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440,, <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />PROJECT COMPLETION AFFIDAVIT <br />PROJECT NAME 2017 Crack Sealing <br />PROJECT NO 117-102 FINAL COST $85,000.00 <br />CONTRACT SIGNED MAINTENANCE AGREEMENT ENDS <br />Perform asphalt crack sealing and filling services at various locations throughout theCityof <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 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 />Exec ed this day of ✓ 201 Asphalt Restoration Services, LLC <br />Company Name <br />Exec <br />PO Box2484 <br />C, /3 rot Company Address <br />Printed Name South Bend, IN 46680 <br />City, State, Zip <br />WITNESSESS: <br />Before me, the undersigned Notary Public in and! for said country and state, personally appea e RYAN P. SOUSLEY <br />,and acknowledged his/her signature to the above Project Corr o[etioNoWfyVWUjqDnsta1e of Indiana <br />SEAL <br />the day of 1 201 Commission Number: 682754 <br />My Commission Expires April 9, 2024 <br />N�ota My Commission Expires <br />Printed Name County of Residence <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 />Corporation by Authority of its governing body, and is within the scope of corporate powers: <br />Secretary's Signature <br />Printed Name <br />Corporate Seal <br />DEPARTMENT' OF PUBLIC WORKS APPROVAL <br />This project is acceptable for approval and we recommend to the Board of Public Works that it be ordained so, <br />Date: f8 <br />Construction ylager <br />BOARD OF PUBLIC WORKS APPROVAL Date: 6,1� (VT <br />Gary A. Gilot, President Suzanna M. Fritzberg, Member ET1—za-6eth7A.'Mh-r- ik, Member <br />Therese J. Dorau, Member Ja s A. Mueller, Member 'Cida M. Martin, Clerl� <br />