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Home My WebLink AboutProject Completion Affidavit - Edison Production Well No 2A Rehab Project No 118-103 - Peerless Midwest Inc1316 COUNTY -CITY BUILDING 227 W.JEFFERSON BOULEVARD SOUTH BEND. INDIANA 46601-1 830 James Williams Peerless -Midwest, Inc. 55860 Russell Industrial Pkwy, Mishawaka, IN 46545 s�I I I l"F E A. G ?;,,w �u 1865 March 26, 2019 PHONE 574/235-9251 FAx 574/235-9171 RE: Project Completion Affidavit — Edison Production Well No. 2A Rehabilitation — Project No. 118-103 Dear Mr. Williams: The Board of Public Works, at its meeting held on March 26, 2019, approved the Project Completion Affidavit for this project in the amount of $63,140. 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, 4 Linda M. Martin, Clerk Enclosure GARY A. GILOT GENEVIEVE MILLER ELIZABETH A. MARADIK LAURA O'SULLIVAN THERESE J. DORAU rfwr,a CITY OF SOUTH BEND, INDIANA;' BOARD OF PUBLIC WORKS PROJECT COMPLETION AFFIDAVIT;; PROJECT NAME Edison Production Well #2A Rehabilitation PROJECT NO, 118-103 FINA L COST $63,140.00 CONTRACT SIGNED 11/27/18 MAINTENANCE AGREEMENT ENDS PROJECT DESCRIPTION Cleanin and ins e.ction _o_f Well 2A Edison,n Well Fie_1_d�_ 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. r Executed this 8th day of March .w 20 19-111111 Signat re Company Name uJames R. Williams 55860 Russell Industrial Pkwy Printed Name Company Address Mishawaka Il9 46545 City/State/Zip WITNESSES Before me, the undersigned Notary Public in and for said country and state, personally appeared " t Completion Affidavit on Y —, g g d � . James i i ams and acknowledged his/her signature to the above Pro ec th th da of March 2019tw�rrsrrrwy CAIHY S. LANCE r " O,o AQ, « r, Notary Public, State of Indiana Notary Sign° afire My Commission Expf 86A St. Joseph County r Eb^G Cathy S. Lance une 06, 2023 Printed Name County of Residence If the Contractor is a corporation, the following certificate will be executed. 1, M1 h el J.., lJj'I , certify that I am Secretary of the Corporation executing this release; that JamesR. William $ who signed this release on behalf of the contractor was then Genera 1 fi n a gne r 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: S cretary's Igna�nre Michael , 'Williams Corporate Seal Printed Name DEPARTMENT OF PUBLIC WORKS APPROVAL This project is acceptable for final approval and we recommend to the Board of Public Works that it be ordained so. " Date: Conslruc�ti anager 11 BOARD OF PUBLIC WORKS APPROVAL, late" I de,-�-,Vieve F Mt'ltlW ;, Member ra,L. O'Sullivan, Member Therese J. Dorau, Member nqL-�, Utk E izc ibeth A. Maradik, Member `-f1 ida M. Martin, C -k AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of jl„SS: b Jug duly sworn that he/she is the Rq n er, L nilgel- e (Maine of Officer) Of Ind,having contracted with S:LtYQL�91W14,I nd i, a n a —9N(Subcontractor/Suppla) - to furnish certain materials and/or labor as follows: _,. Chenjj,1-_ jnd !L _parts (Description) for a project known as FCI 0 -,P.rod u tj (Nanw, of Pr(Iject)" located at Edison Park Well Field and owned by City of South Bend n . . .... I diana., and does hereby further state on the behalf of the aforeniantioned subcontractor/supplier: (PAT01AL WAIVER) that there is due from the Contractor the sum of Dollars El receipt of which is hereby acknowledged; or 'El the payinent of"which has been promised as the sole considerrjtlditfof ilu's AffdWt Md Final Va'iVel° oftlen wfii h is given solely with respect to said atuolirif and. which wai f , it 'I undersigned; p yMentfj,jerqofby,tho (FINAL WAIVER) that the final balance due from the contractor is the sum Of Si Xty-Three Thousand One Hundred Forty J receipt of which is hereby acknowledged; or fbe payniont ofvd-dcli liras been promisod asibe sole consideration for this Affidavit and Final Waiver of Lion which shall beconio effective only ulwil rcccjp[ of SLIC1,1 fraylnent. (TIEREFOIZE2 the iindersigned' wahros and releases iinto tho Own or of sa d all flons oi- clah s whatsoover 0eraiot ld my an 971 ,11 theerr 1,11prett), Suillect to lixkdlaflo)'Is oton(litions if oliy;' rnfd fal-11101° cedl thatno'0111or J)arly has flay claial'', "j, lien, on acobuiit of 4,Iny 1voi-jr, 0'r matella) ight to a &I-hished to f,oi(lvV' give)"Of'LiCiL Id Withil" 1110 4"opo of this Affldayft Peerless -Midwest Inc -7 By at STATE OF -NDIANA IV I Ss' ST. JOSEPH COUNTY Before me, the undersigned, a Notary Public, in and for said County and State, personally jippeared James R. Williams and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN WITNESS VA-11PMOF I have hereunto subscribed iny name and affixed my offici seal on ch 0 day of seal 206 19 CATHY S. LANCE "p, Notary Public, State of Indiana I No, a,' q I U wt 111rc 'yeri St. Joseph county My Commission Expires: , :4F My Commission Expires Cathy S. Lance Residing in Indiana county, K6'Fary paablrc . . . ....... 0 — so BOARD OF PUBLIC WORKS AGENDA ITEM REVIEW REQUEST FORM Date 3/19/19 Department Public Name Becca Plantz Works BPW Date 3/12/19 Phone Extension 5998 immmmim�muw�aae reaurwwaw. ua�,muuuc ww � PPPPMPm0000mmmmmmmmmmmmmmum mu�"flii lNffpp M q!lirSd to Submittal to Board BPW Attorney ® Attorney Name Clara McDaniels Dept. Attorney Attorney Name .... _..... _ _ _......... Purchasing F Check the Appropriate Item Type _.. ❑ Professional Services Agreement ❑ Contract Open Market Contract M Amendment/Addendum Bid Opening ❑ Bid Award Quote Opening E Quote Award Proposal Opening ❑ C/O & PCA No. ❑ Chg. Order, No. ❑ Traffic Control Other: Company or Vendor Name New Vendor MBE/WBE Contractor Project Name Project Number Funding Source Account No. Amount Terms of Contract Purpose/Description Information All Submissions Proposal H Special Purchase, QPA Req. to Advertise Reject Bids/Quotes ® PCA ❑ Resolution Ease./Encroach Peerless Midwest Yes If Yes, Approved by Purchasing No ❑ Title Sheet For Change Orders mOnly_IT mmu Amount of Increase $ [� Decrease ($ Previous Amount $ ..�.Increase..................................................w�.�_ °__...,_..............................................��.....�..�.�..�.. �............................................_ /o ..... Current Percent of Change: Decrease _......._dada_ ( %) New Amount $ Increase /o Total Percent of Change: Decrease %) Time Extension Amount: New Completion Date: