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Home My WebLink AboutProject Completion Affidavit - Engineering Office Improvements Project No 118-107 - Ziolkowski Construction Inc1316 COUNTY -CITY BUILDING 227 W. JEFFERSON BOULEVARD NOI ITH BEND. INDIANA 46601-1830 186 February 12, 2019 Bill Favors Ziolkowski Construction, Inc. 4050 Ralph Jones Drive South Bend, IN 46628 PHONE 574/235-9251 FAX 574/235-9171 RE: Project Completion Affidavit — Engineering Office Improvements — Project No. 118- 107 Dear Mr. Favors: The Board of Public Works, at its meeting held on February 12, 2019, approved the Project Completion Affidavit for this project in the amount of $9,233. 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 17're 2 CITY OF SOUTH BEND, INDIANA BOARD OF PUBLIC WORKS PROJECT COMPLETION AFFIDAVIT PROJECT NAME Engineerin2 Office Inn rovements. PROJECT NO 118-107 FINAL COST $9 233.00 CONTRACT SIGNED 11/27/2018 MAINTENANCE AGREEMENT ENDS PROJECT DESCRIPTION Remodel of several offices aces in the En ineering Department 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 23rd day of January , 2019 Ziolkowski Construction Inc. Company Name Signatu 4050 Ralph Jones DrNe Bill Favors/President & CFO Company Address Printed Name South Bend, IN, 46628 City, State, Zip WITNESSESS: Before me, the undersigned Notary Public in and for said country and state, personally appeared Bill Favors , and acknowledged his/her signature to the above Project Completion Affidavit on the 23rd day of JanurV 2019,.. LYNN r)VINING Seal �� Notary Public-Stzteoflndiana Notary S6 i My Commission Expires March S, 20 y Not._...... t1ik arr VVmty Lynn D. ViningMy Commission Expires Mar6,2025 Elkhart Printed Name County of Residence If the Contractor is a corporation, the following certificate will be executed, 1, Robert Bash certify that I am Secretary of the Corporation executing this release; that B N Favors who signed this release on behalf of the contractor was then Press en `CF ..""""" of said Corporation; that said release was duly signed for and on behalf of said Corporator by tat rit� o "' Igerning body, and is within the scope of corporate powers: Secretary's Signature Robert Bash Corporate Seal Printed Name DEPARTMENT OF PUBLIC WORKS APPROVAL proval and we recommend to the Board of Public Works that it be ordained so. This project Is acceptable r In I' Date: P 1 p Construction Mpar for I' BOARD OF PUBLIC WORKS APPROVAL Date, A% Gary A. GUM, President tax Fritxberg,,,,NJWber kliz—a eth A. Mar'adIInber Therese T Dorau, Member Laura O'Sullivan, M. Martin, Clerk. AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of St Joseph SS:. Bill Favors being duly sworn that he/she is the President & CFO (Name of Officer) (Title) of Construction, Inc having contracted with City of South Bend, Indiana Io ow (ki Construction, Ipp • ) � ITITITITmm ..... Subcontractor/Su leer (Contractor) PCR # 1-Delete Door PCR #2-New Vault Door PCR # 3-Add Power Outlets to furnish certain materials and/or labor as follows: PCR #4-Add Ethernet Ports (Description)_..-...._��.....................m.- for a project known as Engineering Office Improvements - Project Number 118-107 (Name of Project) located at 13th Floor County City Building and owned by City of South Bend, Indiana (Owner) ._.._........_�._.... and does hereby further 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 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 by the undersigned; (FINAL WAIVER) that the final balance due from the contractor is the sum of Nine Thousand Two Hundred ThI.rt Three apd 00/100$ 9�23300 ❑ receipt of which is hereby acknowledged; or ❑X 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, furnished 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 the scope of this Affidavit and Waiver of Lien. Ziolkowski Constructin, Inc By Bill Favors (Firm) ._.. (Author W.....� .�.____. _ ............_....�.... ized Representative) STATE OF INDIANA ) SS: ST. JOSEPH COUNTY ) Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Bill Favors and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN WITNESS WHEREOF, T have hereunto subscribed my name and affixed my official seal on the 23rd day of January, 2019 290 Notary Public S" My Commission Expires: March fr, 2025 Lynn D. Vining Elkhart County, Indiana of c Residing in Co>.m Notary Ptrb�hc h+alte LYNN DVINING Seal CM,)tavy pa jh c - si atte apt Indiana Flktiao t cotlffty Myt:aairmr 55ton bp�[e$ Mar 6, 20 5 BOARD OF PUBLIC WORKS AGENDA ITEM REVIEW REQUEST FORM Date 01/28/2019 Department Public Works .... __. ____. - ....... Name Toy Villa ... Division/Bureau Engineering BPW Date 02/12/2019 Phone Extension 5920 iuwowmmmm mmwmmim�imi�ummimimuwimuwiuwimuwimwwwwwwwwwwuwimwwurc v uono iu=M115111555M „ � _.. 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 ❑ Check the El Agreement Amendment 0 Professional Services Fj Bid Opening El Quote Opening E] Change Order No. EJ Ease/Encroach. Other: iropriate Item Type Required ❑f Submissions ContractEl ❑] Resolution ❑ Bid Award ❑ Req. to Advertise [� Quote Award C/O & PICA No, PICA El Traffic Control: Company or Vendor Name 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 e Chan : % g New Amount $ Total Percent of Chanee: % Copy Original ❑ ❑ ❑ D 0 1:1 uired Information Ziolkowski Construction. Inc. Addendum ❑ Title Sheet Engineering Office Improvements mmmmm 118-107 Professional..Servi.................................�...._._..................,,,,,,......�........... ..�..... ces 101.0602.431.3106 $9,233.00 U Required Contractor's Certification Forms Attached (Non - Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) red For Chanee Orders Onl Dispersal After A