PCA - Olive Road Lighting over the Indiana Toll Road Proj No 115-124 - Michiana Contracting, Inc.

Home Browse Search

State of Indiana, County of AFFIDAVIT AND WAIVER OF LIEN Marshall SS: Scott Wallsmith being duly sworn that lie/she is the President (Name of Officer) (Title) of Michiana Contracting having contracted with City of South Bend (Contractor) (Owner) to furnish certain materials and/or labor as follows: Lighting over Indiana Toll Road (Description) for a project known as Olive Lighting over Indiana Toll Road (Name of Project) located at Olive Street and owned by City of South Bend and does hereby further state on the behalf of the aforementioned subcontractor/supplier: (PARTIAL WAIVER) that there is due from the Contractor the sum of Dollars ($ ) ❑ receipt of which is hereby acknowledged; or ❑ the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which is given solely with respect to said amount, and which waiver shall be effective only upon receipt of payment thereof by the undersigned; (FINAL WAIVER) that the final balance due tiom the contractor is sum of Five Thousand Five Hundred Twenty —Three Dofirms ($5,523.7)4 nd Seventy —Four Cents ❑/ receipt of which is hereby acknowledged; or lw the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which shall become effective only upon receipt of such payment, THEREFORE, the undersigned waives and releases unto the Owner of said premises, any and all liens or claims whatsoever on the above -described property and improvements thereon an account of labor or material or both, furnished b the undersigned thereto, subj act to limitations or conditions expressed herein, if any; and further certified that no other party has any claim or right to a lien on account of any work performed or material furnished to the undersigned for aid project, and within the sco this Affidavit and Waiver of Lien. Michiana Contracting, -Inc.. By _ (Finn) (Authorized Representative) STATE OF INDIANA ) ) SS: ST. JOSEPH COUNTY ) Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared _S c o tt Wallsmith and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my off�cial pal on the9t_ e h day of March 200 2017, otary Public i atm•e My Commission Expires: March27, 2022 A dreg J��OR�A�HSHEA I n d i aM4_ Marshall Notar Pu i • - =1ndiana l Residing in County, NotLPublie2