HomeMy WebLinkAboutPCA - Oliver Plow Pergola Proj No. 116-075 - C&S Masonry Restoration, Inc.1316 COUNTY-GTY BUILDING
227 W. JEFFERSON BOULEVARD
SOUTH BEND. INDIANA 46601-1830
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CITY OF SOUTH BEND PETE BUTTIGIEG, MAYOR
BOARD OF PUBLIC WORKS
January 24, 2017
Steve Fields
C&S Masonry Restoration, Inc.
3725 N Foundation Court, Suite AB
South Bend, IN 46628
PHONE 574/235-9251
FAX 574/235-9171
RE: Project Completion Affidavit — Oliver Plow Pergola - Project No. 116-075
Dear Mr. Fields:
The Board of Public Works, at its meeting held on January 24, 2017, approved the Project
Completion Affidavit for this project in the amount of $22,000.
A copy of the Project Completion Affidavit is enclosed for your records.
If you have any further questions regarding this matter, please call this office at (574) 235-
9251.
Sincerely,
Linda M. Martin, Clerk
Enclosure
c: Toy Villa, Engineering
Sarah Heintzelman, Community Investment
GARY A. GILOT SUZANNA M. FRITZBERG ELIZABETH A. MARADIK JAMES A. MUELLER THERESE J. DORAU
Of50LTN Bet'
CITY OF SOUTH BEND, INDIANA e
BOARD OF PUBLIC WORKS =a
PROJECT COMPLETION AFFIDAVIT as
PROJECT NAME Oliver Plow Pergola
PROJECT NO 116-075 FINAL COST $22,000.00
CONTRACT SIGNED
PROJECT DESCRIPTION
WITNESSETH:
V1z1/zu11J MAINTENANCE AGREEMENT ENDS
Pergola replacement
The work under the above contract between the City of South Bend and the undersigned contractor having been completed,
the City of South Bend, its officials and agents are hereby released from all claims and demands whatsoever arising under or
by such contract, and that the contractor performed the work within the scope of the Specifications and Standards of the City
of South Bend which were a part of the above Contract.
Executed this ID'"L day of -'-54J U A -� 201 "% C & S Masonry Restoration Inc.
_Q_1a r Company Name
Signature 3725 N. Foundation Court, Suite AB
Company Address
Printed Name South Bend, IN 46628
City, State, Zip
WITNESSESS:
Before me, the undersigned Notary Public in and for said country and state, pers(
S re,Qe y) Z • u Lc_ S�` , and acknowledged his/her signature to the above Project
Q day �2p01.
Fj"7" ,a
Notary Signature My Commission Expires
Printed Name County of Residence
`l*= St Joseph C
spq� : � Commission a
If the Contractor is a corporation, the following certificate will be executed.,
1, certify that I am Secretary of the Corporation executing this release; that
who signed this release on behalf of the contractor was then
of said Corporation; that said release was duly signed for and on behalf of said
Corporation by Authority of its governing body, and is within the scope of corporate powers:
Secretary's Signature
Corporate Seal
Printed Name
DEPARTMENT OF PUBLIC WORKS APPROVAL
This project is —s�.. acceptablefor final approval and we recommend to the Board of Public Works that it be ordained so.
VLU . Date: 1 z • 14 • l 4
ConstructioCFanager
BOARD QF PUBLIC WORKS APPROVAL Date: % /Z cI b ! %
Gary A. Gilot, President -Suzanne M. Fri berg, Member E i abeth A. Mai
Therese J. Dorau, Member Jamis A. Mueller, Member 6da M� Martin,
Indiana
AFFIDAVIT AND WAIVER OF LIEN
State of Indiana, County of ST. -5Cr1>Q �k SS:
being duly sworn that he/she is the 0 `(_e_ PR �S tdl r'
(Name of Officer) (Title)
of C'. S M\45c,�Mj Re.--Tcs.-tk-V' (((having contracted with Ns m—,-Sew✓y kes-ro.,y}7,aJ LCC.
(Subcontractor/Supplier) ontractor)
to furnish certain materials and/or labor as follows: 'YeJar LN5T�LLh-r oti
(Description)
for a project known as Okocv%-- �Lcr j e-4i_ee zkA- ot): lllp-D7�
(Name of Project)
located at p(>iJC'��LO�j C T , SE9l{ i� e!V
and owned by Robe -
(Owner)
and does hereby further state on the behalf of the aforementioned subcontractor/supplier:
(PARTIAL WAIVER) that there is due from the Contractor the sum of
Dollars
❑ receipt of which is hereby acknowledged; or
❑ the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which is given
solely with respect to said amount, and which waiver shall be effective only upon receipt of payment thereof by the
undersigned;
(FINAL
from the contractor is the sum of
600,
❑ receipt of which is hereby acknowledged; or
<y the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which shall
become effective only upon receipt of such payment.
THEREFORE, the undersigned waives and releases unto the Owner of said premises, any and all liens or claims whatsoever
on the above -described property and improvements thereon an account of labor or material or both, furnished b the undersigned
thereto, subject to limitations or conditions expressed herein, if any; and further certified that no other party has any claim or right to a
lien on account of any work performed or material furnished to the undersigned for said project, and within the scope of this Affidavit
and Waiver of Lien.
CAS ia9lZSi+r/+z+/ %8s7 g,7r arm LLC, By 424
(Firm) (Authorized Representative)
STATE OF INDIANA )
SS:
ST. JOSEPH COUNTY ) //
Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared < �.. f E n e 1 r1 S
and ackmowledged the execution of the foregoing Affidavit and Waiver of Lien.
IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal on the day of
240ja_L]
DONNASGROVES
:Notary Pijhli,DONNA
c....,. _. �_..__ otary Public Signature
`JC�IlI�i� J `5��11�5
Notary Public Name
BOARD OF PUBLIC WORKS
AGENDA ITEM REVIEW REQUEST FORM
Date 01/17/17
Name
Toy Villa
Department
Engineering
BPW Date
01/24/17
Phone Extension
5920
Legal ❑ Attorney Name
Controller ❑ Controller review is required for all Contracts $5,000.00 or more and
greater than one year in length per the City Purchasing Policy
Purchasing ❑
Check the Appropriate Item Type — Required for Ali Submissions
❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum
❑ Professional Services ❑ Resolution
❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet
❑ Quote Opening ❑ Quote Award
❑ Change Order No. ❑ C/O & PCA No. ® PCA
❑ Ease/Encroach. ❑ Traffic Control
❑ Other:
Company or Vendor Name
New Vendor
MBE/WBE Contractor
MBE/WBE Contractor
Requested
Project Name
Project Number
Funding Source
Account No.
Amount
Terms of Contract
Purpose/Description
Amount of
red Information
Oliver Plow Perg
❑ Yes ® No
❑ MBE ❑ WBE
❑ No ❑ Yes Name of Compan
Oliver Plow Pergola
116-075
Liability Insurance Fund for Property Damage
226.0417.672.39.01
$ 22,000.00
Project Closeout
❑ Required Contractor's Certification Form Attached (Non -
Collusion, Non -Discrimination, Non -Debarment, E-Verifv. Iran, etc.
Increase
Previous Amount
Current Percent of Change:
New Amount
Total Percent of Change:
Copy
Original
®
❑
®
❑
❑
0
For Change Orders On
Dispersal After Approval
Sarah Heintzelman
MR