PCA - Northwest Elevated Tank Site Restoration Proj No. 122-018A - Acorn

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AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of St. Joseph SS: Andrea Ritschard being duly sworn that he/she is the Treasurer (Name of Officer) (Title) of Acorn Landscaping, LLC having contracted with City of South Bend, Public Works (Subcontractor/Supplier) (Contractor) to furnish certain materials and/or labor as follows: Site restoration & asphalt repair of service drive (Description) for a project known as Northwest Elevated Tank Site Restoration (Name of Project) located at Northwest Elevated Tank lot (Vorden Court) and owned by The City of South Bend, Indiana, Department of Public Works (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 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 th@ con a or is the um of Thirty one thousand seven hundred fifty nine collars and zero cents ($31,759.00 ) ❑ 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 ffidavit and Waiver of Lien. �t Acorn Landscaping, LLC By �G (Finn) (Authorized Representative) STATE OF INDIANA ) SS: ST. JOSEPH COUNTY ) Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared 5 and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed m ffieial seal on theI'h day of 20'+ LZO- Nntary Pnhiin Aitmafiirn My Commission Expires: Residing in aL1111t