PCA - Century Center North Bridge LED Lamp Retrofit Proj No 116-007A - Days Corporation

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AFFIDAVIT AND WAIVER OF LIEN State olfIndiana, County of Elkhart SS: A e, (} being duly sworn that he/she is the V t e_- (Name of Officer) (Title) Of Days Corporation having contracted with City of South Bend, Indiana (Subcontractor/Supplier) (Contractor) to furnish certain materials and/or labor as follows: Lamps, Gaskets, Mounting Hardware, and Labor (Description) for a project known as Century Center North Bridge LED Lamp Retrofit •(Name of Project) located at 120 S. St. Joseph St. South Bend, Indiana 46601 and owned by The 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 ($ ) ❑ 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 undersigned; (FINAL WAIVER) that the final balance due from the contractor is the sum of Four Thousand Six Hundred Fifty Three Dollars --------- 00/100 ($ 4,603.00 ) ❑ 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 liens or claims whatsoever on the above -described property and improvements thereon an account of labor or material or both, furnished b 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 Hen on account of any work performed or material furnished to the undersigned for said project, and within the scope of this Affidavit and Waiver of Lien. Days Corporation By (Firm) (Authorized Representative) STATE OF INDIANA ) SS: ST.JOSEPH COUNTY Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared W Yn and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN SS WFIEREOF, I Have hereunto subscribed my name and affixed my offs ial seal on the day of 0\1r �e r 20Jd ( � �t Lk C-L �� LLuVa, Notary Public Signature My Commission Expires: 4 — a-4 Residing in E I "U l"+ County,ta t C IG i L S 1 C J e t S IYl(,11Ct-VIG Notary Public Name