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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 />Remove trees and <br />The work under the above contract between the City of South Bend and the undersigned contractor having been completed <br />the City of South Bend, its officials and agents are hereby released from all claims and demands whatsoever arising under ( <br />by such contract, and that the contractor performed the work within the scope of the Specifications and Standards of the Cit. <br />of South Bend which were a part of the above Contract. <br />Executed this 13 day of ©L- olaQx �r1�7/Ii _. KC Tree, Inc. <br />j Company Name <br />OTA,Q <br />Signature `' 1320 Third St <br />Lt,Lc vc CA,�.rryholmes Company Address <br />Printed Name Osceola, IN 46561 <br />AV9L�G City, State, Zip <br />WITNESSES: �9JFnn\Q`� <br />Before me, the undersigned Notary Public in and f and state, personally appeared <br />xhn✓ , 'hwrvhdwc.cand acknowledged his/her signature to the above Project Completion Affidavit on <br />theblytt` day pof d)AAu t_ , 201 C. <br />��t2 l h a,os.e , z11 <br />Notary Signature My Commission Expires Eeibau my y S, cZo3.4 <br />I)IANC- SzL tczy(c J <br />Printed Name County of Residence S -r o5C.PH <br />If the Contractor is a corporation, the following certificate will be executed. <br />I, certify that I am Secretary of the Corporation executing this release; that <br />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 />Corporation by Authority of its governing body, and is within the scope of corporate powers: <br />Secretary's Signature <br />Printed Name <br />DEPARTMENT OF PUBLIC WORKS APPROVAL <br />Corporate Seal <br />This project is acceptable or nal approval and we recommend to the Board of Public Works that it be ordained so. <br />• Date: t O • t Pi • I (r <br />Constructerr anager <br />. P i <br />