Change Order No 1 & PCA - 2020 Curb & Sidewalk, Divisions B1, B2, B3, C1, and D1 Proj No. 120-001 - Premium Concrete Services, Inc.

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PROJECT NAME PROJECT NO CONTRACT SIGNED CITY OF SOUTH BEND, INDIANA BOARD OF PUBLIC WORKS PROJECT COMPLETION AFFIDAVIT 2020 Curb & Sidewalk (Divisions B1, B2, B3, C1, & 01) 120-001 FINAL COST $196,409.45 5/26/2020 MAINTENANCE AGREEMENT ENDS PROJECT DESCRIPTION WITNESSETH: Remove and replace concrete sidewalk, concrete curb, ADA curb ramps, and concrete approaches at various locations within the City of South Bend. 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. E,ec;z9-\:II day of :':£PT. . 201 di) Signature YY\A) \(EJ\ K..E\.) Printed Name WITNESSES: Premium Concrete Services, Inc. Company Name 712 Richmond Company Address Elkhart, IN 46516 City, State, Zip Before me, the undersigned Notary Public in and for said country and state, personally appeared rn:Ax'\1£.AK.E'-( , and acknowledged his/her signature to the above Project Completion Affidavit on the J,'1•-rl\ day of �I-, 201_.aa_.cw\.ti.,("\ -�Not y Signature J\N£Ef'\1bQN� Printed Name My Commission Expires County of Residence If the Contractor is a corporation, the following certificate will be executed. I, (Y\A��AKF:'-\ , certify that I am Secretary of the Corporation executing this release; th t �--�� who signed this release on behalf of the contractor was then .__ ______ , . of said Corporation; that said release was duly signed for and on behalf of said Corpora ion by Authority of its governing body, and is within the scope of corporate powers: ecretary's Signature «\Ai �tAK.E'-/ Printed Name Corporate Seal DEPARTMENT OF PUBLIC WORKS APPROVAL This project is acceptable for final approval and we recommend to the Board of Public Works that it be ordained so. 7it£, V � Date: ______ _ Construction bf anager BOARD OF PUBLIC WORKS APPROVAL Date: _________ _ Gary A. Gilot, President Jordan Gathers, Member Elizabeth A. Maradik, Member Therese J. Dorau, Member Joseph Molnar, Member Linda M. Martin, Clerk October 27, 2020