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�a� as rQ oA <br />Original <br />0 <br />❑ Revised # <br />NOTICE OF COMPLETION OF PUBLIC WORKS CONTRACT <br />Date: 12/05/2016 <br />Contractor's UBI Number: 578025601 <br />Name & Mailing Address of Public Agency Department Use Only <br />City of u I a Assigned to: <br />6200 Southcenter Blvd <br />Tukwila Wa. 98188 Date Assigned: <br />UBI Number: 179 -00 -208 <br />Notice is hereby give: relative to the completion of contract or project described below <br />Project Name <br />Contract Number <br />116-114 <br />Job Order Contracting <br />Crystal Springs Emergenc Surface Water Repair 91641206 <br />Amount Retained $ <br />❑ Yes V No <br />Description of Work Done /include Jobsite Address(es) <br />Crystal Springs Emergency Surface Water Water Repair. Emergency roadway repair and bypass <br />piping to redirect water from plugged structures. <br />Federally funded transportation project? ❑ Yes 9 No (if yes, provide Contract Bond Statement below) <br />Contractor's Name <br />E -mail Address <br />i D <br />Frank Coluccio Construction Co. ]Lisa <br />Patton lisa @coluccio.com <br />IAdavit <br />671442 <br />Contractor Address <br />Telephone <br />9600 M.L. King Way S. Seattle WA, 98118 -5693 <br />206 - 722 -5306 <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 />I Bond Number: <br />Date Contract Awarded <br />Date Work Commenced <br />Date Work Completed <br />Date Work Accepted <br />09/28/2016 <br />07/21/2016 Emergency Contract <br />11/01/2016 <br />Were Subcontracters used on this project? If so, please complete Addendum A. Wyes ❑ 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 14,236.4 <br />(if various rates apply, please send a breakdown) <br />$ 180,000.00 <br />$ 15,906.46 <br />$ 164,093.54 <br />TOTAL $ 164.093.54 <br />Ivulk: lftese two totals must be <br />Liquidated Damages $ <br />0.00 <br />Amount Disbursed $ <br />156,600.68 <br />Amount Retained $ <br />7,492.86 <br />TOTAL $ 164,093.54 <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: <br />Email Address: <br />Department of Revenue <br />Washington StmcDepartment of <br />Works Section <br />Labor & Industries <br />CPublic <br />(360) 704 -5650 <br />Contract Release <br />PWC@dor.wa.gov <br />(855) 545 -8163, option # 4 <br />ContraclRelease @LNI.WA.GOV <br />REV 31 0020e (4/28)'14) F215- 038 -000 04 -2014 <br />Title: <br />Phone Number: <br />Employment Security <br />Department <br />Registration, Inquiry, <br />Standards & Coordination <br />Unit <br />(360) 902 -9450 <br />publlcworks@esdff.gov <br />