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� *w4B41A Jf Po��✓h <br />CITY OF SOUTH BEND, INDIANA, <br />BOARD OF PUBLIC WORKS 41�. " = S <br />PROJECT COMPLETION AFFIDAVIT " <br />PROJECT NAME Ziker Sample Street Building Restroom Remodel <br />PROJECT NO 117-123A FINAL COST $45,976.00 <br />CONTRACT SIGNED 1/22/2019 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 />of South Bend which were a part of the above Contract. <br />Ex e this day of AA Premier 1 Construction <br />Company Name <br />Signature 105 E. Jefferson Blvd Suite 216 <br />Ifiv M v Company Address <br />Printed Name South Bend, IN 46601 <br />City, State, Zip <br />WITNESSESS: <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 />theday f 201�_. <br />o <br />NotarySignature My Commission Expires <br />( *- AA��--� <br />Printed Name County of Residence <br />If the Contractor is a corporation, the following certificate will be executed. <br />I, 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 C(SL <br />m 'Wf Ifta I <br />"0Corporate Seal <br />g I ,;AS, o.� IN <br />Printed Name Comm. Idiom 612V? <br />DEPARTMENT OF PUBLIC WORKS APPROVAL <br />This project is acceptable for firms pproval and we recommend to the Board of Public Works that it be ordained so. <br />Date: <br />Construction ger <br />P� <br />Iq <br />BOARD OF PUBLIC WORKS APPROVAL Date: <br />Gary A. Gilot, President Ge eve E, M1llpr-;M4berElizabeth A. Maradik, M'ern 11 <br />Therese J. Dorau, Member <br />O'Sullivan, <br />Linda M. Martin, Clerk 1Ang <br />