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CITY OF EVERETT PUBLIC WORKS 00 65 10 SPECIAL PROVISIONS CERTIFICATE OF COMPLETION FORM DOCUMENT 00 65 10—CERTIFICATE OF COMPLETION FORM CONTRACTOR: ' ADDRESS: CITY: STATE: DATE: PROJECT TITLE: Three Lakes Valve Bypass PROJECT NO. UP3611 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 THREE LAKES VALVE BYPASS July 19, 2017 WO# UP3611 00 65 10 - 1