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CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />PROJECT COMPLETION AFFIDAVIT <br />PROJECT NAME <br />PROJECT NO. <br />CONTRACT <br />SIGNED <br />PROJECT <br />DESCRIPTION <br />Star Liquc <br />DP22-018 <br />October 11, 2022 <br />Utility Extension <br />FINAL COST $86,700.00 <br />MAINTENANCE AGREEMENT ENDS N/A <br />WITNESSETH: <br />The work under the above contract between the City of South Bend and the undersigned contractor having <br />been completed, the City of South Bend, its officials and agents are hereby released from all claims and <br />demands whatsoever arising under or by such contract, and that the contractor performed the work within the <br />scope of the Specifications and Standards of the City of South Bend which were a part ofthe above Contract. <br />Si aa�fi} <br />Printed Name <br />WITNESSES <br />20th day of June, 2025. <br />THOMAS PATRICK BURNS <br />Notary Public - Seal <br />Allen County - State of Indiana <br />Commission Number NP0664834 <br />My Commission Expires Mar 2, 2031 <br />Burns Distributing Co., Inc. <br />Company Name <br />140 Green Dr <br />Company Address <br />Avilla, IN 46710 <br />City/State/Zip <br />Before me, the undersi for said country and state, personally <br />appeared Cory tx-o, , - ,,y,. , and acknowledged his/her signature to the above Project Completion <br />Affidavit on the fir, day of Jam,, �, , 20 aS <br />Notary Si afore My Commission Expires <br />2 v�'v, � til <br />1 U 3 I <br />�� <br />Printed Name County of Residence e v� <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 <br />ordained so. <br />&A CITY OF BOARD O SOUTH <br />PUBLIC C WORKS <br />Cons tion Manager tu�a 1�ozm <br />Elizabeth A. Maradik, President <br />Gary A. Gilot, Member <br />Joseph R. Molnar, Vice President <br />BreanaMjicou�,,/Member <br />`�C U f aA✓X&L, <br />Murray L. Miller, Member <br />Attest: Hillary R. Horvath, Clerk <br />Date: July 8. 2025 <br />