HomeMy WebLinkAboutPCA - 2022 Signal Knock Down & Wiring Investigation Proj No. 122-046 - JBL Signals1316 COUNTY -CITY BUILDING
227 W. JEFFERSON BOULEVARD
SOUTH BEND, INDIANA 46601-1830
PHONE 574/235-9251
FAx 574/235-9171
CITY OF SOUTH BEND JAMES MUELLER, MAYOR
BOARD OF PUBLIC WORKS
May 14, 2024
Mr. Tanner Leibovitz
JBL Signals and Lighting LLC
4316 Technology Dr.
South Bend, IN 46628
tannerlgjblsignalsandlighting com
RE: Project Completion Affidavit — 2022 Signal Knock Down & Wiring Investigation
Project No. 122-046
Dear Mr. Leibovitz:
At its May 14, 2024 meeting, the Board of Public Works approved the Project
Completion Affidavit for this project in the amount of $50,000.
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 Hefner
Theresa Heffner, Clerk
Enclosures
TH/lh
ELIZABETH A. MARADIK JOSEPH R. MOLNAR GARY A. GILOT MURRAY L. MILLER BRIANA N. MIcou
CITY OF SOUTH BEND, INDIANA
BOARD OF PUBLIC WORKS
PROJECT COMPLETION AFFIDAVIT y
PROJECT NAME
PROJECT NO
CONTRACT SIGNED
PROJECT DESCRIPTION
2022 Signal Knock Down & Wiring Investigation
122 046 FINAL COST $50,000.00
7/26/2022 MAINTENANCE AGREEMENT ENDS
On -Call contract to repair signal knock downs and intersection wiring
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.
!xe�cutdqy�. of 1 s`{' , 202 zaL JBL Signals and Lighting LLC
09— Company Name
S nature 4316 Technology Dr.
TANNER LEIBOVITZ Company Address
Printed Name
South Bend, IN 46628
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
the l � day of ,� 202
_?fotary Stgnaature My Commission Expires
b e—:b rc— lA b& n s )u
Printed Nime County of Residence
If the Contractor is a corporation, the following certificate will be executed.
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
Printed Name
Corporate Seal
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.
&(A Z_aG 6y- Date: 5/2/2024
Cobitruction Manager
CITY OF SOUTH BEND, INDIANA
BOARD OF PUBLIC WORKS
ta�a
Elizabeth A. Maradik, President
�� Gfv}L(ito�
Gary A. Gilot, Member
,-,k� 4 ,
Murray L. Miller, Member
�i, I
Joseph R. Molnar, Vice President
Briana Micou, Member
Attest: Theresa M. Heffner, Clerk
Date: May 14, 2024
✓lm�y
Debra A Urbanski
Notary Public Seal State of Indiana
St. Joseph County
Commission 0 NP0732273
My Commission Expires 03/09/2029
Final Waiver of Lien
State of Indiana, County SS:
of
being duly sworn that he/she is the l �! ��i11 (Title)
(Name of Officer)
of S �tr'ctor���
Cit of South Bend
�having contracted with Y (Owner )
( 0
to furnish certain materials and/or labor as follows:
(Description)
for a project known as
located at
and owned by City of South Bend
(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 shalt be effective only upon receipt of payment thereof by the
undersigned;
(FINAL WAIVER) that the final balance due from the contractor Is the sum of 00 O O
❑ 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 et, and within the scope of this Affidavit
and Waiver of Lien.
S)i 615 &VA 6i5T3 ,Ul- By 6 TANNER LEIBUVITZ
(Firm) (Authorized Representative)
STATE OF INDIANA )
SS;
ST. JOSEPH COUNTY )
Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared
and acknowledged the execution of the foregoing Affidavit and Waiver of Lien.
IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my o clal seal on the 3 day of
Apo; ) L_ 202� LL"
Notary Public Signature
My Commission Expires: tyr,2 Lk
Residing in County, "Utanskillotary Public Name
o ry dianaCom73
BOARD OF PUBLIC WORKS
AGENDA ITEM REVIEW REQUEST FORM
Date 05/2/2024
Name Kvle Ludlow Department Public Works
BPW Date 05/14/2024 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
Information
Company or Vendor Name JBL Signals and Lighting LLC
New Vendor
MBE/WBE Contractor
Project Name
Project Number
Funding Source
Account No.
Amount
Terms of Contract
U Yes U If Yes, Approved by Purchasing
® No
MBE ❑ WBE Completed E-Verify Form Attached ❑❑ Nos
2022 Signal Knock Down & Wiring Investigation
122-046
PR-18245
412-431000 PO-0018055
$50,000.00
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