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5 CITY OF EVERETT <br /> FINAL CONTRACT VOUCHER CERTIFICATION <br /> CONTRACTOR: KLB Construction ADDRESS: P.O. Box 158 <br /> CITY: Mukilteo STATE: WA 98275 DATE: January 19, 2012 <br /> PROJECT TITLE: Sewer System Replacement"F", Sch B WORK ORDER NO. UP3300-2 <br /> DATE WORK COMPLETE: January 17, 2012 FINAL AMOUNT: $ 3,133,253.81 <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 /> whic I may, S e, a ; ing out of the performance of said contract,which are not set forth in said estimate. <br /> X <br /> áP ,Leg :14 x KELLY LYNN BUPA <br /> CO gAi TIP TITLE • PRESIDENT <br /> KLB onstruction OV <br /> ,&., -..- (.,0:1.4/::.;\ <br /> Subscribed and sworn before `c NOTARY �`' I <br /> me 's day pf q� P l9 i0 <br /> XX J otary Public 1 d� <br /> and rT3he State of Washington,residing at V1'nD , .r; 'x-27-lois _,.c," <br /> PUBLIC WORKS DEPART NT CERTIFICATION (� �/J <br /> I Certify the attached final APPROVED Date: - . v �=/ <br /> estimate to be based upon actual <br /> measurements and to be true and correct. MAY 1 6 2012 <br /> X , �l� X /1119 & <br /> CITY ct F EVERETT <br /> Construction Mana er Public Works Db_ for Construction Management <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 /> 16 <br />