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��,{ <br /> L i Original <br /> ❑ Revised# <br /> dye /A 89 <br /> NOTICE OF COMPLETION OF PUBLIC WORKS CONTRACT <br /> Date: August 24, 2018 Contractor's UBI Number: 602 271 532 <br /> Name& Mailing Address of Public Agency Department Use Only <br /> City of Tukwila Assigned to: <br /> 6200 Southcenter Boulevard <br /> Tukwila, WA 98188 Date Assigned: <br /> UBI Number: <br /> Notice is hereby given relative to the completion of contract or project described below <br /> Project Name Contract Number Job Order Contracting <br /> 2017 Annual Small Drainage Project 17-121 ❑ Yes E'No <br /> Description of Work Done/Include Jobsite Address(es) <br /> Construct drainage improvements at 3 public right-of-way sites: 1) S. 48th St. 2) S 58th St. 3) Strander <br /> Blvd. <br /> Federally funded transportation project? ❑ Yes No (if yes,provide Contract Bond Statement below) <br /> Contractor's Name E-mail Address Affidavit ID* <br /> McCann Construction Inc. arlene@mccannconst.com 851561 <br /> Contractor Address Telephone# <br /> 13029 136th Ave SE Renton, WA 98059 425-228-2316 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 Date Work Commenced Date Work Completed Date Work Accepted <br /> June 19, 2017 August 16, 2017 January 11, 2018 <br /> Were Subcontracters used on this project?If so,please complete Addendum A. E Yes ❑No <br /> Affidavit ID*-No L&I release will be granted until all affidavits are listed. <br /> Contract Amount $ 451,823.75 <br /> Additions (+) $ 7,716.15 Liquidated Damages $ 0.00 <br /> Reductions (-) $ 11,068.19 Amount Disbursed $ 426,048.12 <br /> Sub-Total $ 448,471.71 Amount Retained $ 22,423.59 <br /> Sales Tax Rate 10 <br /> (If various rates apply,please send a breakdown) <br /> Sales Tax Amount $ 0 <br /> TOTAL $ 448.471.71 TOTAL $ 448,471.71 <br /> NOTE: These two totals must be equal <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 SIIALL 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: dianejaber@tukwilawa.gov Phone Number: (206)433-1871 x1871 <br /> gr- <br /> (ea Department of Revenue � Washington state Department of Employment Security <br /> Public Works Section ,Tit Labor & Industries Department <br /> (360)704-5650 Contract Release Registration,Inquiry, <br /> Standards&Coordination <br /> PWC@dorma.gov (855)545-8163,option tt 4 <br /> Unit <br /> ContractRelease@LNI.WA.GOV (360)902-9450 <br /> publicworks@esd.wa.gov <br /> REV 31 0020e(10/26/15) F215-038-000 10-2014 <br /> 55 <br />