HomeMy WebLinkAboutProject Completion Affidavit - Ziker Sample St Building Restroom Remodel Project No 117-123A - Premier 1 Construction1316 COUNTY -CITY BUILDING
227 W.JEFFERSON BOULEVARD
SOUTH BEND. 1NDIANA 46601-1930
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CITY OF SOUTH BEND PETE BUTTIGIEG, MAYOR
BOARDU LIC WORKS
May 14, 2019
Alan Lusk
Premier 1 Construction
105 E. Jefferson Blvd., Suite 216
South Bend, IN 46601
PHONE 574/235-9251
FAx 574/235-9171
RE: Project Completion Affidavit — Ziker Sample Street Building Restroom Remodel —
Project No. I I7-123A
Dear Mr. Lusk:
The Board of Public Works, at its meeting held on May 14, 2019, approved the Project
Completion Affidavit for this project in the amount of $45,976.
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, C1e11of
Enclosure
GARY A. GILOT GENEVIEVE E. MILLER ELIZABETH A. MARADIK LAURA L. O'SULLIVAN THERESE J. DORAU
� *w4B41A Jf Po��✓h
CITY OF SOUTH BEND, INDIANA,
BOARD OF PUBLIC WORKS 41�. " = S
PROJECT COMPLETION AFFIDAVIT "
PROJECT NAME Ziker Sample Street Building Restroom Remodel
PROJECT NO 117-123A FINAL COST $45,976.00
CONTRACT SIGNED 1/22/2019 MAINTENANCE AGREEMENT ENDS
PROJECT DESCRIPTION Remodel and installation of one new restroom.
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.
Ex e this day of AA Premier 1 Construction
Company Name
Signature 105 E. Jefferson Blvd Suite 216
Ifiv M v Company Address
Printed Name South Bend, IN 46601
City, State, Zip
WITNESSESS:
Before 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
theday f 201�_.
o
NotarySignature My Commission Expires
( *- AA��--�
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 C(SL
m 'Wf Ifta I
"0Corporate Seal
g I ,;AS, o.� IN
Printed Name Comm. Idiom 612V?
DEPARTMENT OF PUBLIC WORKS APPROVAL
This project is acceptable for firms pproval and we recommend to the Board of Public Works that it be ordained so.
Date:
Construction ger
P�
Iq
BOARD OF PUBLIC WORKS APPROVAL Date:
Gary A. Gilot, President Ge eve E, M1llpr-;M4berElizabeth A. Maradik, M'ern 11
Therese J. Dorau, Member
O'Sullivan,
Linda M. Martin, Clerk 1Ang
AFFIDAVIT AND WAIVER OF LIEN
State of Indiana, County of
_J4
IV
i
(Name of Officer)
of "-""
(trbcorttractor/Stmpp]ier)
to furnish certain materials and/or labor as follows:
SS:
being duly sworn that he/she is the S
(Title)
.4 ee_
having contracted with-��'�^�~'� l��ynA0L1PC
(Contractor)
(Description)
for a project known as
(Nance of Project)
located atw,s I< -44
and owned by
__2_......._.......e�.. _ . �m.. ._.. n ........ _ - _. _
(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 fiom the contractor is a sum of the A—
❑ 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.
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.
By
�, t ..�10�-��CA`at _. ..—. tativSTATE OF INDIANA�Ii ) ) " f t os, � Pu1114C toai ed Representative)
SS.
i (, 2023
ST. JOSEPH COI rN";Cy �' "ins�., iN .
Before me, the undersigned, a Notary Public, in ail" for spar , in y t nr State, personally appeared '
and acknowledged the execution of the foregoing Affidavit and Waiver of Lien.
IN subscribed my*name and affixed my official seal on the day of
..M..
WITNESS WHEREOF, I havehereunto
200 � q
Ui�ff6ublXicS�itjrdttac
My Commission Expires: ''
Residing in _. rCounty, -�� Notary Public Name
._....._
BOARD OF PUBLIC WORKS
AGENDA ITEM REVIEW REQUEST FORM
Date 5/07/2019
Name _,,,Tqy Villa�mmmmy Department En ineerin
BPW Date 5/14/2019 Phone Extension 5920
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...................... ...,..w.,,, �....�.�....._._�,.......
Required Prior to Submittal to Board
Legal 0 Attorney Name
Controller D 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
Agreement
Professional Services
E] Bid Opening
l Quote Opening
❑ Change Order No.
Ease/Encroach.
Other._
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
)ro riate Item Type
El Contract
Resolution
El Bid Award
❑ Quote Award
El C/O &PCANo.
_
❑ Traffic Control
for All Submissions
I Proposal ❑Addendum
❑ Req. to Advertise ❑ Title Sheet
Required Information
Premier 1 Construction
7 Yes N_No _ ❑^If Yes,
7 MBE FM WBE
Purchasin
Ziker Samp�.l..e...�.�.�.S�....t_..r....ew_...e......t Building: Restroom mRmemodel
mmmmmmmmmmmmmmmmmmmm_w
117-123A
River West......................._................................w_______ m..,....�.�......................
TIF
324.1050.460.42.02 �..... �, �.
$ 45,976.00
Proiect Closeout
❑ Required Contractor's Certification Form Attached (Non -
Collusion„ Non -Discrimination, Non -Debarment, E-Verifv, Iran. etc.
Required For Chane Orders On
Amount of ❑ Increase
❑ Decrease
Previous Amount $....
Current Percent of Change. %
New Amount $
Total Percent of Change: %
Dispersal After Approval
Copy
Original
El
❑
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