FINAL AMOUNT: $2,593,267.88 <br /> 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 furthercertify 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 �Jw �K;,��a� SdM�p r/i� <br /> 471-e° OR <br /> TITLE _���`�,,.•."‘""„ii�.!y 1 <br /> Tri State Construction,Inc. _ c _ \,.9Z�Ut ",,,'�0 i <br /> Subscribed and sworn to before >Z -. ' - <br /> me this ► d. of00"0b - a it ) 4brv03 no� _,� <br /> iX114.1for he State Washi WasNothington,res ding at Public \ oo\r\)i f���iiii 'ro"v.Nd��`= <br /> PUBLIC WORKS DEPARTMENT CERTIFICATION <br /> I Certify the attached final APPROVED Date: <br /> estimate to be based upon actual <br /> measurements and to be true and correct. , <br /> X X / <br /> f ' C( <br /> kA N.. <br /> er <br /> g <br /> onstruction Mana Public Works D`ector <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 /> Revised 9/94 <br /> 10 <br />