HomeMy WebLinkAboutProject Completion Affidavit - 2018 Tree Planting Project No 118-048B - Douglas Landscape Inc1316 COUNTY -CITY BUILDING
227 W. JEFFERSON BOULEVARD
SO[ )TH BEND. INDIANA 46601-1930
44
ell
ITACC
1865
CITY OF SOUTH BEND PETE BUTTIGIEG, MAYCI
BOARD OF ► WORKS I
January 22, 2019
Doug Pittman
Douglas Landscape, Inc.
23590 Ardmore Trail
South Bend, IN 46628
PHONE 574/ 235-9251
FAx 574/ 235-9171
RE: Project Completion Affidavit — 2018 Tree Planting — Project No. 11 8-048B
Dear Mr. Pittman:
The Board of Public Works, at its meeting held on January 22, 2019, approved the
Project Completion Affidavit for this project in the amount of $10,152.
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
GARY A. GILOT SUZANNA M. FRITZBERG ELIZABETH A. MARADIK LAURA O'SULLIVAN THERESE J,
DoRAu
w� rera ,y
CITY OF SOUTH BEND, INDIANA r -
BOARD OF PUBLIC WORKS
PROJECT COMPLETION AFFIDAVIT
PROJECT NAME 2018 Tree Planting
PROJECT NO 118-048B FINAL COST $10,152.00
CONTRACT SIGNED 10/9/2018 MAINTENANCE AGREEMENT ENDS
Furnishing and planting trees within the right of way at various locations within the City of South
PROJECT DESCRIPTION Bend, IN.
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 day, , 201 P. DOUGLAS LANDSCAPE, INC.
•, Company Name
Signature 23590 Ardmore Trail
Company Address
Printed a South Bend, IN 46628
City, State, Zip
WITNESSESS:
are me, the undersigned Notary Public in and for said country and state, personally appeared
, and acknowledged his/her signature to the above Project Completion Affidavit on
the day of 201�.
JUX JENNIFER L SCHULTZ
Notar&qnattWe My Commission Expires q-a7-1 q NOT,'.`�Y PUBLIC - OFFICIAL SEALOf mmt arrftTS4—,J 5 Count
My Comm. Expires September 27, 201
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; 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 final. pproval and we recommend to the Board of Public Works that it be ordained so,
Date: l
Construction 04a4gell N,
OARD OF PUBLIC WORKS APPROVAL Date: . do,,1
� a,
Gary A. Gilot, resident Sup 1 M. Fw'itzbergf111ka:r Elizabeth A. Maradik, Member
&4&
J Mueller Member
t, ALGA CZA... C: r Ve"eL
M. Martin, Clerk
State of Indiana, County of
Final Waiver of Lien
being duly sworn thathe/she is the �rS, d+a +
(Title)
(Contractor) �� "- having contracted with � ne
of (Owner)
p t7 i S h i n S t1nl:L }�1 Qu1f ► n,I �-r re,GS 1+ 1 "+h i n t h e-
to furnish certain materials andlor labor as follows: (Description)
for a project known as _ .ALL(14t�y
to of Project)
located at _Lih'i
and owned by ...... l s i71"t,,A
and does hereby Ai Cher state on the behalf of the aforementioned subcontractor/supplier:
(PARTIAL WAIVER) that there is due from the Contractor the sum of
Dollars ($
❑ receipt of which is hereby aclatowledged; 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 tboreof by the
undersigned;
FINAL W that the final ba
lance due tfom the contractor is the suns of
K 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.
TIJEREFOIM, the undersigned waives and releases onto 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, fltrnisbad b the undersigned
thereto,, subject to hinitations or conditions expressed herein, if any; and f trther certifled that no other party has any claim or right to a
llen on account of any work performed; or material flrnilshed to the undersigned for said project, and wlthln the scope of this Affidavit
and Waiver ofLlem
. e— Er) .t� EY ) _�._...__ (Authorized It epresen Ytive)
STATE OF INDIANA )
S5:
ST, JOSEPH COIJNTY }
Before me, the undersigned, a Notary Public, In and for said County and State, personally appeared 1--ou a
and acknowledged the execution of the foregoing Affidavit and Waiver of Lion.
IN WITNESS WHEREOF, I have hereunto subscribed myn name and affixed my official seal on the o? I St day of
Z
4N4Publi iguatur
My Commission Expires: "� ' [+_ L,
Residing in Tip {, county,�' _
Z + NotaryPublio Name
JEENPIIFER L SCHULTZ
�(- W PUBLIC - OFFICIAL SEAL
Stagy.. md"sana, St. Joseph Count+�
nny Corn+n. P_xpires September 27,201
BOARD OF PUBLIC WORKS
AGENDA ITEM REVIEW REQUEST FORM
Date 01/02/2019 Department Public Works
Name Toy Villa Division/Bureau Engineering
BPW Date 01/22/2019 Phone Extension 5920
Required Prior to Submittal to� ....M
� .............. Board
Legal F-j Attorney Name:
Controller El Controller review is required for all Contracts $5,000.00 or more and
greater than one year in length per the City Purchasing Policy
Purchasing 1:1
Check the
Agreement Amendment
EI Professional Services
Bid Opening
Quote Opening
Change Order No.
D Ease/Encroach.
Other:
Company or Vendor Name
rtoprit Item Tyke
El Contract
Resolution
Bid Award
El Quote Award
[] C/O & PCA No.
El Traffic Control:
New Vendor
MBE/WBE Contractor
MBE/WBE Contractor Requested
Project Name
Project Number
Funding Source
Account No.
Amount
Terms of Contract
Purpose/Description
Amount of Increase
Decrease
Previous Amount$
Current Percent of Change:
New Amount $
Total Percent of Change:
Copy
Original
for All Submissions
➢ Proposal
❑ Req. to Advertise
Required Information
Douglas Landscape, mmInc,
Proiect Closeout
►/ '
Addendum
❑ Title Sheet
❑ Required Contractor's Certification Forms Attached (Non -
Collusion, Non -Discrimination, Non -Debarment, E Verify„ Iran, etc.
squired For Chancre Orders Only
Dispersal After Aooroval