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Date: 4/3/19 <br />❑ Original <br />❑ Revised # <br />NOTICE OF COMPLETION OF PUBLIC WORKS CONTRACT <br />Contractor's UBI Number: 601061071 <br />Name & Mailing Address of Public Agency <br />City of Tukwila <br />6200 Southcenter Boulevard, <br />Tukwila, WA 98188 <br />UBI Number: 179 000 208 <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 />CBD Sewer Rehab - 2018 Construction 91140203 <br />Contract Number <br />18-040 <br />Job Order Contracting <br />❑ Yes 'No <br />Description of Work Done/Include Jobsite Address(es) <br />Install CIPP liners in several sections of sewer main within the Tukwila Urban Core. <br />Federally funded transportation project? ❑ Yes LYJ No (if yes, provide Contract Bond Statement below) <br />Contractor's Name <br />Michels Corporation <br />E-mail Address <br />dphelps@michels.us <br />Affidavit ID* <br />840882 <br />Contractor Address <br />1715 16th Street SE, Salem OR, 97302 <br />Te <br />920-583-3132 <br />ephone # <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: Continental Casualty Company & Liberty Mutual Insurance Bond Number: 30035085/190039223 <br />Date Contract Awarded <br />3/5/2018 <br />Date Work Commenced <br />4/30/2018 <br />Date Work Completed <br />1/15/2019 <br />Date Work Accepted <br />Were Subcontracters used on this project? If so, please complete Addendum A. IfYes ❑ 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 />Amount of Sales Tax <br />10.0 <br />(If various rates apply, please send a breakdown) <br />TOTAL <br />$ 449,633.25 <br />$ 7,107.32 <br />$ 82,685.78 <br />$ 374,054.79 <br />37405.48 <br />Liquidated Damages $ 0.00 <br />$ 411,460.27 <br />NOTE: These two totals must be e <br />q <br />Amount Disbursed $ 392,757.53 <br />Amount Retained $ 18,702.74 <br />ual <br />TOTAL $ 411,460.27 <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 />ts <br />Department 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 />(855) 545-8163, option # 4 <br />ContractRelease@LN I. WA. GOV <br />Title: Fiscal Specialist <br />Phone Number: (206) 433-1871 x 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 (4/28/14) F215-038-000 04-2014 <br />9 <br />