Change Order No 1-PCA - 2017 Lamppost Program Project No 117-011A - Martell Electric LLC

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AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of 5.t_JD3.eP.i1 ._.._. SS: Jennifer Martell being duly sworn that he/she is the President (Name of Officer) (Title) of Martell Electric LLC having contracted with City of South Bend (Subcontractor/Supplier) (Contractor) to furnish certain materials and/or labor as follows: electrical (Description) for a project known as 2017 La -a t Program (Name of Project) located at various Sout Bend locations 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 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 undersigned; (FINAL WAIVER) that the final balance due from the contractor is the sum of Twenty seven th_pgagn five hun rfifty s (g27,550.00) - nreceipt 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 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. Martell Electric LLB _ .... By (Firm) CAithohzed Representative) STATE OF INDIANA ) SS: ST. JOSEPH COUNTY ) Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Jennifer Martell/President 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 71h day of Maw 20§( 19 Notary Public Sigxtattrre My Commission Expires: 02/28/2023 n Residing in County, ty °u µNotar Notary o eq CDW county Notary Public dN e Public Mate of Indh�utu g St Jose h ty, tary Pu' �-- - `';�-�' ""� a" �»`^' My Commission CNpfred