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45 \=ry\ <br />CITY OF SOUTH BEND, INDIANAf <br />BOARD OF PUBLIC WORKS <br />PROJECT COMPLETION AFFIDAVIT <br />PROJECT NAME <br />PROJECT NO <br />CONTRACT SIGNED <br />PROJECT DESCRIPTION <br />WITNESSETH: <br />The work under the above contract between the City of South Bend and the undersigned contractor having been <br />completed, the City of South Bend, its officials and agents are hereby released from all claims and demands whatsoever <br />arising under or by such contract, and that the contractor performed the work within the scope of the Specifications and <br />Standards of the City of South Bend which were a part of the above Contract. <br />xe uted this �2 day of 201 le Torok <br />dL � - Company Name <br />gnature {� k — r 825 Fellows St <br />TCompany Address <br />t.lww W Ie�IF2a�� TVS <br />Printed Name South Bend, IN 46601 <br />City, State, Zip <br />WITNESSES& <br />Before me, the undersigned Notary Public in and for said country and state, personally appeared <br />Vti:\Grn, v\ 10wtk de , and acknowledged his/her signature to the above Project Completion Affidavit on <br />the day of 201 RENEE WIE PUGH <br />I `_ ` NOTARYSEAL <br />ST. JOSEPH COUNTY, STATE OF INDIANA <br />Not ignaturt MytO6gMly§§f@1h 3t wL02 <br />Printed Name County of Residence <br />r <br />If the Contractor is a corporation, the following certificate will be executed. <br />I, Geue r IV R. S,z 1& to certify that I am Secretary of the Corporation executing this release; that <br />Ja1, t1, wnn � . TT ask Z' iti who signed this release on behalf of the contractor was then <br />Pr-k4 i A6 ��— of said Corporation; that said release was duly signed for and on behalf of said <br />Corporation by Authority of its governing body, and is within the scope of corporate powers: <br />oZ) <br />Secretary's Ina re Corporate Seal <br />� iJg-rlv R. SFW H <br />Printed Nanle <br />DEPARTMENT OF PUBLIC WORKS APPROVAL <br />This project is acceptable r final approval and we recommend to the Board of Public Works that it be ordained so. <br />Date: IT Z a • I, G <br />Constructio wager <br />BOARD OF PUBLIC WORKS APPROVAL Date: ,3 ,: 0 <br />� <br />Gary A. Griot, resident vidl�S P. Relo ' ber EFizabeth A Maradik, Member <br />Therese J. Dbrau, Wember James A. Mueller, Member `tyrig0 M. Martin, Clerk <br />