2018/05/16 Council Agenda Packet

• 9 ' • • Application and Certification for Payment To(Owner): City of Everett Purchasing Contract No.: N/A Application No.: 2(FINAL) 3200 Cedar Street#5 Work Order No.: 86 • Application Date: 4'10/2018 Everett,WA Contract PO No.: JC17129 Payment Period: 3/17/18-3/31/18 • WO PO No.: N/A From(Contractor): Forma Construction Company • • 1016 1st Avenue South Ste#400 Seattle,WA 98134 CONTRACTOR'S APPLICATION FOR PAYMENT CONTRACTOR'S CERTIFICATION Application is made for Payment as shown below: The undersigned Contractor certifies that to the best of Contractor's knowledge, information,and belief,the Work covered by his Application for Payment has 1. Original Work Order Sum $ 44,478.11 been completed in accordance with the Contract Documents and in a good and 2. Net Change(s)by Change Order(s) $ 26,756.11 workmanlike manner by appropriate means;that all amounts,including applicable sales tax,have been paid by Contractor for Work for which previous Certificates 3. Total Work Order Sum(Line 1+Line 2) $ 71,234.22 of Payment were issued and payment received from the Owner,that the prevailing 4. TOTAL EARNED(Completed Work) $ 71 234 22 wages have been paid in accordance with the pre-filed statement or statements of intent to pay prevailing wages;and that payment as shown herein is now due. 5. Balance to Complete(Line 3-Line 4) • $ - 6. RETAINAGE on TOTAL EARNED $ - 7. Total Earned Less Retainage(Line 4-Line 6) $ 71,234.22 • 8. Previously Approved(Line 7 from Previous Application) $ 67,672.51 CONTRACTOR: 9. Current Amount Due(Line 7-Line 8) $ 3,561.71 By: T-Q �6, Wm,- Date: 4/10/2018 10. 9.7%WA State Sales Tax,if applicable(Total Applied to Date) $ 345.49 CITY OF EVERETT CERTIFICATE FOR PAYMENT 11. Less WSST Previously Paid $ - 12. WSST Due this Period(Line 10-Line 11) $ 3 '49 In accordance with the Contract Documents and based on observations at the site,review of Contractor's record drawings as of the date of this Application,the Resident Engineer certifies to the Owner that to the best of his/her knowledge, 13. Total Payment Due with WSST(Line 9+Line 12) $ ,. 3,907.20 information and belief,the Work has progressed as Indicated and in accordance with the Contract Documents,that all required inspections have been performed, Retainage Rate 0% and the Contractor is entitled to payment in the Amount Certified below. AMOUNT CERTIFIED (attach explanation if amount certified differs from the amount applied for) CITY OF EVERETT: By: Date: Project Manager This Certificate is not negotiable.The AMOUNT CERTIFIED Is payable onlyto the Contractor named herein. Issuance,payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract. • 96