Change Order No 1 & PCA - Century Center Skylight Beams Painting Proj No 117-004 - Ziolkowski Construction

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State of Indiana, County of Bill Favors (Name of Officer) of Ziolkowsk! Construction, Inc. (Subcontractor/Suppli AFFIDAVIT AND WAIVER OF LIEN St Joseph to furnish certain materials and/or labor as follows: for a project known as located at and owned by SS: being duly sworn that fie/she is the President/CFO (Title) having contracted with The City of South Bend Board of Public Works (Contractor) Skylight Beam Painting - Project Number 117-004 (Description) Century Center South Bend, IN (lame of Project) 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 surn of Dollars F1 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 stern of Eleven Thousand Six Hundred Ninety Five Dollars and Sixty Five Cents ($11,695,65 receipt of which is hereby acknowledged; or the payment of which has been promised as the sole consideration for this Affidavit and Final Waivcr 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 lien 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, Ziolkowski Construction, Inc. By (Firm) (Authorized Representative) STATE OF INDIANA Bill Favors, President CFO S. ST, JOSEPH COUNTY Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Bill Favors and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal on the 5th day of June, 2018 Notary Public My Commission Expires; March 6, 2025 Residing in Elkhart County, Indiana Lynn D. Vin!nL, Notary Pub C Name LYNN oViNING Seal Notary Public - State of Indiana Elkhart County My Comrniss,1011 Expires Mar 6,2025