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51 AI Oti <br />LYI Original <br />l <br />❑ <br />Revised # <br />oy <br />�y eaets ' <br />NOTICE OF COMPLETION OF PUBLIC WORKS CONTRACT <br />Date: January 17, 2017 Contractor's UBI Number: 601061071 <br />Name & Mailing Address of Public Agency Department Use Only <br />City of u I a Assigned to: <br />6200 Southcenter Boulevard <br />Tukwila, WA 98188 Date Assigned: <br />UBI Number: 179000208 <br />Notice is herebv given relative to the conrnietion of contract or nroiect described below <br />Project Name <br />Contract Number <br />Job Order Contracting <br />2015 CBD Sanitary Sewer Rehabilitation Project 91140203 <br />115-178 <br />❑ Yes VNo <br />Description of Work Done /Include Jobsite Address(es) <br />Installation of approximately 6,510 lineal feet of cured -in -place pipe within the right -of -way of Andover <br />Park East, Industry Drive, Minkler Boulevard and private easements to rehabilitate existing sewer pipes. <br />Federally funded transportation project? ❑ Yes LVJ No (if yes, provide Contract Bond Statement below) <br />Contractor's Name <br />E -mail Address <br />Affidavit ID* <br />Michels Corporation <br />ictaverni@michels.us 1656933 <br />Contractor Address <br />Telephone # <br />1715 16th Street SE, Salem, OR 97302 <br />1503-364-1199 <br />If Retainage is not withheld, please select one of the following and List Surety's Name & Bond Number. <br />❑ Retainage Bond ❑ Contract/Payment bond (valid for federally funded transportation projects) <br />Name: <br />jBond Number: <br />Date Contract Awarded <br />Date Work Commenced <br />Date Work Completed <br />Date Work Accepted <br />November 2, 2015 <br />December 7, 2015 <br />June 9, 2016 <br />Were Subcontracters used on this project? If so, please complete Addendum A. Foyes ❑ No <br />Affidavit ID* ` No L &I release will be granted until all affidavits are listed. <br />Contract Amount <br />Additions ( + ) <br />Reductions (- ) <br />Sub -Total <br />Amount of Sales Tax 9.5 <br />(If various rates apply, please send a breakdown) <br />TOTAL <br />$ 482,616.00 <br />$ 26,244.60 <br />$ 43,736.50 <br />$ 465,124.10 <br />$ 44186.79 <br />$ 509,310.89 <br />Liquidated Damages $ <br />0.00 <br />Amount Disbursed $ <br />486,054.68 <br />Amount Retained $ <br />23,256.21 <br />IvU1C: lnese two totals Must bee uat <br />Comments: <br />TOTAL $ 509,310.89 <br />Note: The Disbursing Officer must submit this completed notice immediately after acceptance of the work done under this contract. <br />NO PAYMENT SHALL BE MADE FROM RETAINED FUNDS until receipt of all release certificates. <br />Submitting Form: Please submit the completed form by email to all three agencies below. <br />Contact Name: Diane Jaber <br />Email Address: diane.jaber @tukwilawa.gov <br />Department of Revenue Washington State De paranent of <br />Public Works Section tabor & Industries <br />(360) 704 -5650 Contract Release <br />PWC @dor.wa.gov (855) 545 -8163, option # 4 <br />ContractRelease @LNI. WA. GOV <br />REV 31 0020e (4/28/14) F215- 038 -000 04 -2014 <br />Title: Fiscal Specialist <br />Phone Number: (206) 433 -1671 x 1871 <br />Employment Security <br />Department <br />Registration, Inquiry, <br />Standards & Coordination <br />Unit <br />(360) 902 -9450 <br />publicworks @esd ,M.gov <br />