PCA - Martin Luther King Jr Center HVAC Revisions Proj No 116-064 - Hermann & Goetz Inc.

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AIA Document G706TM -1994 Contractor's Affidavit of Payment of Debts and Claims PROJECT: (Name and address) ARCHITECT'S PROJECT NUMBER: 116-064 OWNER ❑ Martin Luther King Jr. Center CONTRACT FOR: HVAC Revisions ❑ ARCHITECT CONTRACTOR ❑ TO OWNER: (Name and address) CONTRACT DATED: September 15, 2016 SURETY ❑ City of South Bend 227 W. Jefferson B1vdrJ. OTHER ❑ South Bend, IN 46601 STATE OF: Indiana COUNTYOF:St. Joseph The undersigned hereby certifies that, except as listed below, payment has been made in full and all obligations have otherwise been satisfied for all materials and equipment furnished, for all work, labor, and services performed, and for all known indebtedness and claims against the Contractor for damages arising in any manner in connection with the performance of the Contract referenced above for which the Owner or Owner's property might in any way be held responsible or encumbered. EXCEPTIONS: NONE SUPPORTING DOCUMENTS ATTACHED HERETO: 1. Consent of Surety to Final Payment. Whenever Surety is involved, Consent of Surety is required. AIA Document G707, Consent of Surety, may be used for this purpose. Indicate Attachment ❑Yes ❑No The following supporting documents should be attached hereto if required by the Owner. 1. Contractor's Release or Waiver of Liens, conditional upon receipt of final payment 2. Separate Releases or Waivers of Liens from Subcontractors and material and equipment suppliers, to the extent required by the Owner, accompanied by a list thereof. 3. Contractor's Affidavit of Release of Liens CONTRACTOR: (Name and address) Herrman & Goetz, Inc. 225 S. Lafayette Blvd. South Bend, IN 46601 BY�(S , nation of autho ' ed representative) Larry Cripe, Power -of -Attorney (Printed name and title) Subscribed and sworn to before me on this date: January 16, 2017 Notary Public; g ), - CatherineJ. My Commission Expires: (AIA Document G706A). 7 / 13 / 2022 CAUTION: You should sign an original AIA Contract Document, on which this text appears in RED. An original assures that changes will not be obscured. AIA Document G7067a —1994. CopyrightO 1970 and 1994 by The American Institute of Architects. All rights reserved. WARNING: This Al e Document Is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AIA® Document, or any portion of It, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. Purchasers are permitted to reproduce ten (10) copies of this document when completed. To report copyright violations of AIA Contract Documents, e- mail The American Institute of Architects' legal counsel, copyright@aia.org.