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g Original <br />❑ Revised # <br />NOTICE OF COMPLETION OF PUBLIC WORKS CONTRACT <br />Date: August 24, 2018 <br />Contractor's UBI Number: 602 271 532 <br />Name & Mailing Address of Public Agency <br />City of Tukwila <br />6200 Southcenter Boulevard <br />Tukwila, WA 98188 <br />UBI Number: <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 />2017 Annual Small Drainage Project <br />Contract Number <br />17-121 <br />Job Order Contracting <br />• Yes ENo <br />Description of Work Done/Include Jobsite Address(es) <br />Construct drainage improvements at 3 public <br />Blvd. <br />Federally funded transportation project? <br />right-of-way <br />sites: 1) S. 48th St. 2) S 58th St. 3) Strander <br />g No (if yes, provide Contract Bond Statement below) <br />• Yes <br />Contractor's Name <br />McCann Construction Inc. <br />E-mail Address <br />arlene@mccannconst.com <br />Affidavit ID* <br />851561 <br />Contractor Address <br />13029 136th Ave SE Renton, WA 98059 <br />Te <br />425-228-2316 <br />ephone # <br />Ext 7303 <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 />June 19, 2017 <br />Date Work Commenced <br />August 16, 2017 <br />Date Work Completed <br />January 11, 2018 <br />Date Work Accepted <br />Were Subcontracters used on this project? If so, please complete Addendum A. ['Yes <br />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 />(If various rates apply, please send a breakdown) <br />Sales Tax Amount <br />451,823.75 <br />$ 7,716.15 <br />$ 11,068.19 <br />$ 448,471.71 <br />$ 0 <br />TOTAL $ 448.471.71 <br />Liquidated Damages $ 0.00 <br />Amount Disbursed $ 426,048.12 <br />Amount Retained $ 22,423.59 <br />NOTE: These two totals must be equal <br />TOTAL $ 448,471.71 <br />Comments: <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 />n <br />Department of Revenue <br />Public Works Section <br />(360) 704-5650 <br />PWC@dor.wa.gov <br />Washington Sate Department of <br />Labor & Industries <br />Contract Release <br />(855) 545-8163, option # 4 <br />ContractRelease@LNI.WA.GOV <br />Title: Fiscal Specialist <br />Phone Number: (206) 433-1871 x1871 <br />Employment Security <br />Department <br />Registration, Inquiry, <br />Standards & Coordination <br />Unit <br />(360) 902-9450 <br />publicworks@esd.wa.gov <br />REV 31 0020e (10/26/15) F215-038-000 10-2014 <br />42 <br />