Change Order No 1 & PCA - Century Center Skylight Beams Painting Proj No 117-004 - Ziolkowski Construction

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CITY OF SOUTH BEND, INDIANA BOARD OF PUBLIC WORKS PROJECT COMPLETION AFFIDAVIT PROJECT NAME Centug Center Skylight Beams Painting PROJECT NO 117-004 FINAL COST $118,759,22 CONTRACT SIGNED 11/14/2017 MAINTENANCE AGREEMENT ENDS PROJECT DESCRIPTION -Painting of interior and exterior skylight beams. WITNESSETH: 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. Executed this da of et 2Q1 Ziolkowski Construction, Inc. Company Name Signature 4050 Ralph Jones Drive RMCompany Address Printed Name South Bend, IN, 46628 City, State, Zip WITNESSESS: Before me, the undersigned Notary Public in and for said country and state, personally appeared MUIre Harniltorl and acknowledged his/her signature to the above Project Completion Affidavit on the day of _,�YL(AJL,, , 201 DEBRA L JOHNSON Sea] Notary Signature F My Commission Expires Notary Public - State of Indiana arsnall County My Commissars Expires Mar 27, 2024 Printed Name County of Residence If the Contractor is a corporation, the following certificate will be executed. 1, Charles Lewis certify that I am Secretary of the Corporation executing this release; that Mike Hamilton who signed this release on behalf of the contractor was then Divis—on, Manager of said Corporation; that said release was duly signed for and on behalf of said CorpWrn by A thorityyf Its governing body, and is within the scope of corporate powers: ' A& Z Secretary's Signature Corporate Seal Charles Lewis IN =I- NOR DEPARTMENT OF PUBLIC WORKS APPROVAL This project is acceptable forfin approval and we recommend to the Board of Public Works that it be ordained so. 0 Date: (, - I - I r, Construction &ger 1q, BOARD OF PUBLIC WORKS APPROVAL Date: /9" A - "a -A. Gilot-;'f5resicfe_6t Suzanna M. Fritzborg, Member Eliza *et� A. aradik, Member Therese J. rau, Member James A. Mueller, Member Linda M. Martin, Clerk