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�yl 1 tF <br /> ry l4 f��4 <br /> Original <br /> ❑ Revised # <br /> NOTICE OF COMPLETION OF PUBLIC WOR KS CONTRACT <br /> Date: 2/01/2017 Contractor's UBI Number: 600247364 <br /> Name& Mailing Address of Public Agency Department Use Only <br /> City of u wlla Assigned to: <br /> 6200 Southcenter Boulevard <br /> Tukwila, WA 98188 Date Assigned: <br /> UBI Number: 179 000 208 <br /> Notice is hereby given relative to the completion of contractor project described below <br /> Proiect Name Contract Number Job Order Contracting <br /> Crystal Springs Emergency Surface Water Repair(91641206) 116-118 ❑ Yes VNo <br /> Description of Work Done/Include Jobsite Address(es) <br /> Removing and replacing existing storm drain pipes and drainage structures, installation of new storm drain pipes and <br /> drainage structures, removing and replacing HMA roadway paving, removing and replacing cement concrete <br /> sidewalk, and site restoration. �( <br /> Federally funded transportation project? El Yes ICJ No (if yes,provide Contract Bond Statement below) <br /> Contractor's Name E-mail Address Affidavit ID* <br /> Hoffman Construction, Inc. lbrad@hofcon.com 1693970 <br /> Contractor Address Telephone# <br /> P.O. Box 845, Enumclaw, WA 98022 1360-825-9797 <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: Bond Number: <br /> Date Contract Awarded Date Work Commenced Date Work Completed Date Work Accepted <br /> 10/12/16 10/13/16 111/22/16 <br /> ' eee StbcoxTtractcrs used pxta► prbfelcf?If so,pleaonalrlete ddeuditm A Yes l❑Isla z <br /> �ftdavtt 1�*_1�c���tt�lce t11 bt�g�attted-antl�all���itlaa�ils are l���ed: Q '' � � ' ' <br /> Contract Amount $ 203,361.00 <br /> Additions (+) $ 8,586.08 Liquidated Damages $ 0.00 <br /> Reductions (-) $ 0.00 Amount Disbursed $ 201,349.73 <br /> Sub-Total $ 211,947.08 Amount Retained $ 10,597.35 <br /> Sales Tax Rate 0 <br /> (If various rates apply,please send a breakdown) <br /> Sales Tax Amount $ 0 <br /> TOTAL $ 211,947 Q8 TOTAL $ 211,947.08 <br /> NOTE: These two totals must beequal <br /> Comments: <br /> Tax does not apply - Rule 171 <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 Title: Fiscal Specialist <br /> Email Address: Diane.Jaber @TukwilaWA.gov Phone Number: (206)433-1871 <br /> Department of Revenue WasWrKjtm State entof Aw Employment Security <br /> Public Works Section 1r1dL35trtE5 Department <br /> (360)704-5650 Contract Release Registration,Inquiry, <br /> PWC @dor.wa.gov (855)545-8163,option#4 Standards&Coordination <br /> ContractRelease @LNI.WA.GOV Unit <br /> (360)902-9450 <br /> publicworks @esd.wa.gov 2 <br /> REV 31 0020e(10/26/15) F215-038-000 10-2014 <br />