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g Original <br />❑ Revised # <br />NOTICE OF COMPLETION OF PUBLIC WORKS CONTRACT <br />Date: 12/07/2017 <br />Contractor's UBI Number: 600247364 <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 />Cascade View Safe Routes to School <br />Contract Number <br />17-109 <br />Job Order Contracting <br />❑ Yes V No <br />Description of Work Done/Include Jobsite Address(es) <br />S.140th/33rd Ave S. Removed existing pavements; provided erosion/water pollution control. Installed new storm drainage structures, pipes, <br />curb and gutters, sidewalks, driveway entrances, curb ramps,new HMA pavement and channelization. Adjusted utilities to grade. <br />Federally funded transportation project? [if Yes ❑ No (if yes, provide Contract Bond Statement below) <br />Contractor's Name <br />Hoffman Construction, Inc. <br />E-mail Address <br />karen@hofcon.com <br />Affidavit ID* <br />763253 <br />Contractor Address <br />PO Box 845 Enumclaw, WA 98022 <br />Te <br />360-825-9797 <br />ephone # <br />If Retainage is not withheld, please select one of the following and List Surety's Name & Bond Number. <br />❑ Retainage Bond V Contract/Payment bond (valid for federally funded transportation projects) <br />Name: Merchants Bonding Company (Mutual) Bond Number: WAC54496 <br />Date Contract Awarded <br />05/11/2017 <br />Date Work Commenced <br />07/05/2017 <br />Date Work Completed <br />12/08/2017 <br />Date Work Accepted <br />12/08/2017 <br />Were Subcontracters used on this project? If so, please complete Addendum A. [Yes ❑ 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 <br />% <br />(If various rates apply, please send a breakdown) <br />Sales Tax Amount <br />1409797.00 <br />$ 18,802.76 <br />$ 43,954.33 <br />$ 1,384,645.43 <br />Liquidated Damages $ 0.00 <br />Amount Disbursed $ 1,386,650.43 <br />Amount Retained $ 0.00 <br />$ <br />2005.0o <br />TOTAL $ 1 386.650 43 <br />NOTE: These two totals must be equal <br />TOTAL $ 1,386,650.43 <br />Comments: <br />The project was originally bid at 9.5% Sales Tax for Schedule B only. Rates had changed to 10% after the bid and prior to construction. <br />0.5% was added to the Tax Rate which increased the Sales Tax Amount from $3092.25 to $3255.00. Reductions shown above is the <br />difference between contract amount and actual contract payments. Rule 171 applies to Schedule A only. <br />Note: The Disbursing Officer must subrnrLt sis 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 <br />Public Works Section <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 <br />Employment Security <br />Department <br />Registration, Inquiry, <br />Standards 8. Coordination <br />Unit <br />(360) 902-9450 <br />publicworks@esd.wa.gov <br />10 <br />