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PROJECT NAME Di <br />PROJECT NO 11 <br />CONTRACT SIGNED 11 <br />PROJECT DESCRIPTION DE <br />WITNESSETH: <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />PROJECT COMPLETION AFFIDAVIT <br />Phase VIII Division B <br />uu <br />soRARU <br />' O� � \'gyp <br />i <br />1855 <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 />Exec t ��,dayof Mki 201�. Indiana Earth, Inc. <br />—�� <br />Company Name <br />gna ure 10343 McKinley Hwy <br />Company Address <br />MA-kK OnLA. eR SfD6n11— <br />Printed Name Osceola. IN 46561 <br />WITNESSESS:M�SSIo� <br />Before me, the undersigned Notary Public in and for said country and state, personally appeared Sri oats„ <br />and ack wledged his/her signature to the above Project Completion Affdavitar <br />SEAL <br />the _2%�i d of A- 201 i . z <br />Notary Signature My Commission Expires <br />Name County of ResidenceL�j,</i9—a" <br />If the Contractor is a corporation, the following certificate will be executed. <br />I, A4-U L ti SL6k— certify that I am Secretary of the Corporation executing this release; that <br />�ij ir? abLt<�2 who signed this release on behalf of the contractor was then <br />of said Corporation; that said release was duly signed for and on behalf of said <br />Corpolq Ayfhority4 n body, ody, ancj is within the scope of corporate powers: <br />fie (yam Ac-I <br />Printed Name <br />DEPARTMENT OF PUBLIC WORKS APPROVAL <br />Corporate Seal <br />This project is acceepta/bl for final approval and we recommend to the Board of Public Works that it be ordained so. <br />Date: <br />Constructior(!ghager <br />BOARD OF PUBLIC WORKS APPROVAL <br />Gary ary A. Gilot, President �i[ e4id P. Relos, bed <br />Ther�rau, Me ber James A. Mueller, Member <br />Date: 1 Y d 3 1 / <br />E izabeth A Mar dik, Member <br />Lin M. Martin, Clerk l <br />