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AFFIDAVIT AND WAIVER OF LIED <br />State of Indiana, County of SS, <br />me s .R. lit i l ] a s being duly sworn that he/she is the General Manager, <br />.._ <br />�..-..�� <br />of Officer - <br />(I"rtle) k <br />Of Pe—e derl... <br />ess— west, Inc,, having contracted with Indiana <br />( ubcontra6tor/Sazpifliel) —.� ,�m__w . <br />(srratracterr) <br />to furnish certain materials and/or labor as follows: Chemicals <br />_ _ end � ut p,—f—p Dement parts <br />(Description) <br />for a project known as —W_ TrqqA& t <br />,jon^Wel p #6 RthLal 7li.tation <br />(Name Of Project) . <br />located at <br />and owned by City of SouthBendInid1dt10..,. <br />and does hereby further state on the behalf of the aforementioned subcontractor/supplier; <br />(11A1t I I'AL WAIVER) that there is due from the Contractor the sum of <br />Dollars <br />El receipt of which is hereby acknowledged; or <br />0 the payment of which has been promised as the sole considertatlOri f r this Affidavit arr'id Final 4Ta ver° of` iera aal i la is given <br />solely with respect to said amount, and which waiver shal t be et'fe tivb only upon focci t of payraae'nt tllereof'by lire <br />undersigned; <br />(FINAL WAIVER) that the final balance due from the contractor isthe sum ofSixty-Three Thousand Two Hundred <br />h.irt Sven D ol.)_ar .�..00/Cents 323ZM.00� <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 shall <br />become effective only upon receipt of such payment. <br />"I°IJER13 OREA the undersigned walvos and roloases unto the Owner of said premises, any and all liens or clauns wvlratsoover <br />o/a lrc rraov'e cicset ietl gaper°tytratlrrrpr`ovcrrrorats tlrcrcor°r ara aedotant oflarlror or°'rllatel`ial tra` both, far`rrlslia the ttrrdtrrsrped <br />1 > y� further col ti.fied that Tarr otlt,ea` party has ally 0411b 'dt, 1gh't to a <br />tlacr°cto, soil a ct to l'irlaitatioras Or corrtlatlorat expressed scd hcrein ii aar ° and fttr <br />hen. oil acO ulrt of ny work per:f"ormod or raaatcrlal forldshod to the undersigupd for said project„ and within the scope, of lais Affidavit <br />. ara�' Waivarof Lion.. <br />rest Inc <br />Peeless-Midw <br />� ..�..�... �..IT__ _. _�.. . <br />�I irxrt) � (A'�rtlror'ied II".epreseratatra <br />STATE OF INDIANA ) <br />SS: <br />ST. JOSEPH COUNTY ) <br />Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Jame s R . Wi 11 i am <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. <br />IN WITNESS M94BREOF, I have hereunto subscribed nay name and affixed my official e l on t 8 th dr of <br />arch � 19 <br />ors Notary Public, State of India .� <br />St. Joseph County Not y 1'rrhlio Si rre <br />SEAL' 2' My Commission Expires <br />My Commission Expires; ��.` e1w "<" June 0, 2023 <br />y S. Lance <br />Indiana __.Ca S <br />Residing in Coon S Jos h <br />t3', ,,fir, � Ncrt`saaPublifw blame <br />