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�'�yrre <br />CITY OF SOUTH BEND, INDIANA 77 <br />� al <br />BOARD OF PUBLIC WORKS <br />Y � <br />PROJECT COMPLETION AFFIDAVIT <br />PROJECT NAME Walnut Grove and North Riverside Drive Traffic Calming <br />PROJECT NO 119-071 FINAL COST $81,336.00 <br />CONTRACT SIGNED 8/22/2019 MAINTENANCE AGREEMENT ENDS <br />PROJECT DESCRIPTION Installation of speed humps at various locations throughout the Citv. <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 theaboveContract, <br />�C[ <br />Executed this S day of t 201 � Premium Concrete Service, Inc. <br />Company Name <br />4 <br />ignature <br />712 Richmond Street <br />0 <br />N <br />ci <br />MAx <br />Company Address <br />Printed Name <br />Elkhart, IN 46516 <br />Z <br />City, State, Zip <br />wU <br />Zz <br />O <br />H^ W <br />WITNESSESS: <br />Before the Notary <br />Q W <br />me, undersigned Public in and for said country and state, <br />personally appeared <br />ry)FF1p,X EA jC and acknowledged his/her signature to the above Project Completion Affidavit on <br />Wa u <br />� LD <br />the d 1 day of `PT 20'4 ac) <br />Z O <br />+ 9 <br />¢z <br />ZZ <br />002 <br />Nota Signature My Commission Expires <br />I <br />�� , 0- �� <br />tV)U <br />� � <br />�LoIJ �R <br />5o <br />Printed Name County of Residence <br />CL KA AR-7 <br />v <br />If the Contrar is a corporation, the following certificate will be executed. . <br />I, ct KjE , certify that I am Secretary of the Corporation executing this release, that <br />1C 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 i nature <br />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 />Date: 09/30/2020 <br />Constructia Manager <br />BOARD OF PUBLIC WORKS <br />Gary A. Gilot, President <br />Elizabeth A. Maradik, Member <br />7- <br />7-1-Joseph R. Molnar, Member <br />BOARD OF PUBLIC WORKS APPROVAL Date: October 27, 2020 <br />�e_dytrr�.u- <br />Therese J. Doran, Member <br />Jordan V. Gathers, Member <br />ATTEST: <br />z iNAa ol(" <br />Linda M. Martin, Clerk <br />