8816-15 Authorize $676,500 loan with OPWC for Watermain Replacement Project

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Subdivision Na rie: City of Lakewood Project Name: Waternmain Replacement2016 OPWC Control No.: CA16S Appendix E - Page 2 Disbursement Request N_ Is this the final request for disbursement of OPWC funds? ............................ YES NO If the answer is YES or if this disbursement uses the remainder of your OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 59% of the total project cost. AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: Changes to project officials must be submitted in writing.) PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Mark Papke, P.E./Project Manager Date Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION Pursuant to Section 6(b) and 6(c) of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Director to disburse financial assistance moneys made available to Project in Appendix C ofthe Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value ofthe attached cost documentation which was property billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that: 1) Each item of project cost documentation attached hereto is properly payable by the OPWC in accordance with the terms and conditions of the Agreement, and none ofthe items for which payment is requested has formed the basis of any payment heretofore made from the OPWC; 2) Each item for which payment is requested hereunder is or was necessary in connection with the performance of the project; 3) In the event that any of the money disbursed to the Recipient pursuant to this request is to be used to pay Project costs based on an invoice submitted by a contractor of which the Recipients share is yet to be paid, the Recipient shall expend such money to pay such contractor for the Project costs within twenty -four (24) hours after receipt thereof. Recipient shall hold such money uninvested pending payment to the contractor; 4) This statement and attaclunents hereto shall be conclusive as evidence of the facts and statements set forth herein and shall constitute full warrant, protection, and authority to the Director for any actions taken pursuant hereto; and 5) This document evidences the approval of the undersigned Chief Executive Officer and Chief Fiscal Officer of each payment hereby requested and authorized. IN WITNESS WHEREOF, the undersigned have executed this Disbursement Request Form and Certification as of this day 20_ Jennifer Pae/Finance Director CFO Phone: Joe Beno, P.L./Director of Public Works