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SJY IH gg <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />PROJECT COMPLETION AFFIDAVIT ' .a; <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 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 />Execut d. fs ? nof 201Indiana Earth, Inc. <br />Company Name <br />nature 10343 McKinley Hwy <br />AAMV, DSLE� ^419�lfor Company Address <br />Printed Name f Osceola, In. 46561 <br />City, State, Zip <br />WITNESSESS: <br />Before me, the undersigned Notary Public in and for said country and state, personally appeared %%N111111111111 <br />tz <br />MA- 5 and acknowledged his/her signature to the above Project Completion Affida\v�,ABI.AIROS��'! <br />the day of 201�0, F.P <br />� � : a ?a9 ?fly 9'• <br />N Si nature �(ttl soAl N: <br />yA rY / My Commission Expires SEAL <br />-klclb��Al <br />Printed Name County of Residence ``' �� �'%P�o ":�SEPH "� <br />If the Contractor is a corporation, the following certificate will be executed. ��/�-STA����``� <br />/HI <br />I, M,V 12 � <br />tf nS LtR certify that I am Secretary of the Corporation executing this release; INA11aa� <br />M ,44 K Q S LaL who signed this release on behalf of the contractor was then <br />Corpo i <br />. of said Corporation; that said release was duly signed for and on behalf of said <br />py thority o�itaig9d?rning body, d is within the scope of corporate powers: <br />AA /17'.A.�SI.I:k I soc, <br />Printed Name <br />Corporate Seal <br />DEPARTMENT OF PUBLIC WORKS APPROVAL <br />This project is acceptable or final approval and we recommend to the Board of Public Works that it be ordained so. <br />�^ Date: t• l 8• l 4 <br />Constructi d1anager <br />BOARD/;OF PUBLIC WORKS APPROVAL Date: • 2 -% <br />v <br />Therese J. Dor u, Member Jam A. Mueller, Member <br />FA V <br />Elizabet A aradik, Member <br />ink a M. Martin, Clerk` <br />