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;rtiMrre �n CITY OF SOUTH BEND, INDIANA °� <br />BOARD OF PUBLIC WORKS <br />PROJECT COMPLETION AFFIDAVIT <br />PROJECT NAME Ziker Sample Stret Buildin : Restroom Remodel <br />PROJECT NO 117-123 FINAL COST $19„978.00 <br />CONTRACT SIGNED 8/14/2018 MAINTENANCE AGREEMENT ENDS <br />PROJECT DESCRIPTION Remodel and installation of one new restroom, <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 />the , f Executed d <br />0 South Bend whichwhichwere o <br />part f e above Contract <br />201 _f Premier 1 Construction, Inc. <br />Company Name <br />Signature 105 E. Jefferson Blvd, Suite 216 <br />Company Address <br />Printed Name South Bend, IN 46601 <br />City, State, Zip <br />WITNESSETS: <br />Before me, the undersigned Notary Public in and for said country and state, personally appeared <br />and acknowledged his/her signature to the above Project Completion Affidavit on <br />the... _4�'i1 day of 0 201_1 <br />to A <br />Siggnature 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 />Tdla kNl id 1'wl Mile Notary Secretary's Signature "��" — %�"� <br />Public <br />" Corti n. �Expires <br />Aires ng 3�.1,, 202�orporate Seal 1 Rosides ln& 1osepl, ccw., IN <br />• Comniu Nua tm 67237 Printed Name <br />DEPARTMENT OF PUBLIC WORKS APPROVAL <br />This project is acceptable for in pproval and we recommend to the Board of Public Works that it be ordained so. <br />Date: - 1 <br />Construction ger <br />BOARD OF PUBLIC WORKS APPROVAL Dater <br />Gary A. Gilot, President Suzanna M. Fritzberg, Member Eliza eth , a;radik, Member <br />M <br />Therese J. D rau, M67i5ber H James A. Mueller, Member I_' daM. Martin, Clerk <br />