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may result in forfeiture of contractual payments. <br />I hereby affirm under the penalties of perjury that the facts and information contained in the foregoing bid <br />for public works are true and correct. <br />Dated this <br />20th day of 18 <br />..._._._......._._._.. , <br />fCARwgy E <br />CARBON DANIELSON <br />sEat f CON TRUCTION CO, INC. <br />Larson Danielson Construction Co., Inc. <br />Contractor/Bidder (Firm) <br />X <br />Signature of Contractor/Bidder or Its Agent <br />Timothy F. Larson, President <br />Printed Name and Title <br />Subscribed and sworn to before me this loth day of, December % 20 18 <br />My Commission Expires 9/ 8/ 2 3 X <br />Notary Public <br />Michele C. Dzielinski <br />County of Residence LaPorte <br />MICHELE CECELIA DZIELINSKI <br />La Porte County <br />E-. <br />My Commission Expires <br />September 8, 2023 <br />