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Home My WebLink AboutPCA - 2023 Microsurfacing Proj No. 123-023 - National Pavement1316 COUNTY -CITY BUILDING 227 W. JEFFERSON BOULEVARD SOUTH BEND, INDIANA 46601-1830 PHONE 574/235-9251 FAx 574/235-9171 CITY OF SOUTH BEND TAMES MUELLER, MAYOR BOARD OF PUBLIC WORKS October 10, 2023 Mr. Garry Newman National Pavement Maintenance LLC 1928 N. Campbell Ave. Indianapolis, IN 46218 garrykRPm.us.com RE: Project Completion Affidavit — 2023 Microsurfacing Project No. 123-023 Dear Mr. Newman: At its October 10, 2023 meeting, the Board of Public Works approved the Project Completion Affidavit for this project in the amount of $97,960. A copy of the Project Completion Affidavit is enclosed for your records. If you have any further questions, please call this office at (574) 235-9251. Sincerely, /s/ Theresa Heffner Theresa Heffner, Clerk Enclosures TH/lh ELIZABETH A. MARADIK JOSEPH R. MOLNAR GARY A. GILOT ALEXANDRA DOLZ-LANE MURRAY L. MILLER I CITY OF SOUTH BEND, INDIANA BOARD OF PUBLIC WORKS PR03ECT COMPLETION AFFIDAVIT PROJECT NAME 2023 Microsurfacin PROJECT NO 123-023 FINAL COST $97,960.00 CONTRACT SIGNED 7/11/2023 MAINTENANCE AGREEMENT ENDS PROJECT DESCRIPTION Asphalt Microsurface, surface prep and a lication 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 pan of the above Contract. Executed this day of k 41,ib E , 202 3 National Pavement Maintenance Company Name Signature Printed Name _1928 N Campbell Ave. Company Address Indianapolis, IN 46218 City, State, Zip WITNESSESS: Before me, the undersigned Notary Public in and for said country and state, personally appeared . IM Gr ' M, and acknowledged his/her Si etion Affidavit on CURT S PICKARD the day o S' 02 Notary Public • Seal Marion County - State of Indlana 4 Commission Number WP0744 96 Notary Signature C'�tSi4fIfj oct 27, �30� 103 uy Printed Name County of Residence AA A-e r3 If the Contractor is a corporation, the following certificate will be executed. l 4(] (t 1 E W „tA )N AJ certify that i am Secretary of the Corporation executing this release; that (� A, iz rl j.{ �y ; u 4 who signed this release on be of the contractor was then Si-(2 f { r, 1t.1 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 Si ature 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: 10/2/2023 con vrction Marta r CITY OF SOUTH BEND, INDIANA BOARD OF PUBLIC WORKS 1 Elizabeth A. Maradik, President Gary A. Gilot, Member d� r Joseph R. Molnar, Vice President Alexandra Dolz-Lane, Member K�J4 Murray L. Miller, Member Attest: Theresa M. Heffner, Clerk Date: October 10.2023 �+State of Indiana, Cot:nty of ! A (Z t cjv." _ SS: ( 2 ` tj� ("j m Ax) being duly sworn that h0he is the A—P tC 'a (Name of Officer)' C (Title) of /V4r4ytA1 �e�4'i=(�lr�� having contracted with G 1-(f'o (Contractor) I (Owner) �'� r to furnish certain materials and/or labor as follows; AQ� �� 4 ' ''4 04 5 � �� u sF€r< k,Q O I) KL"-'� C1 (Description) yy-. for a project known as F1Atwo�t_''-�/�r."/i1/ (Name o ng)eot) f located at � f "r%k 6 q iE -r-G •, 14 � �T_Z_ n t s _5 and owned by- (Owncr) and does hemby lhrther state on the behalf of the aforementioned subcontractor/supplier: (PARTIAL WAIVER) that there is due from the Contractor the sum of �.` --- -- -- -- --- Dollars- 1_( receipt of which is hereby aelatowledged; 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; (FINA WAIVEthat the finfrom the balanco due frothe contractor is the sum of C, A) receipt ofwhioh is hereby acknowledged; or [� the payment of which has been promised as the sole consideration for this Affldavit 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 &a 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 famished to the undersigned for said project, and within the scope of this Affidavit and Waiver of Lien. � t AC _ i V t fti �r�T �' l fd�' �tv By CA - (Firm) (Authorized Representative) STATE OF INDIANA ) J y ��, `•� �, . SS. ST. IOSEPH COUNTY Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared tom` and aelutowledged the execution of the foregoing Affidavit and Waiver of Lien. WITNESS WHEREOF, I have hereunto subscribed my name and affixed my ofiieill Wei on the 2- day of 202 —.�.�� Notary Public Signature My Commission Expires: ._ / U Z'?- Z e) 2y Residing in l A�/_Ipr! County' .�—n� �) 1 A --_ Notary Public Name CURT S PICKARD F tary Public - Seal ounty - State of Indi]2030 ion Number NP0744ssion Expires Oct 21, BOARD OF PUBLIC WORKS AGENDA ITEM REVIEW REQUEST FORM Date 10/3/2023 Name Kvle Ludlow Department Public Works BPW Date 10/10/2023 Phone Extension 9157 Review and Approval Required Prior to Submittal to Board Diversity Compliance ❑ Officer Name and Inclusion Officer BPW Attorney ❑ Attorney Name Dept. Attorney ❑ Attorney Name Purchasing ❑ Check the Appropriate Item Type — Re uired or All Submissions ❑ Professional Services Agreement ❑ Contract ❑ Proposal ❑ Open Market Contract ❑ Amendment/Addendum ❑ Special Purchase, QPA ❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet ❑ Quote Opening ❑ Quote Award ❑ Reject Bids/Quotes ❑ Proposal Opening ❑ C/O & PCA No. ® PCA ❑ Chg. Order, No. ❑ Traffic Control ❑ Resolution n Other: n Ease. /Encroach Company or Vendor Name New Vendor MBE/WBE Contractor Project Name Project Number Funding Source Account No. Amount Terms of Contract Information National Pavement Maintenance U Yes U If Yes, Approved by Purchasing ® No MBE ❑ WBE Completed E-Verify Form Attached ❑❑ Nos 2023 Microsurfacing 123-023 Economic Development 408-06-602-503-43 6008 $97,960.00 Purpose/Description _Project Closeout For Change Orders Only Amount of ❑ Increase $ ❑ Decrease ($ ) Previous Amount Current Percent of Change New Amount Total Percent of Change: Time Extension Amount: New Completion Date: Increase % Decrease ( %) Increase % Decrease ( %1