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.o�xiT�4 <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />PROJECT COMPLETION AFFIDAVIT � <br />PROJECT NAME 2020 Curb & Sidewalk (Divisions B1, B2, B3, C1 & D1) <br />PROJECT NO 120-001 FINAL COST $196 409.45 <br />CONTRACT SIGNED 5/26/2020 MAINTENANCE AGREEMENT ENDS <br />Remove and replace concrete sidewalk, concrete curb, ADA curb ramps, and concrete <br />PROJECT DESCRIPTION _approaches at various locations within the City of 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 />Executed thi, q day of ,PT, 201 Premium Concrete Services, Inc. <br />Company Name <br />Signature 712 Richmond <br />c <br />Company Address <br />¢ N <br />Printed Name Elkhart, IN 46516 <br />Z N <br />¢ j <br />City, State, Zip <br />Z a <br />WITNESSES: <br />wcc I <br />U O CO V_ <br />Before me, the undersigned Notary Public in and for said country and state, personally appeared <br />z i LL <br />xNtA Cam( and acknowledged his/her signature to the above Project Completion Affidavit on <br />OD J cn z <br />w <br />the .7 q'�h _day of j • 201 0��. <br />�a Q <br />W 4 � Z a 0 <br />Z O u�S v� <br />No4y Signature My Commission Expires <br /><z v 0 2 <br />'c! lC7l�vC1� <br />Q to U <br />Printed Name County of Residence ( <br />J O <br />If the Contract*acgrporation, the following certificate will be executed. <br />wUI, <br />Y certify that I am Secretary of the Corporation executing this release; th <br />>_ <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 />C�orpo�ra jon by Authority of its governing body, and is within the scope of corporate powers: <br />eS cretary's Signature <br />f' IkX Corporate Seal <br />Printed Name <br />DEPARTMENT OF PUBLIC WORKS APPROVAL <br />This project is acceptable for final approval and we recommend to the Board of Public Works that it be ordained so. <br />/b vz&d- Date: <br />Construction Manager <br />BOARD OF PUBLIC WORKS APPROVAL Date: October 27, 2020 <br />BOARD OF PUBLIC WORKS <br />Gary A. Gilm, President n — <br />Elizabeth A. Mmadik, Member <br />Joseph R. Molnar, Member <br />IKT i JJ_ <br />Therese J. Doraa, Member <br />Jordan V. Gathers, Member <br />ATTEST: <br />8c"Id6 CP4mtGr <br />Linda M. Martin, Clerk <br />