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Date: <br />V Original <br />❑ Revised # <br />NOTICE OF COMPLETION OF PUBLIC WORKS CONTRACT <br />Contractor's UBI Number: 601606620 <br />Name & Mailing Address of Public Agency <br />City of Tukwila <br />6200 Southcenter Boulevard <br />Tukwila, WA 98188 <br />UBI Number: 179000208 <br />Department Use Only <br />Assigned to: <br />Date Assigned: <br />Notice is hereby given relative to the completion of contract or project described below <br />Project Name <br />2016 Andover Park East Sewer Repair, 91140203 <br />Contract Number <br />17-092 <br />Job Order Contracting <br />❑ Yes V No <br />Description of Work Done/Include Jobsite Address(es) <br />Replacement of approximately 435 linear feet of asbestos -cement sewer main with PVC pipe, and other necessary works associated with <br />this pipe replacement, within the City right-of-way on Andover Park East. <br />Federally funded transportation project? ❑ Yes No (if yes, provide Contract Bond Statement below) <br />Contractor's Name <br />E-mail Address <br />Affidavit ID* <br />Gary Harper Construction, Inc. <br />gary@garyharperconst.com <br />747289 <br />Contractor Address <br />Te <br />ephone # <br />14831 223rd Street SE, Snohomish, WA 98296 <br />360-863-1955 <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 <br />Date Work Commenced <br />Date Work Completed <br />Date Work Accepted <br />May 15, 2017 <br />July 31, 2017 <br />November 8, 2017 <br />Were Subcontracters used on this project? If so, please complete Addendum A. VY es ❑ 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 />Sales Tax Rate <br />10.0 % <br />(If various rates apply, please send a breakdown) <br />Sales Tax Amount <br />$ 413935.50 <br />$ 0.00 Liquidated Damages $ 0.00 <br />$ 81,714.00 <br />$ 332,221.50 <br />$ 33222.14 <br />TOTAL $ 366_443 64 <br />Amount Disbursed $ 348832.57 <br />Amount Retained $ 16611.07 <br />NOTE: These two totals must be equal <br />TOTAL $ 365,443.64 <br />Comments: <br />Note: The Disbursing Officer must submit this con I leted 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 />Diane Jaber <br />Email Address: diane.jaber@tukwilawa.gov <br />Dep of Revenue <br />Public Works Section <br />C.ra <br />(360) 704-5650 <br />PWC@dor.wa.gov <br />0 Washington State Department of <br />Labor & Industries <br />Contract Release <br />(855) 545-8163, option # 4 <br />ContractRelease@LNI. WA.GOV <br />REV 31 0020e (10/26/15) F215-038-000 10-2014 <br />Title: Fiscal Specialist <br />Phone Number: (206) 433-1871 X 1871 <br />Employment Security <br />Department <br />Registration, Inquiry, <br />Standards & Coordination <br />Unit <br />(360) 902-9450 <br />publicworks@esd.wa.gov <br />2 <br />