Project Completion Affidavit - East Bank Sinkhole Repairs Project No 118-305A - Northern Indiana Construction Co Inc

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Final Waiver of Lien State of Indiana, County of St. Joseph SS: David J. Walorski m — being duty sworn that he/she is the President (Name of Officer) r) (Tine) Of NCX-tJiejai-ladiana—Constructimhaving contracted with City of South Bend, Board of Public Works (Contractor) (Owner) to furnish certain materials and/or labor as follows: AS Needed to Repair Sinkhole at East Bank (Description) for a project ]mown as East Bank Sinkhole Repairs, Project No. 118-305A (Name of Project) located at East Bank, South Bend, Indiana and owned by City of South Bend Indiana (Owner) and does hereby further state on the behalf ofthe 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 tbereofby the undersigned; �Iourt —Sevnt s . _ y T our D WAIVER) that the final balance due from the contractor is the s of ourty-Seven Thousand Two Hundred Niet Four Dollars and Ten C ❑ 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 onlyuponreceipt 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 ry claim or ri to a lien on account of any work performed or material furnished to the undersigtt r s d project, and within the s pe of this vit and Waiver of Lien / -) A ,, .4 /7 Northern Indiana Construction Co.,Inc.�� ° �..�'""`' David J. alorskip Presi ) ( ra red Re resenhativ),r�rs ... STATE OF 1NDIANA ) dent } SS: ST. JOSEPH COUNTY ) Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared David J. Walorski and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my .cl l' seal on ti 30th day of Jul 20k 19 Notary Public � Signature . My Commission Expires: April 16, 2025 Residing in St. Joseph County, Indiana Danisha L. Marable Notary Public Name