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Home My WebLink AboutPCA - Potawatomi Zoo Parking Lot Striping Proj No 115-129B - DBL Services1316 COUNTY -CITY BUILDING 227 W. JEFFERSON BOULEVARD SOUTH BEND. INDIANA 46601-1830 CITY OF SOUTH BEND PETE BUTTIGIEG, MAYOR BOARD OF PUBLIC WORKS March 28, 2017 David Letcher DBL Services, Inc. 1811 Clover Road Mishawaka, IN 46545 RE: Project Completion Affidavit — Potawatomi Zoo Parking Lot Striping Project No. 115-129B Dear Mr. Letcher: PHONE 574/235-9251 FAX 574/235-9171 The Board of Public Works, at its meeting held on March 28, 2017, approved the Project Completion Affidavit for this project in the amount of $4,598.75. 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: John Martinez, Parks Toy Villa, Engineering GARY A. GILOT SUZANNA M. FRITZBERG ELIZABETH A. MARADIK JAMEs A. MUELLER THERESE J. DoRAu CITY OF SOUTH BEND, INDIANA F�.unre�rya� BOARD OF PUBLIC WORKS PROJECT COMPLETION AFFIDAVIT e65 PROJECT NAME Potawatomi Zoo Parking Lot Striping PROJECT NO 115-129 B FINAL COST $4,598.75 CONTRACT SIGNED 12/13/2016 MAINTENANCE AGREEMENT ENDS PROJECT DESCRIPTION Parking Lot Striping at Potawatomi Zoo WITNESSETH: 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 �— day of(�✓ [ \a 201 DBL Services, Inc. p, , e I/ Vt T Company Name u�/S'-i�iggntaatture� ` t x r, x.� 1811 Clover Road op"",0 L��L�r� Company Address Printed Name Mishawaka, IN 46545 City, State, Zip WITNESSES: `—) Before me, the undersigned Notary Public in and for said county and state, personally appeared (nil L C�( c..`�v2 , and acknowledged his/her signature to the above Project Completion Affi avit on the .Q d y of , 201 FRANK C. LAWSON PUBLIC �, &Can"FF920224 NOTARY PUBLIC � STATE OF FLORIDA No tar Signature My CommissionExpires L,4a 4 �� C ` 4� - A) � r r� ExpiresCA,,, 1�119/2019 Printed Na/me Y, L County of Residence f l�hr1l � l A V If the Contractor is a corporation, the following certificate will be executed. I, 0^,YJ L j certify that I am Secretary of the Corporation executing this release; that O v✓3 l Q who signed this release on behalf of the contractor was then J r n �'t_s._yz �� of said Corporation; that said release was duly signed for and on behalf of said Cor oration by th It o rning body, and is within the scope of corporate powers: Secretary's Signature 1 �+� Corporate Seal 0 "� Printed Name L DEPARTMENT OF PUBLIC WORKS APPROVAL This project forfin2l approval and we recommend to the Board of Public Works that it be ordained so. Date: Z . Z 3. 19 Construction ager BOARD OF PUBLIC WORKS APPROVAL Date: Gary A. Gib, President Suzanne M. Fritzberg, Member Elizabeth A. Maradik, Member A. Mueller, Member �- inpa M. Martin, Clerk AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of Sr 750 s2Pl+ `SS': n OA\N o L j i- 0 �R being duly sworn that he/she is tile �/e I L-t (Name of Officer) (Title) of U!-: S LvOt having contracted with J)4-:�L /5Z VI Lrt5S r L (Subcontractor/Supplier) (Contractor) to furnish certain materials and/or labor as follows: for a project known as 1 crt i m-u �T 12A� � —?_ 0 o (Name of Project) located at and owned by L tT 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 WAIVER) that the final balance due from the contractor is the sum of ❑ 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 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 parry 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. p(3L V_KiJ =_3 IW L ByDas. (Firm) (Authoriied Representative) STATE QFINDL BIA ? I" ) mart • f\ ) SS: -STr393E7H COUNTY ) 1 Before me, the undersigned, a Notary Public, in and for said County and State, personally appearedfn�I� and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN WITN ESS WFIEI,iEOF, I have hereunto subscribed my name and affixed my official seal on the � 4 ^ day of ,/i1 `-,/&_2Comn*FF92M4 FRANK C. LAW SON 204 kf NOTARY PUBLIC Ndt ub is Signature STATE OF FLORIDA My Commission Expires: Expires \ r "r �1�. c , L� �s, Residing in �� County, V 1 -\� r 1 rl \N Notary Public Name BOARD OF PUBLIC WORKS AGENDA ITEM REVIEW REQUEST FORM Date 03/15/17 Department Public Works Name Toy Villa Division/Bureau Engineering BPW Date 3/28/17 Phone Extension 5920 Required Prior to Submittal to Board Legal ❑ Attorney Name: Michael Schmidt Controller El review is required for all Contracts $5,000.00 or more and greater greater than one year in length per the City Purchasing Policy Purchasing ❑ George King Check the Appropriate Item Type — Required for All 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: F 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 Increase Decrease Previous Amount Current Percent of Change: New Amount Total Percent of Change: Copy Original ❑ ❑ ❑ ❑ ❑ ❑ uired Information DBL Services El Yes 0 No ❑ If Yes, Approved by Purchasing Ll MBE F1 WBE ❑ No El Yes Name of Company Potawatomi Zoo Parking Lot Striping 115-129B Parks 403 Zoo Fund 75 Project Closeout U Required Contractor's Certification Forms Attached (Non - Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) For Chanqe Orders On