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CITY <br /> Section 006519 <br /> Certificate of Completion Form <br /> CONTRACTOR: Qc•-c.,o C f'.��\ �c.% ,- tee, 11`C <br /> ADDRESS:'�JL C a- -c,�c �v-Q v.-.,7•-.5›,- <br /> C 1TY:S t• o. .•;6\--. STATE:WA DATE: \O- -A-N.51 <br /> PROJECT TITLE: Kasch Park Soccer Fields-Synthetic Turf Replacement Phase 2 <br /> PROJECT NO. PW160550 <br /> DATE WORK COMPLETED: \%tSk FINAL CONTRACT AMOUNT:$3:\\QC:\,\\'\•z:::- <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 /> �t111UUf1/1 <br /> X. ♦� "1/ <br /> X ' �� 1.4/ <br /> CZ <br /> f ►N R• : <br /> OR ..� G�y ,� ��G+;s\ el,.. <br /> Su._cribed and sworn to fore ;off �,`1 •.. Z= <br /> me this.day of C -ti c ��NG • 0 <br /> �.+. lotary Public M t Qv <br /> in for the State of Washington, residing ,;il•' ,� <br /> at CNi.� :� �e.o •"o /9'••...0a •'. ,�,`+�. <br /> PARKS AND RECREATI`t w* "meta CERTIFICATION <br /> APPROVED Date: m1y)t17 9-/ a-Qiq <br /> I Certify the attached final <br /> statement to be true and correct <br /> to the best of my knowledge. y , <br /> ''-%9i1.4.4./ X CI <br /> Protect Manag r Dir of Parks and Recr do <br /> Russell Dance PPu Kattanski ti o i. , 0‘2.t,4„--)11';1' <br /> ADMINISTRATION USE • , y <br /> Date of Acceptance By: X .� -- <br /> Approved as to Form /., Te <br /> ifiv0412c2c2 <br /> X a'i'l//�� D• _/- <br /> f ity Attorney City Clerk <br /> INSTRUCTIONS <br /> The Affidavit of Wages Paid must be prepared by the prime contractor,all 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 Certification must be labeled indicating a claim attached. <br /> Revised 11.03 <br /> 1of1 <br /> Provided to Builders Exchange of WA, Inc. For usage Conditions Agreement see www.bxwa.com - Always Verify Scale <br />