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0 Section 006519 <br /> certificate of Completion Form <br /> CONTRACTOR:Qs *.� a'�� <br /> ADDRESS: <br /> STATE WA DATE: \C) <br /> PROJECT TITLE: Kasch Park Soccer Fields e Synthetic Turf Replacement Phase 2 <br /> PROJECT NO. PW9SQ aD <br /> DATE WORK COMPLETED: \%--": FINAL CONTRACT AMOUNT:$ „\V\ <br /> CONTRACTOR'S CERTIFICATION. <br /> I,the undersigned, having first been duly sworn,certify that the attached statement is a proper charge for work <br /> performed and material furnished to the City of Everett, that the same or any part thereof has not been paid, <br /> and that I am authorized to sign for the claimant; that I have not rented or purchased any equipment or <br /> materials from any employee of the City; I further certify that the attached final statement is a true and correct <br /> statement showing all the moneys due me from the City of Everett under this contract that I have carefully <br /> examined said final statement and understand the same and that I hereby release the City of Everett from any <br /> and all claims of whatsoever nature which I may have,arising out of the performance of said contract,which <br /> are of set forth in said statement <br /> . �,lt�llittr�l1 <br /> �ti <br /> X ., - " Sa <br /> - • <br /> ar R•ny OR N � r_ti <br /> . . ,`ti 4. .6 •. <br /> Sty*cribed and sworn to re _ ;0 cjS �7 Z <br /> me thiscN_day of C�� c c' ;c.) t��-�C o <br /> `=-' otary Public c r. <br /> in rd for the Sate of Washington, residing%atc4 6%. os,s X• 411 <br /> 74 <br /> • <br /> - k <br /> PARKS AND RECREA + , -= T CERTIFICATION. <br /> APPROVED Date: <br /> I Certify the attached final <br /> statement to be true and correct <br /> to the best of my imp -dge. • <br /> Project Manag-r Direciorlof Parks and Re <br /> Russell Dance PauL anski �o r i /?d�„ <br /> ADMINISTRATION USE ONLY <br /> _ Date-ofAccepta - _--_----gy_X=_ <br /> .. � = <br /> MAS'0R e. e. FI-40k <br /> Approved as to Form • <br /> X <br /> City Attorney <br /> INSTRUCTIONS • <br /> The Affidavit of Wages Paid must be prepared by the prime contractor,ail subcontractors,and all subcontractor's agents <br /> and forwarded with the Final Contract Voucher Certification. • <br /> Contractor's Claims,if any,must be included and the Contractor's Cerfification must be labeled indicating a claim attached <br /> ReVGed 11.aa <br /> loft <br /> Provided to Builders Exchange of WA, Inc. For usage Condition Tc.reement see www.bxwa.com — Always Verify Scale <br />