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Q_0UTf) @4 <br />CITY OF SOUTH BEND, INDIANA r <br />BOARD OF PUBLIC WORKS <br />PROJECT COMPLETION AFFIDAVIT <br />Iu5 <br />PROJECT NAME Curb and Sidewalk <br />PROJECT NO 122- 001 FINAI COST. 403 537 98 <br />CONTRACT SIGNED 719619099 MAINTENANCEMAIWIENANCE AGREEMENT ENDS <br />PROJECT DESCRIPTION Qjrh 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 ofthe above Contract. <br />JExecuted this 5q ay of— unL , 2aJ _Premium Concrete Services, Inc. <br />Company Name <br />Signature 40r 712 Richmond St. <br />Xp&keu Company Address <br />Printed Name Elkhart, IN 46516 <br />City, State, Zip <br />WITNESSESS: <br />Before rnie, the undersigned Notary Public in and fo <br />MNK ItA KEN and acknowledged his/her <br />the_ -day of l Ili 20,D_�,_. <br />No ary Signature <br />Printed Name <br />r said country and state, personally appeared <br />signature to the above Project Completion Affidavit on <br />My Commission Expires <br />County of Residence <br />If th�,Contractor is a corporation, the following certificate will be executed. <br />Ick- V Y. certify that I am Secretary of the Corporation executing this release; that <br />'iuy , who signed this release on behalf of the contractor was then <br />VI �•.�r r1r1r10rA - of said Corporation; that said release was duly signed for and on behalf of said <br />R0rp`ora`)on byAAuthoriyJof 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 />Date: <br />Construction Manager <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />-lea <br />Elizabeth A. Maradik, President <br />Gary A. Gilot, Member <br />774, 4 <br />Murray L. Miller, Member <br />Joseph R. Molnar, Vice President <br />Alexandra Dolz-Lane, Member <br />yrk�� <br />Attest: Theresa M. Heffner, Clerk <br />Date: November 14, 2023 <br />JANEE MTOWNER <br />NOTARY PUBLIC <br />SEAL <br />ELKHART COUNTY, STATE OF INDIANA <br />MY COMMISSION EXPIRES FEBRUARY 12, 202 <br />COMMISSION NO.710399 <br />