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Home My WebLink AboutProject Completion Affidavit - Olive Production Well No 6 Rehabilitation Project No 118-102 - Peerless Midwest Inc1316 COUNTY —CITY BUILDING 227 w.JEFFERSON BOULEVARD SOIITH BEND. INDIANA 46601-1 930 ov r11 ;� ac III�r CITY OF # BEND PETE BUTTIGIEG, MAYI BOARD PUBLIC March 26, 2019 James Williams Peerless -Midwest, Inc. 55860 Russell Industrial Pkwy. Mishawaka, IN 46545 PHONE 574/235-9251 FAx 574/235-9171 RE: Project Completion Affidavit — Olive Production Well No. 6 Rehabilitation — Project No. 118-102 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 $63,237. 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 GENEVIEVE MILLER ELIZABETH A. MARADIK LAURA O'SULLIVAN THERESE J. DORAU w r f CITY OF SOUTH BEND, INDIANA q BOARD OF PUBLIC WORKS PROJECT COMPLETION AFFIDAVIT PROJECT NAME Olive Production Well #6 Rehabilitation PROJECT NO. 118 102 FINAL COST ........................ _632.3Z. o....._ CONTRACT SIGNED 11 /27/ 18 MAINTENANCE AGREEMENT ENDS .. PROJECT DESCRIPTION Cleanin and inspection of well #6 at the Olive Well Field 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 8th day of ._.�IM'Iaxic-IKI-,20 Lq P ee r l es s -Mi dwe s Signa# Ire Company Name James R. Williams _ 5560 Russell Industrial Pkwy. Printed Name Company Address Mishawaka, IN 46545 City/State/Zip WITNESSES Before me, the undersigned Notary Public in and for said country and state, personally appeared James R. Williams _ and acknowledged his/her signature to the above Project Completion Affidavit on ....... 5 CATHY S. LANCE rto 8t day of Ma h .. 2019 ��,� i w ' P xt� ,�rrrr�w w � Notary Public, State of Indiana Notary Si tattire My Commission I� xpir St. Joseph counfv h Lace ..WWw Y° ;n o t' �`' June 06 2023 Printed Name County of Residence If the Contractor is a corporation, the following certificate will be executed. I " cha el J. Williams its.........._, certify that I am Secretary of the Corporation executing this release; that James R. Willi ams who signed this release on behalf of the contractor was then General Ma n a e r of said Corporation; that said release was duly signed for and on behalf of said o � "orporalion by AWl arfty ofits governing body, and is within the scope of corporate powers: S cae ry's Sagf)dtLll;e Corporate Seal Michael J. ki,fliams 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. tanstrLrc.............. Date: C r "Manager BOARD OF PUBLIC WORKS APPROVAL Date: . (,, pZo Gary A,.t'3flot,Pres.dAi QeX Vv-reC-,! tlif-rl ,Member ra L. O'StlH —'I''lierese J. Dorau, Member l lrz�fbeth AMaradik Member AltpA. t ..IT. "--]"Aida M. Martin, Clerk. AFFIDAVIT AND WAIVER OF LIED State of Indiana, County of SS, me s .R. lit i l ] a s being duly sworn that he/she is the General Manager, .._ �..-..�� of Officer - (I"rtle) k Of Pe—e derl... ess— west, Inc,, having contracted with Indiana ( ubcontra6tor/Sazpifliel) —.� ,�m__w . (srratracterr) to furnish certain materials and/or labor as follows: Chemicals _ _ end � ut p,—f—p Dement parts (Description) for a project known as —W_ TrqqA& t ,jon^Wel p #6 RthLal 7li.tation (Name Of Project) . located at and owned by City of SouthBendInid1dt10..,. and does hereby further state on the behalf of the aforementioned subcontractor/supplier; (11A1t I I'AL WAIVER) that there is due from the Contractor the sum of Dollars El receipt of which is hereby acknowledged; or 0 the payment of which has been promised as the sole considertatlOri f r this Affidavit arr'id Final 4Ta ver° of` iera aal i la is given solely with respect to said amount, and which waiver shal t be et'fe tivb only upon focci t of payraae'nt tllereof'by lire undersigned; (FINAL WAIVER) that the final balance due from the contractor isthe sum ofSixty-Three Thousand Two Hundred h.irt Sven D ol.)