HomeMy WebLinkAboutProject Completion Affidavit - C&S Masonry Restoration LLC - Leighton Plaza Improvements Phase 2 Division A - Project No 117-054RFinal Waiver of Lien
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State oflndiana, County of __ �� ��fj � Ss'
s -(tr,)e, L "'J being duly sworn that he/she is the 2 ,5,� td�
(Name of Officer) Title
of "S N45-9v�j having contracted with (il ,{
(Contractor} -� , J (Owner)
to Aimish certain materials and/or labor as follows; C'" S7'��" �' ��'"` I0 H>q ' �Z ✓►1
(Description)
for a project known as
located at Z-4e,ff i
and owned by
and does hereby further state on the behalf ofthe aforementioned subcontractor/supplier:
(PARTIAL WAIVER) that Cher$ is due from the Contractor the sum of
Dollars _M ?
❑ receipt of which is hereby aoknowledged; or
❑ the payment of which has boon promised as the sole consideration for this Affidavit and Final Waiver of Lien -which is given
solely/ with respect to said avaount, and which waiver $ball be effective only upon receipt of payment thereof by"
undersigned;
koln the t�tor is the sum of , ��0 ' �11
(s l
❑ receipt ofwbich is hereby acknowledged, or
thepaymeat 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 tho Owner of said promises, any and all lions or claims whatsoever
on tho above -described property and improvements thereon as account of labor or material or both, furnished b the undersigned
therolo, subject to limitations or conditions expressed herein, if any; and norther certified thatno other party has any claim or right to a
lien on account of any work performed or material famished to the undersigned for said -project and witbht the scope ofthis Affidavit
and Waiver of Lien.
[ LAC, By t.PSf�
ntin / (Authorized Representative)
STATE OF INAIANA )
SS:
ST, JOSEPH COUNTY j r
Before me, the undersigned a Notary Public, In and for sold County and State, personally appeared
and aftowledged the execution of the foregoing Affidavit and Waiver of Lien.
IN WITNESS WIBREOF, Ihave hereunto subscribed am` and affixed myofficialseal on the 1 day of
Notary Public Signature
My Commission Expires: �'Ag Z
Residing in k. county, Notary mil/-1�2Public Na R
- S)E-EA L. BROWN
NMARY PUDLiC
£�F /4L_
STA F O?: iNDMA
COIJf"i i Y 0;- :;7 JOSE PH
NAy corn 'Jssion Ex;�ires June 28 2021
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