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45ouTkg'��. <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS ., <br />PROJECT COMPLETION AFFIDAVIT �,abs <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 />Executed this day of _50 <br />42MJA5M, 201 Lo Poblocki Sign Co. L L C. <br />Company Name <br />Signature 922 S. 70th Street <br />Company Address <br />Printed Name Milwaukee_ WI 53214 .•`�_.wt WEN., <br />Vr <br />WITNESSESS: f ?OTAq y '•: <br />Before me, the undersigned Notary Public in and for said country and state, personally appea d i -.-- <br />llbeanl 641ums. and acknowledged his/her signature to the above Project Completion mAffN�QvitAon I '� <br />the & 11'I' day of 5MW-,6of g. , 201 1p �y <br />I. 9T <br />Notary Signature My Commission Expires <br />OU5114 ►a"I=Rr <br />Printed Name County of Residence ���wga N-�t, WAS f,pwS±vy <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 for f' al approval and we recommend to the Board of Public Works that it be ordained so. <br />a Date: 8 • I ei-- I (- <br />Construction & <br />ager / <br />BOARD PUBLIC WORKS APPROVAL Date: <br />Gary A. Gilot, President ,IuZA,,,,. vA.�mber Elizabeth A. Maradik, Member <br />Therese J. Dora ber James A. Mueller, Member Linda M. Martin, Clerk <br />