HomeMy WebLinkAboutProject Completion Affidavit - Human Rights Commission Office Remodel - Premier I Construction1316 COUNTY-CrFy BUILDING
227 W. JEFFERSON BOULEVARD
CITY OF SOUTH BEND PETE BUTTIGIEG, MAYOR
BOARD OF PUBLIC WORKS
July 9, 2019
Alan Lusk
Premier I Construction
105 E. Jefferson Blvd., Suite 216
South Bend, IN 46601
PHONE 574/235-9251
FAX 574/ 235-9171
RE: Project Completion Affidavit — Human Rights Commission Office Remodel
Dear Mr. Lusk:
The Board of Public Works, at its meeting held on July 9, 2019, approved the Project
Completion Affidavit for this project in the amount of $24,129.
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,
,c
Linda M. Martin, Clerk
Enclosure
GARY A. GILOT GENEVIEVE E. MILLER ELIZABETH A. MARADIK LAURA L. O'SULLIVAN THERESE J. DoRAu
CITY OF SOUTH BEND, INDIANA ;
BOARD OF PUBLIC WORKSm�-
PROJECT COMPLETION AFFIDAVIT
PROJECT NAME Human.. Rights Commission Office Remodel
PROJECT NO N/A FINAL COST $24,129,011 10
CONTRACT SIGNED 4/23/2019 MAINTENANCE AGREEMENT ENDS
PROJECT DESCRIPTION Remodel of interior offices at the HRC buildin
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 day of gel . A201
YAff �_• Premier 1 Construction
Company Name
::Signat re 105 E. Jefferson Blvd, Suite 216
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
th day of 201
N ary nature~ w My Commission Expires
(Aaw
7C C
Printed ame County of Residence
If the Contractor is a corporation, the following certificate
thatl be am Secretary of the Corporation executing this I' / � Lam ' ty rY rp g release; that
who signed this release on behalf of the contractor was then
71
C'or or ti b but rlt z • of said Corporation; that said release was duly signed for and on behalf of said
P y y f its gover ing body, and is within the scope of corporate powers:
Secr tary's Signd JE Notary Public - eal
A/ State of Indiana pora'te Seal
f v Count
t Joseph y C
Printed Name °� fT11SSl
' on f Xpires Apr 15, 2023
DEPARTMENT OF PUBLIC WORKS APPROVAL
Tho project is acceptable for final approval and we recommend to the Board of Public Works that it be ordained so.
Date:
Construction Manager
BOARD OF PUBLIC WORKS APPROVAL Date: o `' (,!
AEfizabe
Gary A. Gi ot„ President Genevieve E. Miller Member V.Ma4raik,Member
harass J. D43r '� ..
„ Me bar Laura O'Sullivan, Member Linda M. Martin, Clerk
Final Waiver of Lien
State of Indiana, County of , os Ss
(Name...�.�.,,..„,,��� being duly sworn that he/she is the
Officer)
(Title).
of �+ .
having contracted with "44 . ,.
(Contractor)
(Owner)
to famish certain materials and/or labor as follows; �I "1U t . -
(Description)
for a project known as
(lwlaane ofrojootj-�,�,-..�
-W located at
and owned by i►��i , e �e s L L e
(Owner)
and does hereby further state on the behalf ofthe aforementioned subcontractor/supplier.-
(PARTIAL WAVER) that there is due from the Contractor the sum of
Dollars ,
❑ receipt of which is hereby acknowledged; or
❑ rite payment of which has been promised as the sole consideration fbr this Affidavit anti Final Waiver ofUenwhich is given
solely with respect to said amount, and which waiver shall be effective only upon receipt of paayment thereof by the
uaadersigned;
v the stern, of
ll'I�IAL WAl"�lllt th t .� e final balance due f era the con is
receipt of which is hereby acknowledged; or
❑ the payment of w}rich bas been promised as the sole consideration for this Affidavit and Final Waiver of Lien which shall
become effeotive only upon receipt of such payment.
TIEWOft,E, the underaigned waives and releases unto the Ovaaier ofsald promises, any and all liens or claims whatsoever
on the above -described property and im1wovemeawts thereon au accctuwt of labor or trmterial or both, fbrnished b the undersigned
thereto, subject to limitations or conditions expressed herein, if any, and fi rther certiflod that no other party has any claim or right o a
t
Ilea on acconaat of any wont performed or rawaterlaI i?umishe to the undersigned for said project, and within the scope of this Affidavit
and Waiver ofL,lea
(Firm)By
cif
STATE OF'INDIANA A(Awx rI ed Itepresc�aa live)
ST. IOSEm CO NI*y.
SS;:
Refore me the undersigiwed, a Notary Public, In and for said County and State, personally appeared
and acknowledged, the execution oftlao foregoing Affidavit and. Waiver of Lion,
Ilwl WITN ESS WBE-REOF, I have haarounto subscribed my name and afli'xed
200
My Commission Expires-,,
Real� " ,
d o E County,
�ota
State of Indlana
�. St Joseph County
twty Commission Expires Apr 15, 2023
BOARD OF PUBLIC WORKS
AGENDA ITEM REVIEW REQUEST FORM
Date June 28, 2019
Name Adam Parsons ..............._. _. ...........
Central Services
BPW Date duel ° 9 019 Phone Extension 9302
u�so-raRGemrmwwwmm�mns^r^uwnTiu�u�wr��n��,.�.,�»,.,.�,�,t.,,»,!rrr,rum�rni�mar-tmi,rri��w;��mzz!.,;tr.,w�.� � �A ��✓�� �mr�uuuuuuuuuuuuuwr;�trr*rkum+er�m���ann�r�e .,���:r�;,�cRvwr�wa rsrrwr�aw��esa,�,mvr_ �r �uare�r+u�ae��arnrid�miwumn
_
m... Required Prior to Submittal to B.o..ard ......_._ �. ,��_.m.. .
BPW Attorney X Attorney Name Clara McDaniels
Dept. Attorney ❑ Attorney Name
Purchasing
Check the
Item l woc . Required t /,• All Submissions
Professional Services Agreement ❑ Contract
Open Market Contract ❑ Amendment/Addendum
E]'
Bid Opening ❑ Bid Award
E]
Quote Opening ❑ Quote Award
❑
Proposal Opening n 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
uired Information
Proposal
_�w_rww
Special Purchase, QPA
Req. to Advertise
Reject Bids/Quotes
PCA
Resolution
❑] Ease./Encroach
❑ Title Sheei
Premier I Construction
Yes .. ....................w.
❑j ❑ If Yes, Approved by Purchasing
No
❑ MBE WBE Completed E-Verify Form Attached ! Nos
Human Rights Commission — Office Remodel
COIT
404-0.�..� .�.�..�.�...�....
617-631.36-01
Lug... Sum
......................W.......
Project Closeout
For '",tagyOrders Ord°
Amount of El Increase $
Decrease
Previous Amount $
Current Percent of Change
New Amount
Total Percent of Change:
Time Extension Amount:
New Completion Date:
Increase %
Decrease _�............_..........�.�.%
Increase %
..........
Decrease...........