Project Completion Affidavit - Fire Station No 4 Project No 116-066 - Gibson Lewis LLC

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AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of St. Joseph SS: Robert A. Lingenfelter being duly sworn that he/she is the President (Name of Officer) (Title) of Gibson -Lewis, LLC having contracted with City of South Bend Board of Public Works �lS ( uboontraoto /S uplalier) (Contractor) to furnish certain materials and/or labor as follows: (Description) for a project ]mown as City of South Bend Fire Station #4 Project #116-066 ('Nave of Project) located at 220 N. Olive treet _w_outh Bend IN and owned by City of South Bend Board of Public Works (Owner) and does hereby further state on the behalf of the aforementioned subcontractor/supplier: Dollars ITITm ) ❑ 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 One Hundred Sixty Seven Thousand Five Hundred Fifty Three &_l 8/100 ❑ 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 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. Gibson -Lewis, LLC By (Firm) ....... __. (Authorized Reres ntative:) STATE OF INDIANA SS: ST, JOSEPH COUNTY ) Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Robert A. Lingenfelter and acknowledged the execution of the foregoing Affidavit and Waiver of Lien, the 8th da �w IN WITNESS WH0 REOF I have hereunto subscribed name and affixed my o r s sea on y of day Vnf Notary Public Signature My Commission Expires: July 10, 2024 Elizabeth A. Biddle Residing in St. Joseph County, Indiana Notary rt lc° )c E L I ZA B ET H A. B I D D L E Notary Public, State of Indiana +r� t," St. Joseph County ,�a y My Commission Expires �u July 10, 2024