Project Completion Affidavit - Century Center Kitchen Door Installation Project No 118-036B - Larson Danielson Construction Co Inc

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AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of LaPorte SS: .. F. . n (Name of Officer) •� • �• .... being duly sworn that he/she is the rest t a ��(Title) ........_ ... .—...... g_.... _ brsrucltaa Co.,Inc. o having contracted with Larson Danielson Co (Subcontractor/Supplier) _ (Contractor) to furnish certain materials and/or labor as follows: P � -B 0,o : IL ion (Description) Hall. for a project known as Cen,tur,y Cente ,m I a t cka to f?o Inst 114.ti,on m..�............ ..... (Name of Project) y Martin Luther King Jr Blvd South Bend, IN.446601 located at entur Center 20 S M and owned by __ .by_. !.; b.t .l.t.Lh__Be d.,_._1.tad (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 Sae,.v.._e..nteen Thousand, Nine Hundred Seventy —Five y.FiveDollars ($_.17 .9�5..�1 ............... ......... & 11/100 ❑ receipt of which is hereby acknowledged; or R1 1 a iw ® the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which sha`' 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 whatso vest ccnn on the above -described property and improvements thereon an account of labor or material or both, furnished b the undersigned � z thereto, subject to limitations or conditions expressed herein, if any; and further certified that no other party has any claim or rig $' to ts n lien on account of any work performed or material furnished to the undersigned for said project, and within the scope of this Aft'% avi8 z and Waiver of Lien. z m CD_.m.:.... l.sralattnasomal. Construction _C,.� Inc. BY ....." (Firm) (Authorized Representative) z STATE OF INDIANA ) Timothy F. Larson, President ' LaPorte ) SS: -S-'-JG&E ?H COUNTY ) Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Timothy F. Larson and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal on the 2 th day of January 20 ?019• Notary Publ' S ature My Commission Expires: February 11, 2024 679923 _.. �athE....A La Pone County Residing in .. LaPorte m County, Intla Notary Pubhi1a CATHYA SALE �k my My Commission Expires %'�'' February t1, 2024