HomeMy WebLinkAboutProject Completion Affidavit - 2017 Crack Sealing Proj No 117-102 - Asphalt Restoration Services LLC1316 COUNTY -CITY BUILDING
227 W. JEFFERSON 13oi)i,,FVARD
So(rri,i BEND, INDIANA 46601-1830
CITY OF S,OUTH BEND PETE BUTTIGIEG, MAYOR
BOARD OF PUBLIC WORKS
June 26, 2019
Jamie Brown
Asphalt Restoration Services LLC
PO Box 2484
South Bend, IN 46680
PHONE 574/235-925
FAX 574/ 235-9171
RE: Project Completion Affidavit — 2017 Crack Sealing — Project No. 117-102
Dear Mr. Brown:
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 $85,000.
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
440,,
CITY OF SOUTH BEND, INDIANA
BOARD OF PUBLIC WORKS
PROJECT COMPLETION AFFIDAVIT
PROJECT NAME 2017 Crack Sealing
PROJECT NO 117-102 FINAL COST $85,000.00
CONTRACT SIGNED MAINTENANCE AGREEMENT ENDS
Perform asphalt crack sealing and filling services at various locations throughout theCityof
PROJECT DESCRIPTION South Bend,
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.
Exec ed this day of ✓ 201 Asphalt Restoration Services, LLC
Company Name
Exec
PO Box2484
C, /3 rot 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 appea e RYAN P. SOUSLEY
,and acknowledged his/her signature to the above Project Corr o[etioNoWfyVWUjqDnsta1e of Indiana
SEAL
the day of 1 201 Commission Number: 682754
My Commission Expires April 9, 2024
N�ota My Commission Expires
Printed Name County of Residence
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 of corporate powers:
Secretary's Signature
Printed Name
Corporate Seal
DEPARTMENT' OF PUBLIC WORKS APPROVAL
This project is acceptable for approval and we recommend to the Board of Public Works that it be ordained so,
Date: f8
Construction ylager
BOARD OF PUBLIC WORKS APPROVAL Date: 6,1� (VT
Gary A. Gilot, President Suzanna M. Fritzberg, Member ET1—za-6eth7A.'Mh-r- ik, Member
Therese J. Dorau, Member Ja s A. Mueller, Member 'Cida M. Martin, Clerl�
Final Waiver of Lien
State pfindiana, County of SS:
1� C91� being duly sworn that helshe is the
(Nance of Officer) (Title)
or i�.2M hs'Iag contracted with 71�9-0- j
(Contractor) Mwneri
to furnish cortaltr nmterlals and/or)
for a project known os
located at
and owned by
and sloes hereby further state on the behalf ofthe aforemmaoned subcontraotor/supplier;
(PARTIAL WAMR) that there is due from. the Cootractor 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 oflliea-which is given
solely V th respect to said ain nut, and which waiver sbalt be, effective only upon receipt ofpayuaent thereof by the
undersigned;
(FINAL WAIVER) that the final balance due from the coruractor is the sum of
❑ recelpt ofwhich is hemby acknowledged; or
❑ thepayment of which has been promised as the sole consideration for this Aff"rdavlt and Final Waiver of Lien which snail
become effective only upon receipt of such payment.
TBEREFORE, the undersigned waives and releases unto the Owner of said promises, any and all liens or claims whatsoever
on the above-doscribedproperty and improvements theteon an account of labor or material or both, furnished b the undersigned
thereto, subj cot to limitations or conditions expressed herein, if any; and further certified thatno other party has any claim, or right to a
lion on account of any work perfomod or material famished to the undorsigned for saldprojeet, and within the scope of this Affidavit
and Waiver of Lien.
(Firm)
(Authorized Reprsscntative}
STATE Olt lN7DIANA )
ST. JOSEPH COUNTY )
Before me, the undersigned, a Notary public, In and for said Coiwty and State, personally appeared
and acknowledged tho execution of the foregoing Affidavit and Waiver of Lion. /�,�
IN WITNESS WI3EREQF, I have hereunto subscribed my namand affixed my official, seal on th r� / � day of
— I4j' 200
.
/ / Signaturo �'
MyCommissloftRxpires,• 7 O
Residing fn 7' . n.0 ounfy, � I -�! J lotazyl'uhlia l`tarne
EMY
RYAN P.SOUSLEY
tary Public - State of Indiana
SEAL
ommission Number. 682754
ommission Expires April 9, 2024
BOARD OF PUBIJC WORKS
AGENDA ITEM REVIEW REQUEST FORM
Data 06/13/2018 Department Public Works
. . .... ......
Name Toy Villa Division/Bureau Engineering
BPW Date 06/26/2018 Phone Extension 5920
Required, Prior to Submittal to Board
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
" Agreement Amendment
�E] Professional Services
F-1 Bid Opening
F-1 Quote Opening
❑ Change Order No.
❑ Ease/Encroach.
Other:
Company or Vendor Name
LJ Contract
F-1 Resolution
Bid Award
Quote Award
E] C/O & PCA No.
El Traffic Control:
New Vendor
MBE/WBE Contractor
MBE/WBE Contractor Requested
Project Name
Project Number
Proposal Ll Addendum
El Req. to Advertise El Title Sheet
Asphalt Restoration Services, LLC
El Yes E] No ❑ If Yes, Approved by
Purchasing . .. . .......
-E[—MBE E] WBE
E] No E] Yes Name of Company
2017 Crack Sealing
117-102
Funding Source
LRSA - Street Maintenance
Account No.
251.0608.431 36, 10
Amount
$85,000.00
Terms of Contract
Purpose/Description
E] Required Contractor's Certification Forms Attached (Non -
Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran:, etc.)
Required, For Chart O�rders, Only
Amount of F-1
F
increase $
Decrease $
Previous Amount
$
Current Percent of Change: %
New Amount
$
Total, Percent of Change: %
Dispersal After Approval
Copy Original
Roger Nawrot, Assistant City Engineer
F-1
Derick Roberts, Streets Department
El El