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CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />PROJECT COMPLETION AFFIDAVIT <br />PROJECT NAME Jefferson Alley Repair <br />PROJECT NO 124-048 FINAL COST $27,243.52 <br />CONTRACT SIGNED 8/16/2024 MAINTENANCE AGREEMENT ENDS <br />Full depth resonstruction of the alley north of Jefferson BLVD between Williams and <br />PROJECT DESCRIPTION Franklin <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 />D2 Premium Concrete Services <br />WITNESSESS: ' l <br />the day of �� �I 12024 <br />Not y Signature My Commission Expires <br />AN)ECO) TWMER <br />Printed Name County of Residence <br />Company Name <br />712 Richmond St <br />Company Address <br />Elkhart, IN 46516 <br />City, State, Zip <br />oaI p,Iac�aq <br />ELK Air <br />If th Contractor is a corporation, the following certificate will be executed. <br />I, � #& N Ihti , certify. that I am Secretary of the Corporation executing this release; that <br />f Yin L yin I11m who signed this release on behalf of the contractor was then <br />PYCS i� of said Corporation; that said release was duly signed for and on behalf of said <br />Corporation by Aut •ity of its governing body, and is within the scope of corporate powers: <br />Secretary' ignature Corporate Seal <br />Printed Name <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 />&I Date: 11 /18/2024 <br />Constr tion Manager <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />tjW�k <br />Elizabeth A. Maradik, President <br />Gfs�`i(at <br />Gary A. Gilot, Member <br />Murray L. Miller, Member <br />M, <br />Joseph R. Molnar, Vice President <br />Blria�na MMiicou, Member <br />I ' " /` <br />Attest: Theresa M. Heffner, Clerk <br />Date: November 26, 2024 <br />N <br />O <br />Q N <br />¢C" <br />n <br />Zorn <br />LL2C') <br />O cao <br />ZJ W W <br />Co I-- U- <br />�Oa B(D W Z <br />2Q N Q O <br />Wg Z X U) <br />QZ OZM <br />-� UO2 <br />�— Fn O <br />QrnU <br />W Q <br />WV <br />