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I <br /> Section 00 65 19 <br /> Certificate of Completion Form <br /> CONTRACTOR: <br /> ADDRESS: <br /> CITY: STATE:WA DATE: <br /> PROJECT TITLE: Phil Johnson Ballfields Renovation <br /> PROJECT NO. PW 2019-054 <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 charge for <br /> work performed and material furnished to the City of Everett, that the same or any part thereof has not been <br /> paid, 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 <br /> correct statement showing all the moneys due me from the City of Everett under this contract; that I have <br /> carefully examined said final statement and understand the same and that I hereby release the City of Everett <br /> from any and all claims of whatsoever nature which I may have, arising out of the performance of said <br /> contract,which are not set forth in said statement. <br /> X X <br /> CONTRACTOR TITLE <br /> Subscribed and sworn to before <br /> me this day of <br /> X _Notary Public <br /> in and for the State of Washington, <br /> residing at <br /> I <br /> PARKS AND COMMUNITY SERVICES CERTIFICATION <br /> APPROVED Date: <br /> I Certify the attached final <br /> statement to be true and <br /> correct to the best of my <br /> knowledge. <br /> X X <br /> Project Manager Director of Parks and Community Services <br /> Dean Shaughnessy Lori Cummings <br /> ADMINISTRATION USE ONLY <br /> Date of Acceptance By: X <br /> IPhil Johnson Ballfields Renovation MAYOR Cassie Franklin 1 of 2 <br /> I <br />