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DOCUMENT 00 65 10—CERTIFICATE OF COMPLETION FORM <br /> CONTRACTOR: <br /> ADDRESS: <br /> CITY: STATE: WA DATE:_ <br /> PROJECT TITLE: WPCF FEN Chlorination Building Upgrade <br /> PROJECT NO. 3614 <br /> DATE WORK COMPLETED: FINAL CONTRACT AMOUNT: <br /> CONTRACTOR'S CERTIFICATION <br /> I, the undersigned, having first been duly sworn, certify that the attached statement is a proper <br /> charge for work performed and material furnished to the City of Everett, that the same or any part <br /> 1 thereof has not been paid, and that I am authorized to sign for the claimant;that I have not rented or <br /> purchased any equipment or materials from any employee of the City; I further certify that the <br /> attached final statement is a true and correct statement showing all the moneys due me from the <br /> City of Everett under this contract; that I have carefully examined said final statement and <br /> understand the same and that I hereby release the City of Everett from any and all claims of <br /> whatsoever nature which I may have, arising out of the performance of said contract,which are not <br /> set forth in said statement. <br /> X X <br /> CONTRACTOR <br /> TITLE <br /> Subscribed and sworn to before <br /> me this_day of <br /> • X Notary Public <br /> in and for the State of Washington, residing <br /> at <br /> 111 <br /> DEPARTMENT CERTIFICATION <br /> APPROVED Date: <br /> I Certify the attached final <br /> statement to be true and correct <br /> to the best of my knowledge. <br /> X X <br /> Project Manager <br /> Director <br /> I <br /> 1 <br /> 10023829 City of Everett Public Works July 2018 <br /> WPCF FEN Chlorination Building Upgrade Work Order 3614 <br /> CERTIFICATE OF COMPLETION FORM <br /> 00 65 10-1 Issue for Bid <br />