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V <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />PROJECT COMPLETION AFFIDAVIT <br />PROJECT NAME -Specialty Pavement Markings <br />PROJECT NO 117-039 FINAL COST $20,620.26 <br />CONTRACT SIGNED, 6/27/20l17 MAINTENANCE AGREEMENT ENDS <br />Restri:lpe existing transverse and specialty pavement markings within the City of <br />PROJECT DESCRIPTION South Bend. <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 ail 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 />Executed 201 DBL Services, Inc. <br />It d thi� AU��. day of Company Name <br />Signature 1811 N. Clover Rd. <br />0 L, Company Address <br />Printed Name Mishawaka, IN 46545 <br />City, State, Zip <br />WITNESSESS: <br />Before me, the undersi ed Notary Publilic in and for said country and state, personally appeared <br />l r D L <br />IT, and acknowledged his/her signature to the above Project Completion Affidavit on <br />the 5 f/A day of be,e,&Mh,,C -, 2017 . ....... . <br />My Commission Expires <br />Notary Signature A'vii <br />fu <br />Printed Name County of Residence J#se-vk <br />I <br />If the Contractor is a corporation, the following certificate will be executed. <br />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 />Corr) ration by Authority of its governing body, and is within the sc of Coll, r Doriii:: to ol <br />c <br />MEREDITH REIF <br />14wary Public, State of Indiana <br />Saint Joseph County <br />Secretary's Signature SEA Commission # 639359 Corporate Seal <br />My Commission Expires <br />mOctober23,F202O <br />Printed Name <br />DEPARTMENT OF PUBLIC WORKS APPROVAL <br />This project is acceptable fo fi I approval and we recommend to the Board of Public Works that it be ordained so. <br />�T I Date: <br />Construction a * <br />Gary A. Gilot, President <br />Th6rese J. Dora,u, Meifiber <br />BOARD OF PUBLIC WORKS APPROVAL Date: I, ) 2, ( L (-,) I � <br />Suzanna M. Fritzberg, Member Elizabeth A Ivlaradik, Member <br />