HomeMy WebLinkAboutProject Completion Affidavit - 2017 Riverside Sidewalk and Driveway Proj No 118-050 - TX Concrete1316 COUNTY -CITY BUILDING
227 W. JFTFERSON 130(fl,EVARD
SOUTH 1IFNI). INTMANA46601-1830
Cn"Y oF So[ rii BEND PETE BUTTIGIEG, MAYOR
BOARD OF PUBLIC WORKS
August 14, 2018
Jose Quijada
TX Concrete
24899 Fillmore Road
South Bend, IN 46619
Pimp, 574/235-9251
FAX 574/ 235-9171
RE: Project Completion Affidavit — 20,17 Riverside Sidewalk and Driveway — Project No.
118-050
Dear Quijada:
The Board of Public Works, at its meeting held on August 14, 2018, approved the Project
Completion Affidavit for the above project in the amount of $2,224.40.
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
GMy A. Gii,oi' SUZANNA M. FRITZBFRG Euz-ABE"I'li A. MARADIK JAW.,,"s A. MUELLER T1]1,.RF'SF'J. DORAU
CITY OF SOUTH BEND, INDIANA
BOARD OF PUBLIC WORKS
PROJECT COMPLE MON AFFIDAVIT
PROJECTNAME 2017 Riverside Sidewalk and Dri
PROJECT NO,
CONTRACT SIGNED
118-050 FINAL COST $2,224.40
April 24, 2018 MAINTENANCE AGREEMENT ENDS
PROJECT DESCRIPTION Installation of sidewalk and driveway
WITNESSETTI:
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 Spec ificationsand Standards of the City of !�uth Bend which were a part of the above Contract,
Executed, its I--,-/ day 201
TX Concrete
Company Name
24899 Fillmore Road
Printed Name Company Address
South Bend, In. 46619
City/State/Zip
WITNESSES
Before me, the undersigned Notary Public in and for said country and state, personally appeared
-,>C156 j,r4,,'and acknowledged his/her signature to the above Project Completion Afflidavit on
the day of
or 20
1v i�.; I (MIA E. MTH
NO,TAI,k,YPUBa,lCqQlXrE(Yits
ANA
ary Sig UlFe My Commission Expires ST , 10SEPH COk Nll�—
MY COMMISSION EXPRES 10110/118
Printed Name County of Residence
If the Contractor is a corporation, the following certificate will be executed.
certify that I arn 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 duty 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 Corporate Seal
Printed Name
DEPARTMENT OF PUBLIC WORKS, APPROVAL
This project is acceptable for final approval and we recornmend to the Board of Public Works that it be
ordained so.
Date:
ConstrucoiNanager
BOARD OF PUBLZICRKS APPROVAL Date
A/ ki
Gary A. Gilot, President su&ri`nff M. Friltzberg,vNqember
James A. Mueller, Member Therese J. Doran, Member
Elizabeth A. Maradik,Membcr
I
st�
u—V k, ICY"
inda M. Martin; Clerk
AFFIDAVIT AND WAIVER OF LIEN
� I I h"t Vh
State of Indiana, County of A" SS:
LRK, ouivkctik -
(Name of OfMer)
being duly sworn that he/she is the
of bilk, having contracted with
(Subcontractor/Supplier)
to furnish certain materials and/or labor as follows:
for a project known as
located at
ME
(Title)
001) Nhl (C h[Loyks
(0fitractor)
WAY It (10Y)NIO-A-C
(Description)
VOW- no
(Name of Project)
and owned by 'A,A (I IAJJA , V (Owner)
and does hereby farther state on the behalf of the aforementioned subcontractor/supplier:
(PARTIAL WAIVER) that there is due from the Contractor the sum of
Dollars
0 receipt of which is hereby acknowledged; or
El 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;
6�t
WAIVER at the final balance due from the contr t )r is the u of S( ( TAT
Elc
in twt�A+j fvw- 140
E-1 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, famished 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 �thesco e of this Affidavit
and Waiver of Lien.
By
(Firm)
STATE OF INDIANA (Authorized Representative)
SS:
ST. JOSEPH COUNTY
Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared -I)s r— Z A-6
and acknowledged the execution of the foregoing Affidavit and Waiver of Lien.
IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official s ado lve day of
vic 'TORIA V, SMITH ota u 9 tare
NO WAI*V V,Uoij(: $TATEOF IINNANA
My Commission Expires: P"'T j(),,Em; coutqlry
Residing in County, my (",(;)MOISSIONa drXF'IRE S 1011011
8 Notary Public Name
BOARD OF PUBLIC WORKS
AGENDA ITEM REVIEW RE, QUEST FORM
Date July 24, 2018 Department Engineering
Name Toy Villa Division/Bureau DPW
BPW Date August 14, 2018 Phone Extension 5920
Controller
Purchasing
LJ Agreement
El Professional Services
F-1 Bid Opening
F1 Quote Opening
F-1 Change Order No.,
0 Ease/Encroach.
F-1 Other:
El Attorney Name:
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
1:1
H Contract
El Resolution
El Bid Award'
R Quote Award
F-1 C/O & PCA No
F-1 Traffic Control:
Company or Vendor Name
New Vendor
MBEANBE Contractor
MBEANBE Contractor Requested
Project Name
Project Number
Funding Source
Account No.
Amount
Terms of Contract
Purpose/Description
Amount of F-1 increase
0 Decrease
Previous Amount
Current Percent of Change
New Amount
TX Concrete
Proposal
F1 Req. to Advertise
NEWME,
0 E WBE
E k .
E ki 0■Yes 11.2ittei of Com *,;�tiv
2017 Riverside Sidewalk & Driveway
118-050
MVH
202.0619A31.31.06
$2,224.40
Project Closeout
l= 11=40
El Title Sheet
F-1 Required Contractor's Certification Forms Attached (Non -
Collusion. Non -Discrimination. Non -Debarment. E-Verifv, Iran, etc.
Total Percent of Change: %
Dipersl After Approval......
Copy Original
F-1 F-1
1-1 1-1
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