PCA - Central Services Roof Replacement -Proj No 115-035 - Northern Indiana Roofing

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CONTRACTOR'S AND SUPPLIER'S AFFIDAVIT AND WAIVER OF LIEN X Final Partial Payment to follow The undersigned, being first duly sworn on his oath or affirming, states that: 1. Jan W. Sircey (name) is the President (Title) of Northern Indiana Roofing & Sheet Metal Corp. (Company), (hereinafter called "Company" of and is familiar with the facts herein stated and makes this affidavit for and on behalf of himself and the Company, being duly authorized to bid the Company by the Statements herein contained. 2. The Company having contracted with City of South Bend, has preformed work and labor or furnished materials supplies or equipment in the construction of certain improvement on the real estate commonly known as South Bend Central Services in South Bend (City), Indiana which real estate is owned by Cith of South Bend (hereinafter called "Owner"). 3. Company has, or will within 10 days of receipt of payment due from Owner noted in item 4, paid for all work, labor, materials, equipment, and supplies performed or furnished by it and by its subcontractors, material - men and supplies upon such premised or in connection therewith and no person, other than Company, has any claim or right to a lien for any work, materials or services on account of any transaction undertaken by Company with respect to said premises, except as specially noted below: Name of Company Amount Owed Explanation for Withholding Payment 4. The amount due Company from Owner: PARTIAL WAIVER that the balance due is the sum of. Dollars ($ receipt of which is hereby acknowledged, or, the payment of which is promised as the sole consideration for this Affidavit and Partial Waiver of Lien which is given to and for said amount, effective upon receipt of such payment. FINAL WAIVER that the final balance due is the sum of: Thirty -Five Thousand Three Hundred Ninety -Two and 80/100 Dollars ($ 35,392.80 ) receipt of which is hereby acknowledged, or, X the payment of which is promised as the sole consideration for this Affidavit and Partial Waiver of Lien which is given to and for said amount, effective upon receipt of such payment. THEREFORE, the undersigned waives and releases under the statutes of the state of Indiana, unto the Owner of said premises, any and all lies of claim whatsoever on the above -described property and improvements thereon account of LABOR or material or both, furnished by the undersigned thereto, and further certifies that no other party has any laim or right to a lies on account of any work performed or material furnished to the undersigned for said oject,/except as ted above, and within the scope of this affidavit and waiver. By: !�✓ Title: President WITNESS MY HAND AND NOTARIAL SEAL, this 2nd day of Au¢ust, 2016. My Commissio xpires: Aril 3, 2018 County of Residence: Allen (Not ub