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Date: 10-9-2018 <br />Original <br />❑ Revised # <br />NOTICE OF COMPLETION OF PUBLIC WORKS CONTRACT <br />Contractor's UBI Number: 601 006 854 <br />Name & sMailing Address of Public Agency <br />City of Tukwila <br />6200 Southcenter Blvd Tukwila, WA 98188 <br />UBI Number: 91-6001519 <br />Assigned to: <br />Date Assigned: <br />Department Use Only; <br />Notice is hereby given relative to the completion of contract or project described below <br />Project Name <br />2017 Annual Overlay Program 917104401 <br />Contract Number <br />17-141 <br />Job Order Contracting <br />• Yes VNo <br />Description of Work Done/Include Jobsite Address(es) <br />Hot Mix Asphalt (HMA) Overlay at the following locations: S.128th St, S.133rd St, S.130th St, S.143rd <br />St, 45th Ave s and Ft dent park. <br />Federally funded transportation project? ❑ Yes LyJ No (if yes, provide Contract Bond Statement below) <br />Contractor's Name <br />ICON <br />E-mail Address <br />mark.eichelberger@iconmatemj <br />Affidavit ID* <br />771616 <br />Contractor Address <br />1508 Valentine Ave SE Pacific, WA 98047 <br />Te <br />206-575-3200 <br />ephone # <br />If Retainage is not withheld, please select one of the following <br />Retainage Bond <br />and <br />List Surety's Name & Bond Number. <br />bond (valid for federally funded transportation projects) <br />j♦ Contract/Payment <br />Name: Fidelity and deposit Company of Maryland Bond Number: 9262708 <br />Date Contract Awarded <br />8-7-17 <br />Date Work Commenced <br />8-14-2017 <br />Date Work Completed <br />10-4-2018 <br />Date Work Accepted <br />Were Subcontracters used on this project? If so, please complete Addendum A. [1�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 n/a rule 171 <br />(If various rates apply, please send a breakdown) <br />Sales Tax Amount <br />Comments:' <br />659,441.00 <br />$ 96,278.62 <br />$ 563,162.38 <br />$ <br />TOTAL $ 563.162.38 <br />Liquidated Damages $ 0.00 <br />NOTE: These two totals must be e <br />9 <br />Amount Disbursed $ 563,162.38 <br />Amount Retained $ 0.00 <br />ual <br />TOTAL $ 563,162.38 <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 />"somaDepartment of Revenue <br />�Public Works Section <br />(360) 704-5650 <br />PWC@dor.wa.gov <br />Washington State Department of <br />Labor & Industries <br />Contract Release <br />(655) 545-8163, option # 4 <br />ContractRelease@LNI. WA.GOV <br />Title: Fiscal Specialist <br />Phone Number: 206-433-1871 <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 />