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CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />PROJECT COMPLETION AFFIDAVIT <br />PROJECT NAME <br />PROJECT NO. <br />CONTRACTSIGNED <br />2016 Cold Milling <br />116-030 FINAL COST 30,284.06 <br />►1 S <br />PROJECT DESCRIPTION Cold milling of streets - <br />WITNESSETH: <br />the Street <br />The work under the above contract between the City of South Bend and the undersigned contractor having <br />been completed, the City of South Bend, its officials and agents are hereby released from all claims and <br />demands whatsoever arising under or by such contract, and that the contractor performed the work within the <br />scope of the Specifications and Standards of the City of South Bend which were a part of the above Contract. <br />Executed this day of <br />Signature /Gi sci�GssLs �.r o <br />Printed Name <br />J.L. Milling, Inc. <br />Company Name <br />15262 Industrial Dr. <br />Company Address <br />Schoolcraft MI 49087 <br />City/State/Zip <br />WITNESSES <br />Before me, the undersigned Notary Public in and for said country and state, personally appeared <br />, and acknowledged his/her signature to the above Project Completion Affidavit on <br />the e?� day of W c%/am l¢ e r , 201 M <br />QNotary Signature My Commission Expires <br />Printed Name County of Residence <br />If the Contractor is a corporation, the following certificate will be executed. <br />I, 1�k) u , �r kk rlq certify that I am Secretary of the Corporation executing this release; that <br />L,rAVA ffe- A q 2, who signed this release on behalf of the contractor was then <br />/71yl+e3 I d c,,$ 7"" of said Corporation; that said release was duly signed for and on behalf of said <br />Corporation by Authority f its governing body, and is within the scope of corporate powers: <br />cretary' Signature Corporate Seal <br />r¢ i �u fe,4) <br />Printed Name <br />DEPARTMENT OF PUBLIC WORKS APPROVAL <br />This project is acceptable for final approval and we recommend to the Board of Public Works that it be <br />ordained so. <br />—� Date: It- 11. 1 L <br />Construq�JrManager <br />BOARD OF PUBLIC -WORKS APPROVAL Date: / / 7 <br />AAA <br />Gary A. Gilot, President Suzanna FrWerg, Me Elizabeth A. Maradik, Member <br />James A. Mueller, Member Therese J. Dorai <br />M. Martin, <br />