Project Completion Affidavit - Engineering Office Improvements Project No 118-107 - Ziolkowski Construction Inc

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AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of St Joseph SS:. Bill Favors being duly sworn that he/she is the President & CFO (Name of Officer) (Title) of Construction, Inc having contracted with City of South Bend, Indiana Io ow (ki Construction, Ipp • ) � ITITITITmm ..... Subcontractor/Su leer (Contractor) PCR # 1-Delete Door PCR #2-New Vault Door PCR # 3-Add Power Outlets to furnish certain materials and/or labor as follows: PCR #4-Add Ethernet Ports (Description)_..-...._��.....................m.- for a project known as Engineering Office Improvements - Project Number 118-107 (Name of Project) located at 13th Floor County City Building and owned by City of South Bend, Indiana (Owner) ._.._........_�._.... 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 from the contractor is the sum of Nine Thousand Two Hundred ThI.rt Three apd 00/100$ 9�23300 ❑ receipt of which is hereby acknowledged; or ❑X 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, subject 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 said project, and within the scope of this Affidavit and Waiver of Lien. Ziolkowski Constructin, Inc By Bill Favors (Firm) ._.. (Author W.....� .�.____. _ ............_....�.... ized Representative) STATE OF INDIANA ) SS: ST. JOSEPH COUNTY ) Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Bill Favors and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN WITNESS WHEREOF, T have hereunto subscribed my name and affixed my official seal on the 23rd day of January, 2019 290 Notary Public S" My Commission Expires: March fr, 2025 Lynn D. Vining Elkhart County, Indiana of c Residing in Co>.m Notary Ptrb�hc h+alte LYNN DVINING Seal CM,)tavy pa jh c - si atte apt Indiana Flktiao t cotlffty Myt:aairmr 55ton bp�[e$ Mar 6, 20 5