Project Completion Affidavit - Century Center Lower Level Restroom Remodel Project No 118-082A - Brown and Brown

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AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of Elkhart SS: Y„ w (Marne of Officer Wu being duly sworn that he/she is the President Eric Brown (Title) ..m.__�. of Brown & wBrown General Conptractors, Inc. having contracted with City of South Bend, IN ) (Subcontractor/Suplies) ..._. _ �..._ (C«��ttcto to furnish certain materials and/or labor as follows: complete construction (Description) for a project known as Century Center lower level restroom remodel ....,, _ ._.m (Name of Project) located at South Bend, IN and owned by City of South Bend, IN_�....�.�"`.`"..._.��....._......._�..._.........�..._._._._....��,..... (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 C. ❑ receipt of which is hereby acknowledged; or El 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 ireceipt of payment titereof by the undersigned; (FINAL WAIVER) that the final balance due from the contractor is the sum of thousand six„ n� dollars hundred tree an 53/100 ($12 603.53 , ❑ 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 et'fkctl've 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 patty 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. Brown & Brown General Contractors Inc .. BY .....� ._ um (Autltctr6�ed Re resent ....�..w��.. STATE OF INDIANA ) ) p atuve) SS: ST. JOSEPH COUNTY ) Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Eric Brown 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 6th day of August200 2019 Notary Public mmSignature— —... My Commission Expires: _ 4/3/2025 Todd A. Marek II Indiana Residing in Marshall Not rY I 11011C NanIcrrxidAMarek Notary Public SEAL Marshall County, State of Indiana My Commission Expires April 3, 2025 Commission Number: 698752