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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of La Porte SS: <br />math F. Larson ,.•. _........ being duly sworn that he/she is the President <br />(Name of Officer) (Title) <br />of %-- ' having contracted with Larson=Danielson Construction Co., Inc. <br />(Subcontractor/Supplier) (Contractor) <br />to furnish certain materials and/or labor as follows: Morris Theater Mezzanine Handrails <br />(Description) <br />for a project known as 211 N. Michigan Street, South Bend, IN 46601 <br />- -----, (Name of Project) <br />located at <br />City of South Bend Indiana Board of Public Works <br />and owned by <br />_ _. ... <br />(Owner) <br />and does hereby further state on the behalf of the aforementioned subcontractor/supplier: <br />(PARTIAL WAIVER) that there is due from the Contractor the sum of <br />Dollars <br />❑ receipt of which is hereby acknowledged; or <br />❑ the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which is given <br />solely with respect to said amount, and which waiver shall be effective only upon receipt of payment thereof by the <br />undersigned; <br />(FINAL WAIVER) that the final balance due from the contractor is the sum of <br />Fz.gAy ;ml Vie.... ousand. Y9_.. m_ndJgd _,Ty?.nt"!v and �_...0�... <br />Elreceipt of which is hereby acknowledged; or00/100 <br />)A <br />C <br />© the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien whi <br />become effective only upon receipt of such payment. <br />THEREFORE, the undersigned waives and releases unto the Owner of said premises, any and all liens or claims mai " v'8 <br />on the above -described property and improvements thereon an account of labor or material or both, furnished b the undersi ed <br />thereto, subject to limitations or conditions expressed herein, if any; and further certified that no other party has any claim c I rio tip <br />lien on account of any work performed or material furnished to the undersigned for said project, and within the scope of dfl Afl2aFm <br />and Waiver of Lien. c-) <br />o ZO <br />n Co., Inc. B i <br />STATE OFINDIAN (Firm)nstructio Y <br />ta�horr'zed Representative) <br />A ) Timothy F. Larson, President <br />LAPORTE ) SS: <br />)�MOXX COUNTY ) <br />Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Timothy F . Larson <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. __................. _ _....W__. - <br />IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal on the 13 th day of <br />..... bruary...... ­­­)m 2olq_ <br />Notary Publi ignature <br />M Commission Ex ices: February 11, 2024 <br />Y P <br />iCA <br />_ . <br />Residing in La Porte . <br />. County, of ..._. N ary Publ�� � � �, ��:� ��,��9 � Vy A»ir'tit.E <br />p V1 WIrv' 1,� �FI�� <br />sIM d yi rnu�:wssy a fry�x�PdiuVs <br />