HomeMy WebLinkAboutProject Completion Affidavit - 2017 Infrared Asphalt Pavement Patching Proj No 117-074 - Asphalt Restoration Services LLC1316 COUNTY -CITY Bun,Dmci
227 W. JEFFERSON BouLEVARD
Souk ii BLND. INDIANA 46601-1830
CITY OF SOUTIA BEND PETE BUTTIGIEG, MAYI.."19
BOARD OF PUBLIC VA-TVI(Si
February 13, 2018
Jamie Brown
Asphalt Restoration Services, LLC
PO Box 2484
South Bend, IN 46680
PHONE 574/235-9251
FAX 574/ 235-9171
RE: Project Completion Affidavit — 2017 Infrared Asphalt Pavement Patching — Project
No. 117-074
Dear Mr. Brown:
The Board of Public Works, at its meeting held on February 13, 2018, approved the Project
Completion Affidavit for this project in the amount of $57,250.
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
Kara Boyles, Engineering
Pete Kaminski, Streets
Derick Roberts, Streets
Terri Swift, Streets
GARY A. Gii,o-r S1JZANNAM.FRrrZBEjz(3 ELIZAK"i,iiA.MARADIK JAMEs A. MOELLER THERESE J. DORAU
CITY OF SOUTH BEND, INDIANA
BOARD OF PUBLIC WORKS
PROJECT COMPLETION AFFIDAVIT
PROJECT NAME 20�17 Infrared Asphalt Pavement Patching
PROJECT NO 117-074 FINAL COST $57,250,00
CONTRACT SIGNED 7111/2017 MAINTENANCE AGREEMENT ENDS
The placement and finishing of asphalt pavement patches by infrared methods and all other
PROJECT DESCRIPTION necessary work on various streets within the Citv of South Bend.
LTN",1TNzMA:11W
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,
Exe d this day of n—, 201, Asphalt Restoration Services, LLC.
Company Name
lf�ignature PO Box2484
Company Address
Printed Name South Bend, IN 46680
City, State, Zip
WITNESSESS:
Before me, the, undersigned Notary Public in and for said country and state, personally appeared
. and acknowledged his/her signature to the above Project Completion Affidavit on
the 41 day of &��, 201
Cd" mt&�—
Notary Signature My Commission Expires
ir&�,
Printed Name County of Residence
-15 4 , . �"
If the Contractor is a corporation, the following certificate will be executed.
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 corporatewmM, MOORE
Not" Public - State of Indiana
SEAL
Secretary's Signature Commission Number: 682645 orporate Seal
MY Commission Expires May 6 2024
Printed Name
DEPARTMENT OF PUBLIC WORKS APPROVAL
This project is acceptable for fi, I approval and we recommend to the Board of Public Works that it be ordained so.
&A Date: IZ, - V7
Constructi Eger
B R OF PUI�LIC WORK APPROVAL Date: 31,,
OA UV_
A L P
I IM
Gary A. Gilot, P'risi&ent Suzahna M. Frberg-, Meiriber Elizabeth A Maradik, Member
... .... . . . . . . .
T'lierese J, Dorad, M6mber James A, Mueller, Member �,4QLid a M.
State of Indiana, County of
t
�\Jmto -&MO)n being duly sworn that he/she is the otuq a ,
(Name of Officer) (Title)
M
(Subcontractor/Supplier)
to famish certain materials and/or labor as follows:
for a project known as
located at
and owned by
having contracted with a
A n
Y& UC
(Contractor)
ff ()escription)
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
0 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;
WAIVER) that the fitlal ba,lance 4ue from the contractor is the sum of
El 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 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.
CARW_ M. MOORE
(Firm) Notary Public - State at Indiana--
Qr- I
SS:
Representative)
I
STATE E UP INDIANA Commission Number: 682645
) SS: My Commission Expires May 6,2024
ST, JOSEPH COUNTY
Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared
and acknowledged the execution of the foregoing Affidavit and Waiver of Lien.
IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed any official seal on the
"' Inn ,
Notary Public Signature
My Commission Expires:
Residing in 51 County, V,
__r- _p,j a 6 Notary Public Name
/ 0 4 day of
BOARD OF PUBLIC WORKS
AGENDA ITEM REVIEW I�X, QUEST FORM
Date
01/2012018
Department
Public Works
Name
Toy Villa
Division/Bureau
Engineering
BPW Date
02,/13/20,18
Phone Extension
59,20
Recluired Prior to Submittal to Board
Legal F-1 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 R
H Agreement Amendment
U Contract LJ Proposal ❑ Addendum
F] Professional Services
F] Resolution
El Bid Opening
El Bid Award F] Req. to Advertise El Title Sheet
Quote Opening
El Quote Award
Change Order No.
❑ C/O & PCA No. PCA
❑ Ease/Encroach.
Traffic Control:
F-1 Other:
Company or Vendor Name
Asphalt Restoration Services, LLC
El Yes M No E] If Yes, Approved by
New Vendor
Purchasing
MBEANBE Contractor
[:] MBE F] WBE mm
MBE/WBE Contractor Requested
F-1 No [J Yes Name of Company
Project Name
2017 Infrared Asphalt Pavement Patching
Project Number
117-074
Funding Source
LRSA
Account No.
251,0608.431.36.10
Amount
$ 57,250.00
Terms of Contract
Purpose/Description
Project Closeout
El Required Contractor's Certification Forms Attached (Non -
Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.)
Amount of F] increase $
R Decrease $
Previous Amount $
Current Percent of Change: %
New Amount $
Total Percent of qhanqe: 1/o
Copy
Origiinal
E] Kara Boyles
F-1 Pete Kaminski and Derick Roberts
F Terri Swift