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CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />PROJECT COMPLETION AFFIDAVIT <br />PROJECT NAME -Miain Street at Washington Street Roadside Improvements <br />PROJECT NO 116-OOIA FINAL COST $107,461.50 <br />CONTRACT SIGNED 7/11/2017 MAINTENANCE AGREEMENT ENDS <br />Roadside improvements in the northwest quadrant of the intersection of Main Street & <br />PROJECT DESCRIPTION Washinaton Street. <br />The work under the above contract between the City of South Bend and the undersigned contractor having been completed, <br />the City of South Bend, its officials and agents are hereby released from all claims and demands whatsoever arising under or <br />by such contract, and that the contractor performed the work within the scope of the Specifications and Standards of the City <br />of South Bend which were a part of the above Contract, <br />4 <br />Ex ed, thi dgf 1201 -1 Premium Concrete Services, Inc. <br />Company Name <br />IR Z.- <br />Aidb t-ulre � 712 Richmond Street <br />Company Address <br />Printed Nam el Elkhart, IN' 46516 <br />City, State, Zip <br />WITNESSESS: <br />, Before methe undersigned Notary Public in and for ppeared <br />,5r :CX VCAXE V, and acknowledged his/her si t t?, VOFr Com letion Affidavit on <br />aNN'Sootary knitna <br />the t—f day of PfLELq&6JL, 201 '1 my 00m E; 1. KHART County <br />, s� "o, <br />My Commission Expires 0412412024 <br />Notary Signature My Commission Expires <br />A 1-,e I dLA 'aWC& S <br />Printed Name County of Residence <br />If the Contractor is a, cprpation, the following certificate will be executed, <br />I, ftv Ke-' Yt V certify that I am Secretary of the Corporation executing this release; that <br />L'4 who signed this release on behalf of the contractor was then <br />FIE �f We of said Corporation; that said release was duly signed for and on behalf of said <br />Corporation uthority of its governing body, and is within the scope of corporate powers: <br />$Wrd'Cry's Signature Corporate Seal <br />MAV! /�- <br />Printed Name <br />DEPARTMENT OF PUBLIC WORKS APPROVAL <br />This project is prova an acceptable for I rI d we recommend to the Board of Public Works that it be ordained so. <br />C <br />Date: <br />Construction V�9'Tger <br />Gary A. Gilot, President <br />BOARD OF PUBLIC WORKS APPROVAL Date: <br />S,uzanna M. Fritzberg, Member <br />Therese J. Derau, Mdtuber Jame A. Mueller, Member <br />Elizabeth A Maradik, Member <br />066 M. Martin, Clerk L <br />