Change Order No. 2 - PCA - Fellows St. and Dubail St. Neighborhood Improvements Proj No 116-041A - Airmarking Co., Inc.

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AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of SS: frig Lowe being duly sworn that he/she is the President (Name of Officer) (Title) Of The Airmarkin Co. Inc. having contracted with The Airmarking Co.,Iuc. Subcontractor/Supplier) (Contractor) to furnish certain materials and/or labor as follows: Pavement Markings (Description) for a project known as Fellows Street and Dubail Street (116-041A) Division A (Name of Project) located at Fellows Street and Dean Johnson Parkway South Bend IN and owned by City of South Bend (owner) and does hereby further state on the behalf of the aforementioned subcontractor/supplier- (PARTIAL WAIVER)that there is due from the Contractor the sum of Dollars ($ ) Q receipt of which is herby acknowledged:or 0 the payment of which has been promised as the sole consideration for the 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 WIAVER)that the final balance due from the contractor is the sum of FIFTY FOUR THOUSAND TWO HUNDRED SEVENTEEN DOLLARS AND SEVENTY FIVE CENTS ($ 54,217.75) Qreceipt 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 theownerof said premi_ses,any and all liens or claims whatsoever on the above -described property and improvements thereon an account of labor or material or both,furnished by 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 furnis ed to the undersigned for said project,and within the scope of this Affidavit and Waiver of ien. f The Airmarking Co Inc By ' (Firm) Authorized Representative) STATE OF INDIANA ) Greg Lowe Sf SOSEPH CpktXC4 ) SS: Before me,the undersigned, a Notary Public,in and for said County and State, personally appeared Greg Lowe and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN 'WITNESS WREREOF,l have hereunto subscribed my name and affixed my official seal on the a L day of )DVCMSFR 20 U. My Commission Expires: September 21,2022 ) Residing in Rochester,IN County, Fulton Nota Pub Signature C. �P(h E Notary Public Name