Community Development Department Use ONLY:
Reviewed by: ______________________________ Date: ____________
Approved by: ______________________________ Date: ____________
Certificate of Completion
This form must be completed & submitted with the Final Inspection Report & Final Request for Payment for all CDBG
funded construction projects.
(SUBMIT ONE FOR EACH PRIME CONSTRUCTION CONTRACT)
*Su
Subrecipient/Recipient Department Name
CDBG Contract Number (Ordinance Number)
Prime Contractor Contract Number (Ordinance Number)
This is to certify that the final inspection for the above referenced project was conducted on ______ day of _________________, _________.
Contract was entered into on the _______ day of ____________________, _________ between the City of Pasadena, Texas and
_____________________________________________ for the above referenced CDBG Project.
This is to further certify that:
1. The work has been completed in accordance with the plans and specifications and all amendments, change orders and
supplemental agreements thereto, with the following exceptions:
______________________________________________________________________________________________________________________________________
________________________________________________
2. The sum of $ _____________, has been deducted from the final payment to the Contractor is a fair and equitable settlement for
the foregoing expected work.
3. All federal requirements for the above referenced project have been met, all claims and disputes have been settled, and all
warranties have been received.
4. All charges or bills for labor or services performed or materials furnished, and other charges against the project, including
those incurred by Subcontractors, have been paid in full and in accordance with the terms of the contract.
5.
Amount of Original Contract
6. The Final Payment above is now due and payable
Certified and Approved by the Following:
CONTRACTOR SIGNATURE PRINT NAME DATE
X
PROJECT INSPECTOR SIGNATURE PRINT NAME DATE
X
CHIEF INSPECTOR SIGNATURE PRINT NAME DATE
X
ENGINEER/PROJECT MANAGER SIGNATURE PRINT NAME DATE
X
CERTIFYING OFFICIAL SIGNATURE (SUBRECIPIENT/RECIPIENT DEPT) PRINT NAME DATE
X
