HomeMy WebLinkAboutProject Completion Affidavit - 2017 Central Services Remodel Proj No 117-118 - Gibson Lewis LLC1316 COUNTY -CITY BUILDING
227 W, JEFFERSON BoULEVARD
Souni BENI), INDIANA 46601-1830
CITY OF SOUTH BEND PETE BUTTIGIEG, MAYOR
BOAMR4W4' IYMI--S---_
June 26, 2018
Robert Lingenfelter
Gibson -Lewis, LLC
1001 W I 11h Street
Mishawaka, IN 46544
PHONE 574/235-925
FAX 574/235-9171
RE: Project Completion Affidavit — 2017 Central Services Remodel — Project No.
117-118
Dear Mr. Lingenfelter:
The Board of Public Works, at its meeting held on June 26, 2018, approved the Project
Completion. Affidavit for this project in the amount of $ 5 5,2 5 8.
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
CITY OF SOUTH BEND, INDIANA
BOARD OF PUBLIC WORKS
PROJECT COMPLETION AFFIDAVIT
PROJECT NAME 2017 Central Services Remodel
PROJECT NO 117-118 FINAL COST $55,258.00
CONTRACT SIGNED 11/28/2017 MAINTENANCE AGREEMENT ENDS
PROJECT DESCRIPTION Remodel of Central Services including carpet, drywall, paint, and lighting.
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 reieased 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.
Exeou this 11 th day of. May 201 8
Signature
Robert A. Lingenfelter, President
Printed Name
Gibson -Lewis LLC
Company Name
1001 W. 11 th Street
Company Add',ress
Mishawaka, IN 46544
City, State, Zip
WITNESSESS:
Before me, the undersigned Notary Public in and for said country and state, personally appeared
Robert A- TAnclenfe.1ter and acknowledged his/her signature to the above Project Compietion Affidavit on
th � �lth day of May 8
NotaSignature My Commission Expires
Elizabeth A.
Printed Name
July 10, 2024
County of Residence St. Joseph
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
Printed (Name
Corporate Seal
DEPARTMENT OF PUBLIC WORKS APPROVAL
This projects acceptable for in~ 1F pprovai and we recommend to the Board of Public Works that it be ordained so.
Date: :5,
Constructor �� ager
BOARD OF PUBLIC WORKS APPROVAL Date: �X)61,�,lx
Gary A. Gilot, President Suzanna M. Fritzberg, Member F r,7aR'eth A - aradik, Member
%
p ten„
aLinTherese J. Dorau, Member Ja A. Mueller, Member 9M. �Martin, CI6 k
7
AFFIDAVIT AND WAIVER OF LIEN
State of Indiana, County of St. Joseph SS:
Randall H. Rice being duly sworn that he/she is the Asst. Secretary
(Name of Officer) (Title)
of Gibson-1_6wis, LLC having contracted with Citv of South Bend
(Subcontractor/supplier) Mmumm) (Owner)_
to furnish certain materials and/or labor as follows, Geoeral Construction Per Base Bid & Alternate A & B
(Description�)
for a project known as 2.G.17 Central -Se vices Remodel - Project No, 117-118
(Name of Project)
located at 1045 W. Sam le Street, South Bend 11\146619
and owned by . ...... CitV of South Bend Board of Public Works
(Owner)
and does hereby further stateon the behalf of the aforementioned,subcontrartor/supplier:
Dollars
E71 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 b the
undersigned; y
(FINAL WAIVER) that the final balance due from the contractor is th f
Five Thousand Seven Hundred Eleven Dollars and 7TAMV ($5,711,71
❑ 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 lions or claims whatsoever
on the above -described property and improvements thereon an account of labonor material or both, rurnished b the undersigned
thereto, subject to limitations or conditions expressed herein, if any; and further certified iat no other party ln�s any claim or right to a
lien on account of any work performed or material furnished to the unde ' ic - aid p oject, and within the scope of this; Affidavit
and Waiver of I L! en. rsigi 7t
Gibson -Lewis, LLC By
(Firm) (Authorized Rer oscutative)
STATE OF INDIANA
SS:
ST. JOSEPH COUNTY
Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Randall H. Rice
and acknowledged the execution of the foregoing Affidavit and Waiver of'Lien,
IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my qffi i I seal on the I 1th day of
MnAl 20 2018,
Notark Public Signature
MY Commission Expires: July 10, 2024,
Elizabeth A. Biddle
Residing in St. Joseph County, Indiana
Notary Public Name
BOARD OF PUBLIC WORKS
AGENDA ITEM REVIEW REQUEST FORM
Date 0�6/1!8/2018
Name Toy Villa -,a Department Engineering
BPW Date 06/26/2018 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 1:1
HI Agreement
F1 Professional Services
[:1 Bid Opening
E] Quote Opening
F] Change Order No.
❑ Ease/Encroach.
F-1 Other:
Company or Vendor Name
New Vendor
MBE/WBE Contractor
MBENVBE Contractor
Requested
Project Name
Project Number
Funding Source
Account No.
Amount
Terms of Contract
Purpose/Description
LJ Contract LJ Proposal Ll Addendum
F-1 Resolution
F] Bid Award El Req. to Advertise Title Sheet
❑ Quote Award
C/O & PCA No. PCA
El Traffic Control
-Gibson-Lewis, LLC
El Yes M No E] If Yes, Approved by Purchasing
F] MBE F-1 VVBE
F] No F-1 Yes Name of Compan
2017 Central Services Remodel
117-118
Capital Budget
224.0605.419A310
Project Closeout
El Required Contractor's Certification Form Attached (Non
Collusion, Nan -Discrimination. Non -Debarment. E-Verifv. Iran. etc.
Amount of increase $
❑ Decrease $
Previous Amount $
Current Percent of Change: %
New Amount $
Total Percent of Change: %
Copy Original
0 F1 Mary Wisnewski
El F1
El 1:1