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I <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />PR03ECT COMPLETION AFFIDAVIT <br />PROJECT NAME 2023 Microsurfacin <br />PROJECT NO 123-023 FINAL COST $97,960.00 <br />CONTRACT SIGNED 7/11/2023 MAINTENANCE AGREEMENT ENDS <br />PROJECT DESCRIPTION Asphalt Microsurface, surface prep and a lication <br />WITNESSETH: <br />The work under the above contract between the City of South Bend and the undersigned contractor having been <br />completed, the City of South Bend, its officials and agents are hereby released from all claims and demands whatsoever <br />arising under or by such contract, and that the contractor performed the work within the scope of the Specifications and <br />Standards of the City of South Bend which were a pan of the above Contract. <br />Executed this day of k 41,ib E , 202 3 National Pavement Maintenance <br />Company Name <br />Signature <br />Printed Name <br />_1928 N Campbell Ave. <br />Company Address <br />Indianapolis, IN 46218 <br />City, State, Zip <br />WITNESSESS: <br />Before me, the undersigned Notary Public in and for said country and state, personally appeared <br />. IM Gr ' M, and acknowledged his/her Si etion Affidavit on <br />CURT S PICKARD <br />the day o S' 02 Notary Public • Seal <br />Marion County - State of Indlana <br />4 Commission Number WP0744 96 <br />Notary Signature C'�tSi4fIfj oct 27, �30� 103 uy <br />Printed Name County of Residence AA A-e r3 <br />If the Contractor is a corporation, the following certificate will be executed. <br />l 4(] (t 1 E W „tA )N AJ certify that i am Secretary of the Corporation executing this release; that <br />(� A, iz rl j.{ �y ; u 4 who signed this release on be of the contractor was then <br />Si-(2 f { r, 1t.1 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 Si ature 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: 10/2/2023 <br />con <br />vrction Marta r <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />1 <br />Elizabeth A. Maradik, President <br />Gary A. Gilot, Member <br />d� r <br />Joseph R. Molnar, Vice President <br />Alexandra Dolz-Lane, Member <br />K�J4 <br />Murray L. Miller, Member <br />Attest: Theresa M. Heffner, Clerk <br />Date: October 10.2023 <br />