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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 />e <br />PROJECT COMPLETION AFFIDAVIT <br />b and Sidewalk Construction <br />116-029 FINAL COST $404,298.70 <br />of new curb 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 or <br />by such contract, and that the contractor performed the work within the scope of the Specifications and Standards of the City <br />of South Bend which were a part of the above Contract. <br />WITNESSES: <br />13efore me, If <br />the ojv day of <br />201 Premium Concrete <br />Company Name <br />712 Richmond St <br />Company Address <br />Elkhart, IN 46516 <br />City, State, Zip <br />ad Notary Public in and for said county and state, personally appeared ifAXY'r• 7L0.KEy 44 <br />and acknowledged hiCompletion Affidavit on <br />Notary Signaturk w I \` <br />Gti� ( J. l ay%s .__ <br />Printed Name <br />^�Eo CHERYL J TAYLOR <br />Notary Public, State of Indana <br />- Elkhart County <br />Commission N 61663ii <br />M y, Commission Expire_ <br />omrr teJM ExRir'MI 8 <br />03 �17�a O /d <br />( O <br />County of Residence <br />If the Contractor is a corporation, the following certificate will be executed. <br />I, 04a v A Vd 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 />[ den of said Corporation; that said release was duly signed for and on behalf of said <br />Corporation byhgfhority of its governing body, and is within the scope of corporate powers: <br />Secretary's Signature Corporate Seal <br />Mau A Ye 60Lkcs <br />Printed Name <br />DEPARTMENT OF PUBLIC WORKS APPROVAL <br />This project is acceptable or al approval and we recommend to the Board of Public Works that it be ordained so. <br />Date: <br />Construct n- tanager <br />BOARD OF PUBLIC WORKS APPROVAL Date: <br />Gary A. Gil resident uza na erg, M ber Elizabeth A Maradik, Member <br />n <br />Y. b%iL-o- <br />Therese J. Do(,au, Wmber James A. Mueller, Member A,i da M. Martin, Clerk <br />