DEPARTMENT OF GENERAL SERVICES
BUREAU OF CONSTRUCTION

CERTIFICATE OF CONTRACT COMPLETION


AGENCY:

PROJECT:

CONTRACTOR:

CONTRACT FOR.-'

CONTRACT DATE:


CONTRACT AMOUNT:


CONTRACTOR'S AFFIDAVIT


I solemnly swear (or affirm): That the work under the above named contract and all
amendments thereto have been satisfactorily completed; that all amounts payable for
materials, labor and other charges against the project have been paid; that no
liens have been attached against the project; that no suits are pending by reason -
of work on the project under the contract; that all Workmen's Compensation claims
are covered by Workmen's Compensation insurance as required by law; and that all
public liability claims are covered by insurance.
CONTRACTOR:


(SEAL)


Title:

Date:


STATE OF
COUNTY OF
Personally appeared before me this day of 197


~~~___~~___________, known (or made known) to


me to be the


(Owner)


(Partner)


(Corporate Officer -


Title)


Contractor (s), who, being by me duly sworn, subscribed to the foregoing affidavit

in my presence.


(Notary Public)
(Type Name):

My Commission Expires:


Page I of 2 Pages






Certificate of Contract Completion

CERTIFICATE OF ARCHITECT/ENGINEER


I CERTIFY: That the work under the above named contract has been satisfactorily
completed under the terms of the contract; that the project is recommended for
occupancy by the owning agency; that the contractor has submitted satisfactory
evidence that he has paid all labor, materials and other charges against the project
in accordance with the terms of the contract.


Date


Days


Contract Date __ NI/A -

Contractor Notified to Proceed N/A -

Days Allowed by Contract N/A -

Extensions Granted by C.O. N/A -

Total Days Allowable' N/A __-

Work Began 6 Oct. '75 -
Project Substantially
Completed 13 May '76 -

Days to Complete___ 221

Underrun N/A

Overrun, N/A ___


A/E Firm Name: Fisher &


Shepard. Archite~t~&


Inc.
Planners,/


Date: 13 July 1976


CERTIFICATE


By: /z 6 LA


OF ACCEPTANCE BY USING AGENCY


THIS IS TO CERTIFY: That to the best of my knowledge and belief the statements
made in the above affidavit and certificate are true, and the project is satis-
factorily completed under the terms of the contract and is hereby accepted for
occupancy, operation and maintenance.

Agency:


Title:


APPROVED BY DEPARTMENT OF GENERAL SERVICES


Projects Manager


Administrator
Construction Supervision Section


Page 2 of 2 Pages


V


Date:


Date:


Date:


SheDard. Architects &