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Home My WebLink AboutProject Completion Affidavit - Century Center Vestibule Heater Replacement Proj No 117-044 - Edward J White Inc.1316 COUNTY-Crry BUILDING 227 W. JEFFERSON BOULEVARD SO] JTH 131,M), INDIANA 46601-1830 CITY OFSOUTH BEND PETEBUTTIGIEG, MAYOR BOARD OF PUBLIC WORKS August 14,2018 Joe White Edward J. White, Inc. 10 11 S. Michigan St. South Bend, IN 46601 ['110M., 574/2359251 FAX 574/ 235-9171 RE: Project Completion Affidavit — Century Center Vestibule Heater Replacement — Project No. 117-044 Dear Mr, White: 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 $34,150.74. A copy of the Project Completion Affidavit is enclosed for your records, If you have ally further questions regarding this matter, please call this office at (574) 235- 925L Sincerely, 'C-i- Linda M. Mai -tin, Clerk Enclosure GARY A. Gji,o'r SUZANNA M, Fiu'rm ztw ELIZABE i'i ARAWs A. MUELLER i A, MDIK JATifERESE J, DORAU CITY OF SOUTH BEND, INDIANA BOARD OF PUBLIC WORKS PROJECT COMPLETION AFFIDAVIT PROJECT NAME -Century Center Vestibule Heater Replacement PROJECT NO 117-044 FINAL COST $,34,150.74 CONTRACT SIGNED 12/12/2017 MAINTENANCE AGREEMENT ENDS, PROJECT DESCRIPTION Replace vestibule heaters at the Centuiry Center, 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. Eed t is day, of J 1201 Edward J. White, Inc. x7�,qktmk— Company Name It 14 nature 1011 S. Michigan St. Joe ICJ4," Company Address Printed Name South Bend, IN, 46601 City, State, Zip k1i Vfin' WITNESSESS: Befol,e me, the undersigned Notary Public in and for said country and state, personally appeared tjk,.44 and Af be- acknowledged his1her signature to the above Project Completion fid the S44- day of Jut (,% 201 -DQZ, No Signature My Commission Expires 0 12L A( Printed Name County of Residence If the Contractor is a corporation, the following certificate will be executed. I, mickael I ayl certify that I am Secretary of the Corporation executing this release; that f� ,.-k 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: — INC. Secre4ry's Signature) Qorpo*V-eX1,' A yr ra Printed Name "-3 DEPARTMENT OF PUBLIC WORKS APPROVAL This projegLiaacceptabl rc fl a approval and we recommend to the Board of Public Works that it be arclainedJo. Date: Constructiow ager BOARD OF PUBLIC WORKS APPROVAL Date• Id CV V A I , 4 Gary A,Gresident (14'zaifna10. Fr berg'Mem- bir Elizabeth A.%Maradik, Member Hot,rV L Therese J. Dorau, Member James A. Mueller, Mernber 'Cq4da M. Martin, Clerk F1 State of Indiana. County of Jeff Bucher, Jr. (Name of Officer) ISA Form # 1-402 PREPARE IN DUPLICATE Original - Contractor Duplicate - SubcontractGr/SuppIler AFFIDAVIT AND WAIVER OF LIEN J0 Final 10' Partial Payment to Follow. St. Joseph SS: being duly sworn states that he is the Vice -President _ of little) Edward J. White, Inc. having contracted with C4-,,J to furnish certain iS ubcontracior,'Supplier) 0 (Contractor) materials and/or labor as follows: mechanical material and labor t known as dDescriptil") L L fora projeccmS 0 il located at l�05, At, A4,, A LA �0,80u/ rand owned by Ckr S',41 A"J &,,4 d 64/,�:- 11,h-S C) 0 lOwnerl and does hereby further state on behalf of the aforementioned subcontractorlsupplier; , (PARTIAL WAIVER) that there is due from the contractor the sum of Dollars ($ [ ] reoeipt of which is hereby acknowledged; or 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 waivershall be effective only upon receipt of payment thereof by the undersigned; (FINAL 'WAIVER) that the final balance due from the 'nMez vlooS40 F-0t.4- 401v6PZC-0 Ptr--TZFCW A,,jg�N 0 2 ractor is 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 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. i Form) Bye ~ Title Vice -President % (AuYh6rued Flepr6entatwe) WITNESS MY HAND AND NOTARIAL SEAL, this zl�m 0 Yl^ - day of JU I-e. - .20 t A My Commission Expires: August 10, 2.021Z Residing in _ St. Joseph County 0 1979 INDIANA SUBCONTRACTORS ASSOCIATION. INCORPORATED Unauthorized Ropraduclion Prohibited Notary E. Tay for R6Vr IM2 BOARD OF PUBLIC WORKS AGENDA ITEM REVIEW REQUEST FORM Date 07/24/20�18 Department --Public Works Name Toy Villa ---rvl Division/Bureau Engineering BPW Date 08/14/2018 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 F-1 Agreement Amendment ❑ Contract LJ Proposal LJ Addendum F Professional Services ❑ Resolution F Bid Opening D Bid Award ❑ Req. to Advertise E] Title Sheet El Quote Opening El Quote Award E] Change Order No. F-1 C/O & PCA No. PCA ❑ Ease/Encroach. ❑ Traffic Control: Other: Company or Vendor Name Edward J. White, Inc. F1 Yes H No E] If Yes, Approved by New Vendor Purchasing MBEANBE Contractor F] MBE 0 WBE MBE/WBE Contractor Requested F-1 INo F] Yes Name of CompAn Project Name Century Center Vestibule Heater Project Number 117-044 Funding Source Hotel -Motel Tax Account No. 7304.42010.000.0099 Amount $34,150.74 Terms of Contract Purpose/Description Project Closeout Amount of F] F] F-1 Required Contractor's Certification Forms Attached (Non - Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. Increase $ Decrease $ Previous Amount Current Percent of Change: New Amount Total Percent of Chancre: Dispersal After Approval Copy Original 11 F] F-1 El El E]