HomeMy WebLinkAboutChange Order & PCA - Fire Dept Training Center Site Improvements Proj No 117-013 - TX ConcreteTay
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AFFIDAVIT AND WAIVER OF LIEN
State of Indiana, County of SS:
rr�� ,
��e_ L u c j�_V:l� [ # t A Gt _ being duly sworn that he/she is the 0 w Y� c r'
(Name of Offkdr) (Title)
Of }laving contracted with ' ��� �� �r r� '
(Subcontractor/Supplier)� - t) 0 `
(Contractor)
to furulsh certain materials and/or labor as follows: Cc-) � G 1": e
for a project known as
located at
and owned by
(Owner)
and does hereby further state on the behalf of the aforementioned subcontractor/supplier:
(PARTIAL WAIVER) that there is due &•om 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 the contractor is the sum of
❑ 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 bout, 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 sal project, and within th!2_wo is Affidavit
and Waiver of Lien.
BY r �
(Firm) By
Representative)
STATE OF INDIANA )
) SS:
ST. JOSEPH COUNTY }
Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared L Y�.tT JAJDA
and acknowledged the execution of the foregoing Affidavit and Waiver of Lien, t.""'
IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal on the � ay of
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Notary Public Signature
My Commission Expires: j S gw-o
Residingin 'r >JR �N %t.7r,x'ucF�
S 3aSP County, Notary Public Name
AARON MISTR011TRIILM
Notary Public, State of fnd[ana
St. Joseph County
My Commiss3on fxptres
October 15, 28Zt)
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