Project Completion Affidavit - 2017 Infrared Asphalt Pavement Patching Proj No 117-074 - Asphalt Restoration Services LLC

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CITY OF SOUTH BEND, INDIANA BOARD OF PUBLIC WORKS PROJECT COMPLETION AFFIDAVIT PROJECT NAME 20�17 Infrared Asphalt Pavement Patching PROJECT NO 117-074 FINAL COST $57,250,00 CONTRACT SIGNED 7111/2017 MAINTENANCE AGREEMENT ENDS The placement and finishing of asphalt pavement patches by infrared methods and all other PROJECT DESCRIPTION necessary work on various streets within the Citv of South Bend. LTN",1TNzMA:11W The work under the above contract between the City of South Bend and the undersigned contractor having been completed, the City of South Bend, its officials and agents are hereby released from all claims and demands whatsoever arising under or by such contract, and that the contractor performed the work within the scope of the Specifications and Standards of the City of South Bend which were a part of the above Contract, Exe d this day of n—, 201, Asphalt Restoration Services, LLC. Company Name lf�ignature PO Box2484 Company Address Printed Name South Bend, IN 46680 City, State, Zip WITNESSESS: Before me, the, undersigned Notary Public in and for said country and state, personally appeared . and acknowledged his/her signature to the above Project Completion Affidavit on the 41 day of &��, 201 Cd" mt&�— Notary Signature My Commission Expires ir&�, Printed Name County of Residence -15 4 , . �" If the Contractor is a corporation, the following certificate will be executed. certify that I am Secretary of the Corporation executing this release; that who signed this release on behalf of the contractor was then of said Corporation; that said release was duly signed for and on behalf of said Corporation by Authority of its governing body, and is within the scope corporatewmM, MOORE Not" Public - State of Indiana SEAL Secretary's Signature Commission Number: 682645 orporate Seal MY Commission Expires May 6 2024 Printed Name DEPARTMENT OF PUBLIC WORKS APPROVAL This project is acceptable for fi, I approval and we recommend to the Board of Public Works that it be ordained so. &A Date: IZ, - V7 Constructi Eger B R OF PUI�LIC WORK APPROVAL Date: 31,, OA UV_ A L P I IM Gary A. Gilot, P'risi&ent Suzahna M. Frberg-, Meiriber Elizabeth A Maradik, Member ... .... . . . . . . . T'lierese J, Dorad, M6mber James A, Mueller, Member �,4QLid a M.