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PROJECT NAME <br />PROJECT NO <br />CONTRACT SIGNED <br />PROJECT DESCRIPTION <br />WITNESSETH: <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />PROJECT COMPLETION AFFIDAVIT <br />Install roof replacement improvements according to the intent of the <br />plans and specifications at the South Bend Equipment Services Building located at 1045 W <br />Sample St, South Bend, IN 46619. <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 />Execute this= day of Ay Gy S f 201% Northern Indiana Roofing & Sheet Metal <br />7reSt�QenF Company Name <br />Sign t re Q 23495 Edison Rd <br />'TA r,.) k s t ti C E"{ Company Address <br />Printed Name South Bend, IN 46628 <br />City, State, Zip <br />W ITNESSESS: <br />Before me, the undersigned Notary Public in and for said country and state, personally appearedand acknowledged his/her signature to the above P <br />the 2 4 day <br />of t GJ s i , 201 lP <br />of gnatureg� My Commission Expires <br />LLPC) A tL 5C2i T30 <br />Printed Name County of Residence <br />If the Contractor is a corporation, the following certificate will be executed. �r4AiD / A N P`\\\``,� <br />I, KC-�-K,4 G r•o v certify that I am Secretary of the Corporation executing t 111W$8+e; that <br />T� r, w • S', r ce ti who signed this release on behalf of the contractor was then <br />I, S : e . z 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 />Secretary's nature <br />Kcrlkv fpOYNS Corporate Seal <br />Printed Natne <br />DEPARTMENT OF PUBLIC WORKS APPROVAL <br />This project is acceptabl fo final approval and we recommend to the Board of Public Works that it be ordained so. <br />Date: i- 18 • 1 tr <br />Constructi anager <br />BOARD OF PUBLIC WORKS APPROVA <br />Gary A. Gilot, President Vivid P. Relos, tuber <br />There/ se J. D rau; fvlember James A. Mueller; Member <br />L <br />Date: <br />Elizabeth A vlaradik, Member <br />Linda M. Martin, Cler <br />