Project Completion Affidavit - Erskine Clubhouse Renovation Project No 116-108 - Ziolkowski Construction

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AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of t osc,la SS: R;11 Favors being duly sworn that he/she is the President & CFO (Name of Officer) (Title) _....� of Ziolkowsld Construction, Inc. � having contracted with Vorks Cit of South Bend, Indiana (Subcontractor/Supplier) (CITontractor) to furnish certain materials and/or labor as follows: onstructiotr General ,. (Description) ._ for a project known as _,EL4jh1r C,�house Renovation Pro'ect Number 116-106 (Name of project) located at th Bend Indiana and owned by t a:4.of (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 ❑ 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 winch 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 0 �asand One Hundred ";l"lt�at Four and 20/100 �110,114.20 ❑ 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 relcascs Unto the Owner of said premises, any and all liens or claims whatsoever on the above -described property and iinprovements thereon an account of labor�or material or bode, furnished b the undersigned thereto„ subj cot 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, Ziulk9wski Construction, Inc. �(A � ��)--*' By-thorized �Reptntativ STATE OF INDIANA ) SS: ST. JOSEPH COUNTY ) Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared B,ll Favors 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 1�t day of Au ust, 2019 -- 200 Notary Public Signa� My Commission Expires: - mar S LYNN QVINING Residing in Elkhart County,Indiana �� u� l'"UL seal "rotary Public Nat Notary 0-UM-7"` a e O Rana Elkhart County My Commission Expires Marti, 2025