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PROJECT NAME <br />PROJECT NO <br />CONTRACT SIGNED <br />PROJECT DESCRIPTION <br />WITNESSETH: <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />PROJECT COMPLETION AFFIDAVIT <br />Curb and Sidewalk Round 1 (Div 3 + 4 + 5) <br />001122- FINAL COST $403,537.98 <br />7/26/2022 MAINTENANCE AGREEMENT ENDS <br />Curb and Sidewalk replacement at various locations <br />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. <br />Executed this � ay of � , 2ai:3____ Premium Concrete Services, Inc. <br />Signature tla.� Yea�1 Printed Name <br />Company Name <br />712 Richmond St. <br />Company Address <br />Elkhart, IN 46516 <br />City, State, Zip <br />WITNESSESS: <br />Before (TI/::, the undersigned Notary Public in and for said country and state, personally appeared ffif\£_ ::LE'S KE'( _.: and acknowledged his/her signature to the above Project Completion Affidavit on <br />the 0 tf\ day of ..JU �F , 2ofi__. <br />�� My Commissioo E,pirns �) ;J.. [JDJ_� 3ANt:�Tow0tg_ C, YlJ � o--1 Printed Name County of Residence !,..L��=-L..::,i..J....!..n.L..C�"'-..1--------- <br />lf th,1,Contractor is a corporation, the following certificate will be executed. <br />I, /:>lCll'4 Y@Y,tlJ , certify that I am Secretary of the Corporation executing this release; that a � who signed this release on behalf of the contractor was then <br />' ,.., -of said Corporation; that said release was duly signed for and on bel1alf of said <br />ng body, and is within the scope of corporate powers: <br />Corporate Seal <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 />Construction Manager <br />Elizabeth A. Maradik, President <br />Gary A. Gilot, Member <br />Date: --------- <br />BOARD OF PUBLIC WORKS APPROVAL Date: ________ _ <br />Jordan V. Gathers, Member <br />Murray L. Miller, Member <br />Joseph R. Molnar, Member <br />Anne Fuchs, Clerk <br />JANEE M TOWNER NOTARY PUBLIC <br />SEAL ELKHART COUNTY, STATE OF INDIANA <br />MY COMMISSION EXPIRES FEBRUARY 12, 2026 <br />COMMISSION NO. 710399 November 14, 2023