Laserfiche WebLink
AFFIDAVIT AND WAIVER OF LIEN <br />X Final Partial Payment to Follow <br />State of Indiana, County of St. Joseph SS: <br />Whereas, the undersigned Herrman &Goetz, Inc. has been employed by _C <br />lity of S(Llti Bend to furnish <br />certain labor and material as follows: install a variable finequency drive on water minip for the building <br />located at Erskine Well House and owned by City of South Bend and does hereby further state on behalf of <br />the aforementioned subcontractor/supplier. <br />(PARTIAL WAIVER) that there is due from the subcontractor the sum of <br />Dollars ($ <br />[ ] receipt of which is hereby acknowledged; or <br />[ ] the payment of which has been promised as the sole consideration <br />for this Affidavit and Final Waiver of Lien which shall become <br />effective only upon receipt of payment thereof by the undersigned; <br />(FINAL WAIVER) that the final balance due from the contractor is the sum of <br />Six Thousand One Hundred,& Seventy Five ...... _ Dollars ($6,175.00 <br />[ ] receipt of which is hereby acknowledged; or <br />[xxx] the payment of which has been promised as the sole consideration <br />for this Affidavit and Final Waiver of Lien which shall become <br />effective upon receipt of such payment. <br />THERFORE, the undersigned waives and releases unto the Owner of said premises, any and all lien or <br />claim whatsoever on the above described property and improvements thereon on account of LABOR or <br />MATERIAL or both, furnished by the undersigned thereto, subject to limitations or conditions expressed <br />herein, if any; and further certifies that no other party has any claim or right to a lien on account of any <br />work performed or material furnished to the undersigned for said project and within the scope of this <br />affidavit and waiver. <br />Herrman & Goetz Service& lt�te 1 � ... Title Division Manager <br />WITNESS MY HAND AND NOTARIAL SEAL, this 7Lh. .... day of. Au st._.__, 20,19 ww__. <br />My Commission Expires: 7/ 13/2022 Printed: "1:11:ne J. Gruber <br />Residing in St._Joeph County <br />