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CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />PROJECT COMPLETION AFFIDAVIT y <br />PROJECT NAME <br />PROJECT NO <br />CONTRACT SIGNED <br />PROJECT DESCRIPTION <br />2022 Signal Knock Down & Wiring Investigation <br />122 046 FINAL COST $50,000.00 <br />7/26/2022 MAINTENANCE AGREEMENT ENDS <br />On -Call contract to repair signal knock downs and intersection wiring <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 part of the above Contract. <br />!xe�cutdqy�. of 1 s`{' , 202 zaL JBL Signals and Lighting LLC <br />09— Company Name <br />S nature 4316 Technology Dr. <br />TANNER LEIBOVITZ Company Address <br />Printed Name <br />South Bend, IN 46628 <br />City, State, Zip <br />WITNESSESS: <br />Before me, the undersigned Notary Public in and for said country and state, personally appeared <br />, and acknowledged his/her signature to the above Project Completion Affidavit on <br />the l � day of ,� 202 <br />_?fotary Stgnaature My Commission Expires <br />b e—:b rc— lA b& n s )u <br />Printed Nime County of Residence <br />If the Contractor 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 />Printed Name <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 />&(A Z_aG 6y- Date: 5/2/2024 <br />Cobitruction Manager <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />ta�a <br />Elizabeth A. Maradik, President <br />�� Gfv}L(ito� <br />Gary A. Gilot, Member <br />,-,k� 4 , <br />Murray L. Miller, Member <br />�i, I <br />Joseph R. Molnar, Vice President <br />Briana Micou, Member <br />Attest: Theresa M. Heffner, Clerk <br />Date: May 14, 2024 <br />✓lm�y <br />Debra A Urbanski <br />Notary Public Seal State of Indiana <br />St. Joseph County <br />Commission 0 NP0732273 <br />My Commission Expires 03/09/2029 <br />