HomeMy WebLinkAboutIowa Department of Transportation-10/14/2013Form 640003
03-04 wd
l-1 Iowa Department of Transportation
CERTIFICATE of COMPLETION and
FINAL ACCEPTANCE of AGREEMENT WORK
COMPANY: Benton's Sand & Gravel, Inc. COUNTY/CITY: Cedar Falls, Iowa 50613
ADDRESS: 905 Center Street PROJECT NO.: RM -8155(727)-9D-07
KIND OF WORK: F.Y. 2012 Geraldine Road Extension - Contract No. 821
AGREEMENT DATE: 8/13/12 FIELD COMPLETION DATE: 9/10/13
This is to certify that the work covered by the above referenced agreement has been completed in accordance with
said agreement and is hereby accepted, subject to final audit of costs.
SIGNATURE:
*SIGNATURE:
inset (Res. (Area
Project g Construction) Engineer) (County) (City)
(Consultant)
District (Construction) (Maintenance) (Local Systems) Engineer
DATE: 10/8
DATE:
2013
Year
Year
Approved and work accepted by the Board of Supervisors/City
Council of
this 11-1-11A
day of CC-4-010ev— , 2LD I �{
Year
SIGNATURE:
Chairman/Mayor
Acknowledge completion of project in accordance with referenced agreement by the Iowa Department of
Transportation
this day of
Year
SIGNATURE:
Iowa Department of Transportation
*On Local State Assisted
Projects District does
NOT certify but
acknowledges
completion of project.
DO NOT WRITE IN THIS BOX. CENTRAL OFFICE USE ONLY.
(Check or Initial Appropriate Box)
❑ Office of Audits ❑ Copy to Company
❑Copies to District 0 Original to Files