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CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />PROJECT COMPLETION AFFIDAVIT <br />PROJECT NAME 2016 Curb and Sidewalk Construction Phase III <br />PROJECT NO <br />CONTRACT SIGNED <br />PROJECT DESCRIPTION Install new concrete curb around two islands on Mishawaka Ave. <br />WITNESSETH: <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 c <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 <br />this _ da �cci�U' 201 w TX Concrete LLC <br />4G rx Co e-r u c' _ Company Name <br />Sig ture —_ 24899 Fillmore Road <br />%/(6Se /er) ( Jdut9ctct -xCw Lu Company Address <br />Printed Name South Bend, IN 46619 <br />City, State, Zip <br />WITNESS ESS: I <br />Bftfore me, the undersigned Notary Public in and for said country and state, personally appeared <br />l uls ��,and acknowledged his/her signature to the above Project Completion Affidavit on <br />th0'4 day of , 201. <br />� vkG 6GRIAE SMITH <br />ola Signature �� �f, My Commission Expires NOTARY PUBLic STATE OF 14DIANA <br />N 'i C�Zf`� O, �rr - My COMMISSION EXPIRES 1011008 <br />Printed Name <br />County of Residence <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 f/ojr ,fii al approval and we recommend to the Board of Public Works that it be ordained so. <br />Ste. Date: [ F •{ , t tb <br />Constructiop, pager <br />BOARD OF PUBLIC WORKS APPROVAL Date: �0-d-A, <br />Gary A. Gilot, resident Suzanne M. Fritzberg, Member Elizabeth A. Maradik, Member <br />Therese J. Dorau, Member Jame, A. Mueller, Member Lihda M. Martin, Clerk <br />