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Date: 7-9-2018 <br />g Original <br />❑ Revised # <br />NOTICE OF COMPLETION OF PUBLIC WORKS CONTRACT <br />Contractor's UBI Number: 602-286-010 <br />Name & Mailing Address of Public Agency <br />City of Tukwila <br />6300 Southcenter Blvd 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 />Baker Non -Motorized improvement project 91610409 <br />Contract Number <br />17-128 <br />Job Order Contracting <br />❑ Yes IlifNo <br />Description of Work Done/Include Jobsite Address(es) <br />Construction of new curbing, gutters, decorative sidewalks, storm improvements, illumination, ADA <br />improvements and rechannelization of Baker Blvd. Job site: 120 Christensen rd Tukwila, WA 98188 <br />Federally funded transportation project? ❑ Yes WI No (if yes, provide Contract Bond Statement below) <br />Contractor's Name <br />E-mail Address <br />Affidavit ID* <br />Road Construction Northwest <br />matt@rcnw.com <br />851566 <br />Contractor Address <br />Te <br />ephone # <br />PO Box 2228, Renton, WA 98056 <br />425-777-7321 <br />If Retainage is not withheld, please select one of the following and List Surety's Name & Bond Number. <br />❑ Retainage Bond <br />• 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 />7-17-2017 <br />8-16-2017 <br />7-2-2018 <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 n/a rule 171 <br />(If various rates apply, please send a breakdown) <br />Sales Tax Amount <br />;, " <br />Comments: <br />TOTAL <br />799,143.00 <br />$ 29,380.09 <br />$ 828,523.09 <br />$ 828.523.09 <br />Liquidated Damages $ 0.00 <br />NOTE: These two totals must be e <br />9 <br />Amount Disbursed $ 828,523.09 <br />Amount Retained $ 0.00 <br />ual <br />TOTAL $ 828,523.09 <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: <br />Email Address: <br />Diane Jaber <br />Diane.jaber@tukwilawa.gov <br />raDepartment of Revenue <br />filiC„, Public Works Section <br />(360) 704-5650 <br />PWC@dor.wa.gov <br />Washington State Department of <br />Labor & Industries <br />Contract Release <br />(855) 545-8163, option # 4 <br />ContractRelease@LN I. 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 />pu bl i cworks@esd.wa.gov <br />REV 31 0020e (10/26/15) F215-038-000 10-2014 <br />6 <br />