_ar .�..00/Cents 323ZM.00� 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. "I°IJER13 OREA the undersigned walvos and roloases unto the Owner of said premises, any and all liens or clauns wvlratsoover o/a lrc rraov'e cicset ietl gaper°tytratlrrrpr`ovcrrrorats tlrcrcor°r ara aedotant oflarlror or°'rllatel`ial tra` both, far`rrlslia the ttrrdtrrsrped 1 > y� further col ti.fied that Tarr otlt,ea` party has ally 0411b 'dt, 1gh't to a tlacr°cto, soil a ct to l'irlaitatioras Or corrtlatlorat expressed scd hcrein ii aar ° and fttr hen. oil acO ulrt of ny work per:f"ormod or raaatcrlal forldshod to the undersigupd for said project„ and within the scope, of lais Affidavit . ara�' Waivarof Lion.. rest Inc Peeless-Midw � ..�..�... �..IT__ _. _�.. . �I irxrt) � (A'�rtlror'ied II".epreseratatra STATE OF INDIANA ) SS: ST. JOSEPH COUNTY ) Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Jame s R . Wi 11 i am and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN WITNESS M94BREOF, I have hereunto subscribed nay name and affixed my official e l on t 8 th dr of arch � 19 ors Notary Public, State of India .� St. Joseph County Not y 1'rrhlio Si rre SEAL' 2' My Commission Expires My Commission Expires; ��.` e1w "<" June 0, 2023 y S. Lance Indiana __.Ca S Residing in Coon S Jos h t3', ,,fir, � Ncrt`saaPublifw blame 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 ��o�� NNvivi arrmmo�wm�o�� mYer¢.... muuuum �wavmmmumuuumr�uu��rsrawu,�mmmmumumuuuuuuuuuuuuuuuuuuuuumwmummmumNm�mr��rt�uuumrc�wrd�vauv uemrw,�m�oaumuwu�wwwwomommmmomow Required Prior to Submittal to Bo ..................... and ...�_._� w__._.........._ W ....�.__ __ BPW Attorney Attorney Name Clara McDaniels Dept. Attorney -1 Attorney Name Purchasing El Check the Appropriate Item Type Professional Services Agreement ❑ Contract Open Market Contract ❑] Amendment/Addendum ❑ Bid Opening ❑ Bid Award ❑ Quote Opening [] Quote Award [❑ Proposal Opening ❑ C/O & PCA No. ❑ Chg. Order, No. Traffic Control ElOther: 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 U Proposal E]Special Purchase, QPA Req. to Advertise Reject Bids/Quotes ®_ PCA Resolution Ease./Encroach ❑ Title Sheet Peerless Midwest .................. Yesf. Yes, ww......��.......� �.... �._...........................................�..._................... Approved by Purchasing ® No [❑ MBE Completed E-Verify Form Attached El Yes WBE ❑ No Olive Production Well #6 Rehabilitation 118-102 Water Works O&M 620-0640-602-31-06 $63,237.00 _ Hourly Not to Exceed, _ Lump....Sum. The close out of the Olive Production Well #6 Rehabilitatimon................................m� For Chrnp..OrdersmQnl...._.. Amount of F1 Increase $ F Decrease $ � Previous AmountIncrease $ �...................... Current Percent of Change: Decrease A,_...........................................��.......................... ( /o) New Amount $ .m........�__ .�s_� Increase................................�..................................................%..............................�w�� _��.�.�.�.�...... �........................................ �........_... Total Percent of Change: Decrease _(OR 0 Time Extension Amount: New Completion Date: