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Home My WebLink AboutProject Completion Affidavit - Century Center Kitchen Door Installation Project No 118-036B - Larson Danielson Construction Co Inc0V T1i. 1316 COUNTY -CITY BUILDING 227 W.JEFFERSON BOULEVARD SOUTH BEND. INDIANA 46601-1 830 I�'y k"►[As"�7 "F CITY OF SOUTH BEND PETE BUTTIGIEG, MAYOR BOARD OF PUBLIC WORKS February 26, 2019 Timothy Larson Larson Danielson Construction Co., Inc. 302 Tyler Street LaPorte, IN 46350 PHONE 574/235-9251 FAx 574/235-9171 RE: Project Completion Affidavit — Century Center Kitchen Door Installation — Project No. 118-036B Dear Mr. Larson: The Board of Public Works, at its meeting held on February 26, 2019, approved the Project Completion Affidavit for this project in the amount of $17,975.11. 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 PROJECT NAME PROJECT NO CONTRACT SIGNED PROJECT DESCRIPTION WITNESSETH: CITY OF SOUTH BEND, INDIANA BOARD OF PUBLIC WORKS PROJECT COMPLETION AFFIDAVIT Century Center Kitchen Door Installation 118-036B FINAL COST $17,975.11 7/24/2018 MAINTENANCE AGREEMENT ENDS Install a kitchen door entrance to the A-B Convention Hall 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. Larson Danielson Construction Company, Executed this 29th da of January 201 9 Inc. Company Name Signature 4 302 Tyler Street --Timothy F. Larson, President Company Address Printed Name LaPorte, IN 46350 City, State, Zip WITNESSESS: Before me, the undersigned Notary Public in and for said country and state, personally appeared Timothy F. Larson , and acknowledged his/her signature to the above Project CompN :Expires the 9 h da f Januar ,2019 .'hOTA"%'La PorTHY ,y :�"� nona��.; La Porte CMy Commissio February 1Notary SignaturMy Commission Expires Februa'r Cathy A. Sale 679923 Printed Name County of Residence LaPorte If the Contractor is a corporation, the following certificate will be executed.. I, Terry A. Larson , certify that I am Secretary of the Corporation executing this release; that Timothy ITITF _ Larson_ who signed this release on behalf of the contractor was then pt of said Corporation; that said release was duly signed for and on behalf of said Corp t" n b Au only of its governing body, and is within the scope of corporate powers: Secretary's Si natur )ZLc,-AC V NI L 'or orate Seal _ Terry A. Larson st��dN Cn, INC. Printed Name DEPARTMENT OF PUBLIC WORKS APPROVAL This project is acceptable for~ f' I approval and we recommend to the Board of Public Works that it be ordained so. L'o �70 Date: t Constructio gel .f BOARD OF PUBLIC WORKS APPROVAL Gary A. GNlot, President &w T ereseJ. Date: 1 0" �,-/ 0 l Jz— Elf—z9beth A. Maradik, Member LihA M. Martin, Clerk AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of LaPorte SS: .. F. . n (Name of Officer) •� • �• .... being duly sworn that he/she is the rest t a ��(Title) ........_ ... .—...... g_.... _ brsrucltaa Co.,Inc. o having contracted with Larson Danielson Co (Subcontractor/Supplier) _ (Contractor) to furnish certain materials and/or labor as follows: P � -B 0,o : IL ion (Description) Hall. for a project known as Cen,tur,y Cente ,m I a t cka to f?o Inst 114.ti,on m..�............ ..... (Name of Project) y Martin Luther King Jr Blvd South Bend, IN.446601 located at entur Center 20 S M and owned by __ .by_. !.; b.t .l.t.Lh__Be d.,_._1.tad (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 Sae,.v.._e..nteen Thousand, Nine Hundred Seventy —Five y.FiveDollars ($_.17 .9�5..�1 ............... ......... & 11/100 ❑ receipt of which is hereby acknowledged; or R1 1 a iw ® the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which sha`' 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 whatso vest ccnn on the above -described property and improvements thereon an account of labor or material or both, furnished b the undersigned � z thereto, subject to limitations or conditions expressed herein, if any; and further certified that no other party has any claim or rig $' to ts n lien on account of any work performed or material furnished to the undersigned for said project, and within the scope of this Aft'% avi8 z and Waiver of Lien. z m CD_.m.:.... l.sralattnasomal. Construction _C,.� Inc. BY ....." (Firm) (Authorized Representative) z STATE OF INDIANA ) Timothy F. Larson, President ' LaPorte ) SS: -S-'-JG&E ?H COUNTY ) Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Timothy F. Larson 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 seal on the 2 th day of January 20 ?019• Notary Publ' S ature My Commission Expires: February 11, 2024 679923 _.. �athE....A La Pone County Residing in .. LaPorte m County, Intla Notary Pubhi1a CATHYA SALE �k my My Commission Expires %'�'' February t1, 2024 BOARD OF PUBLIC WORKS AGENDA ITEM REVIEW REQUEST FORM Date 02/07/2019 Department Public Works Name Toy Villa � Division/Bureau �Engineeri ng BPW Date 02/26/2019 Phone Extension 5920 �� iurew mlimummmmmm mmmmmmn7l'momoummuweuwwuwww - .... ........_......._....... _.............. ..�...�. Required Prior to Submittal to Board Legal ....El Attorney Name: ITITITmmmITITITITITITmmm�WWWW��W� Controller El Controller review is required for all Contracts $5,000.00 or more and greater than one year in length per the City Purchasing Policy Purchasing El Check the j Agreement Amendment ❑ Professional Services ❑, Bid Opening F Quote Opening ❑ Change Order No. 0 Ease/Encroach. F Other: Company or Vendor Name iropriate Item Tree — Rem ❑ Contract Resolution Bid Award [� Quote Award �j C/O & PCA No. ❑ Traffic Control: New Vendor MBE/WBE Contractor MBE/WBE Contractor Requested Project Name Project Number Funding Source Account No. Amount Terms of Contract for All Submissions I Proposal ❑ Req. to Advertise ired Information Larson -Danielson Construction Co., Inc. Addendum ❑ Title Sheet Purpose/Description Project Closeou t ❑ Required Contractor's Certification Forms Attached (Non- Collusion,IT Non -Discrimination„ Non -Debarment, E-Vergy�mmmIran, mmmetc. Required For Change Orders Only Amount of El Increase �$ ❑ Decrease $ Previous Amount $ Current Percent of Change: New Amount $ Total Percent of Change: Disoersal After Aohroval Copy Original ❑ ❑ El ❑