HomeMy WebLinkAboutProject Completion Affidavit - Century Center Cooling Tower Replacement Proj No 117-035 - Edward J White1316 COUNTY-Crry ffintmmi
227 W, JETFERSON BOULEVARD
SOUM BEND. INDIANA 46601-1830
CrrYOFSOUTH BEND PE'rEBUTTIGIEG, MAYOR
BOARD OF PUBLIC WORKS
251MM
Jeff Bucher
Edward J. White, Inc.
1011 S. Michigan Street
South Bend, IN 46601
P110M, 574/235-9251
FA X 574/ 235-9171
RE: Project Completion Affidavit — Century Center Cooling Tower Replacement — Project
No. 117-035
Dear Mr. Bucher:
The Board of Public Works, at its meeting held on May 8, 2018, approved the Project
COMpletiOD Affidavit for this project in the amount of $226,63 1.
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,
'Vo-kt
Linda M. Martin, Clerk
Enclosure
c: Toy Villa, Engineering
Kara Boyles, Engineering
Scott I-Terczeg, Century Center
Learma Belew, Century Center
GARY A. Gij-o'r SUZANNA M. FRrrZBERG ELIZABE'm A. MARADIK JAMEs A. MUELLEiz TH17RESE J. DORAU
00
CITY OF SOUTH BEND, INDIANA
BOARD OF PUBLIC WORKS
PROJECT COMPLETION AFFIDAVIT
PROJECT NAME -Century Center Cooling Tower Replacement
PROJECT NO 1117-035 FINIAL COST $226,631.00
CONTRACT SIGNED -7/11/2017 MAINTENANCE AGREEMENT ENDS
PROJECT DESCRIPTION Replacement of Century Center cooling tower.
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 I � *'� day of. 201 Edward J. White, Inc.
\ X K A Company Name
Signbturg 1011 South Michigan Street
Company Address
Printed Name South, Bend, IN 46601
City, State, Zip
WITNESSES&
Before me, the undersigned Notary Public in and for said country and state, personally appeared
r and acknowledged his/her signature to the above Project Completion Affidavit ',oh"" '<J rl
the I "Y+k day of 201 8
Not afy Signature My Commission Expires
A(4 6
Printed Name County of Residence
if the Contractor is a corporation, the following certificate will be executed.
I. certify that I am Secretary of the Corporation executing this release
6-(A�er-' , rwho 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:
INc.
seqp6tary's Signaturr,)
&6r
Printed Name
DEPARTMENT OF PUBLIC WORKS APPROVAL
This project is acceptable forl'i I approval and we recommend to the Board of Public Works that it be Date: ordain�4,i*
"Ill"," 8
1
constructioyM nager -5/0 J
BOARD OF PUBLIC WORKS APPROVAL Date: 112c)
11A— - - ------------
Gary A. Gilot, President Suizanna M. Fritzbergi, Member Elizabeth A. Maradik, Member
Therese J. Oorau, Member Jam— 6 A. Mueller, Member biiAa M. Martin, Clerk
'
u
State of Indiana. County of
Jeff Bucher, Jr.
ISA Form # 1-402
AFFIDAVIT AND WAIVER OF LIEN
Final 0 Partial V' Payment to Follow,
St. Joseph , SS:
IName of Officer)
Edward J. White, Inc.
{Subcontractor: Supplier)
materials and/or labor as follows:
PREPARE IN DUPLICATE
original - Contractor
Duplicate - Subcontractor/Supplier
being duly sworn states that he is the Vice -President of
[Tatel
having contracted with64ner•, °- AFL', I,, LJ-,-Is _ to furnish certain
(Contractor)
mechanical material and labor
j'Pescriplio )
for a project known as m.,c ,4*..Ci �vl•^�
U— —
located at tuo !.us >7 SL Scu"Pvrrof Li and owned by Cr �,,, n�► �Je�v�. ����
(Owner)
and does hereby further state on behalf of the aforementioned subcontractorisupplier: .
(PARTIAL WAIVER) that there is due from the contractor the sum of
Dollars ($
[ 1 reoelpt of which is hereby acknowledged; or
[ 1 the payment of which has been promised as the sole consideration of this Affidavit and Partial 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
77f1L�z; eu5�,�p AjJn " oo Dollars (S �� 000 .00
[ [ 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 upon receipt of such payment.
THEREFORE, the undersigned waives and releases unto the Owner of said premises, any and all lien or claim whatsoever
on the above -described property and improvements thereon on account of LABOR or material or both, furnished by the
undersigned thereto, subject to limitations or conditions expressed herein, if any; and further certifies 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.
Edward J. White, Inc.
1 Firml
WITNESS MY HAND AND NOTARIAL SEAL, this
My Commission Expires: August 10, 2UZ2
By 1 Title
ulKortzed 11,
esenlative)
Residing in _ St. Joseph County
0 1979 INOIANA SUBCONTRACTORS ASSOCIATION. INCORPORATED
Unauthorized Reproducuan Proh,biled
Vice -President
Z 3 r day of20 ! g
` INotaf ubilcl
. Prt d: &6hael E. Taylor
`� { • .x°`} Rev. 10182
Date 04/23/2018
Name Toy Villa
130ARD OF PUBLIC WORKS
AGENDA ITEM REVIEW REQUEST FORM
Department
Division/Bureau
Public Works
Engineering
BPW Date 05/08/2018 Phone Extension 5920
Legal ❑ Attorney Name:
Controller El 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 El
H Agreement Amendment
LJ Contract LJ Proposal LJ Addendum
[_] Professional Services
F-1 Resolution
El Bid Opening
F-1 Bid Award El Req. to Advertise E] Title Sheet
n Quote Opening
n Quote Award
n Change Order No.
E] C/O & PCA No. Z PCA
F-1 Ease/Encroach.
F-1 Traffic Control:
f l Other:
Company or Vendor Name Edward J. White, Inc.
El Yes Z No E] If Yes, Approved by
New Vendor
Purchasing
MBE/WBE Contractor
E] MBE E] WBE
MBE/WBE Contractor
Requested E] No E] Yes Name of Company
Project Name
Century Center Cooling Tower
Project Number
117-035
Funding Source
Hotel -Motel
Account No.
7304.42010.000,0099
Amount
$226,631.00
Terms of Contract
Purpose/Description
Project Closeout
El Required Contractor's Certification Forms Attached (Non -
Collusion, No n-Discrim i nation, Non -Debarment, E-Verify, Iran, etc.)
Rrrd F'or d6an,6W-0-74-e`0,n
Amount of El
R
increase $
Decrease $
Previous Amount
$
Current Percent of Change: %
New Amount
$
'Total Percent of Change:
%
Dispersal After Approval
Copy Original
E F-1
Kara M. Boyles
F-1 El
z
Scott Herczeg, Leanna Belew