Change Order No. 2 - PCA - Jefferson Boulevard Striping Phase I Proj No 116-037A - Airmarking Co

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AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of Fulton SS: Greg Love being duly sworn dtathelshe is the Preniflpn} (Name of Officer) (Title) of The Airmarking Go., ine. having contracted with The Airmarkin¢ co. Inc. (Subcontractor/Supplier) (Contractor) to furnish certain materials andloriabor as follows: memant Marking-n (Description) for a project known as Jefferson Boulevard Striping Phase 1 116-037A) (Name of Project) located at _ Jefferson Boulevard Smith Bud IN and owned by City of South Bend and does hereby further state on the behalf of the aforementioned subcontractar/supplier: (PARTIAL WAIVER) that there is due from the Contractor the sum of Dollars _ (S' ) ❑ 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 by the. uaddersigned; (FINAL WAIVER) that the final balance due from the contractor is. the sum of FTFKY Srx • HOMANn SEMM EIRMvn Tnrumv F"ECEE MLLARS _ ($56, 738.Oq ❑ receipt ofwhich 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'w.aives and releases unto the Owner of saidpreinises, anyand all liars or claims: whatsoever on the above.desctibed property bnprovemehts thereon an account of labor or material or both, furnished b the undersigned thereto; subject to limitations or conditions expressed herein, if any, and f nther certified that no other arty has any claim oX right to e lien on account of any work performed or material furnished to the undersigned fa s ' project, and yftthin:the scope ofthis Affidavit and Waiver ofLien. f, /J The Airmarkfng Co.,Inc. By� (F�) Greg a (uthorizedRepmsentative) STATE OF MIANA. ) SS: ST. dOSEPH COUNTY ) Before me, the undersigned; a Notary Public, imand for said County and State, personalty appeared Greg Lowe and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN WITNESS WHEREOF, I,have hereunto subscribed mymand affixed my official seal on the r4sd Of November 200 l NotatyPublit S" Penny L. Pike My Commission Expires September 21.2022 Residing in Rochester, IN C Pe nnY L. Pike County, Fulton County Notary Public Name