Project Completion Affidavit - 2017 Central Services Remodel Proj No 117-118 - Gibson Lewis LLC

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AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of St. Joseph SS: Randall H. Rice being duly sworn that he/she is the Asst. Secretary (Name of Officer) (Title) of Gibson-1_6wis, LLC having contracted with Citv of South Bend (Subcontractor/supplier) Mmumm) (Owner)_ to furnish certain materials and/or labor as follows, Geoeral Construction Per Base Bid & Alternate A & B (Description�) for a project known as 2.G.17 Central -Se vices Remodel - Project No, 117-118 (Name of Project) located at 1045 W. Sam le Street, South Bend 11\146619 and owned by . ...... CitV of South Bend Board of Public Works (Owner) and does hereby further stateon the behalf of the aforementioned,subcontrartor/supplier: Dollars E71 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 b the undersigned; y (FINAL WAIVER) that the final balance due from the contractor is th f Five Thousand Seven Hundred Eleven Dollars and 7TAMV ($5,711,71 ❑ 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 lions or claims whatsoever on the above -described property and improvements thereon an account of labonor material or both, rurnished b the undersigned thereto, subject to limitations or conditions expressed herein, if any; and further certified iat no other party ln�s any claim or right to a lien on account of any work performed or material furnished to the unde ' ic - aid p oject, and within the scope of this; Affidavit and Waiver of I L! en. rsigi 7t Gibson -Lewis, LLC By (Firm) (Authorized Rer oscutative) STATE OF INDIANA SS: ST. JOSEPH COUNTY Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Randall H. Rice and acknowledged the execution of the foregoing Affidavit and Waiver of'Lien, IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my qffi i I seal on the I 1th day of MnAl 20 2018, Notark Public Signature MY Commission Expires: July 10, 2024, Elizabeth A. Biddle Residing in St. Joseph County, Indiana Notary Public Name