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Q_0 TM F4 <br />CITY OF SOUTH BEND, INDIANA r <br />BOARD OF PUBLIC WORKS <br />PROJECT COMPLETION AFFIDAVIT <br />PROJECT NAME Curb and Sidewalk Round 1 Div 3 + 4 + 5 <br />PROJECT NO 122-001 FINAL COST $393,685.00 <br />CONTRACT SIGNED 7/26/2022 MAINTENANCE AGREEMENT ENDS <br />PROJECT DESCRIPTION Curb and Sidewalk replacement at various locations <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 oflthe <br />—above Contract. <br />Executed this y of d�V- 2033 Premium Concrete Services, Inc. <br />Company Name <br />Signature / 712 Richmond St <br />XP&Eeu _ <br />Printed Name <br />Company Address <br />Elkhart, IN 46516 <br />City, State, Zip <br />WITNESSESS: <br />Before the undersigned Notary Public in and f <br />_MNi K and acknowledged his/her <br />the day of )(;_ 20D <br />qN ary Signature <br />&) OC <br />Printed Name <br />r said country and state, personally appeared <br />signature to the above Project Completion Affidavit on <br />My Commission Expires a ) a I "loa. <br />County of Residence ELrii A �_ i <br />If th Contractor is a corporation, the following certificate will be executed. <br />I, ck-a vacht certify that I am Secretary of the Corporation executing this release; that <br />_41Q w �!� ►�, who signed this release on behalf of the contractor was then <br />0110— �..,.-ae alp of said Corporation; that said release was duly signed for and on behalf of said <br />ira)on by AuthoriWof it§ govelning body, and is within the scope of corporate powers: <br />Printed <br />DEPARTMENT OF PUBLIC WORKS APPROVAL <br />Corporate Seal <br />This project is acceptable for final approval and we recommend to the Board of Public Works that it be ordained so. <br />/lid �ut- Date: 6/12/2023 <br />Consoction Manager <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />Elizabeth A. Maradik, President <br />Gary A. Gilot, Member <br />Murray L. Miller, Member <br />�pl <br />Joseph R. Molnar, Vice President <br />Jorrdd�ann V. Gathers, Member <br />Attest: Theresa M. Heffner, Clerk <br />Date: June 27, 2023 <br />JANEE MTOWNER <br />NOTARY PUBLIC <br />SEAL <br />ELKHART COUNTY, STATE OF INDIANA <br />MY COMMISSION EXPIRES FEBRUARY 12, 2026 <br />COMMISSION NO, 710399 <br />