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BENJAMIN MARLATT <br />Notary Public <br />State of Indiana <br />Commission No. 711569 <br />E s <br />My Commission xplre CITY OF SOUTH BEND, INDIANA r <br />March 22, 2026'� <br />PROJECT NAME <br />PROJECT NO <br />AGREEMENT SIGNED <br />PROJECT DESCRIPTION <br />WITNESSETH: <br />BOARD OF PUBLIC WORKS .# ;� <br />PROJECT COMPLETION AFFIDAVIT ' <br />FINAL CO V-p Q+& <br />The work under the above agreement between the City of South Bend and the undersigned owner having been completed, <br />the City of South Bend, its officials and agents are hereby released from all claims and demands whatsoever arising under <br />or by such agreement, and that the owner performed the work within the scope of the Specifications and Standards of the <br />City of South Bend which were a part of the above agreement. <br />Executed this Z` day of <br />Company Name <br />Signat a SVb <br />Company Address <br />Printed Name �t n�`-�CU UCy- A , �3 Oy 0� <br />City, State, Zip <br />WITNESSES: <br />Be1re me, the undersigned Notary Public in and for said country and state, personally appeared <br />.► 11 OQ V-, Q' et and acknowledged his/her signature to the above Project Completion Affidavit on <br />the 2&"L Py of ZoZ� <br />Nota re My Commission Expires `vlA C' -w 2'Z, Zouo <br />Printed Name County of Residence <br />If the owner is a corporation, the following certificate will be executed. <br />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 <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: <br />Construction Manager <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />taa 101-1rt <br />Elizabeth A. Maradik, President <br />Gary A. Gilm, Member <br />Murray L. Miller, Member <br />Joseph R. Molnar, Vice President <br />Jo``rrd�danV. Gathers, Member <br />Attest: Theresa M. Heffner, Clerk <br />Date: June 27, 2023 <br />