Change Order No 1 & PCA - Cleveland Well Refurbishments – Well Cleaning Proj No. 118-021C - Peerless Midwest

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AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of Janes R . Williams �ITIT p being duly sworn that he/she is the General Manager (Name of Officer) - (Title) of Le nc.� having contracted with City of South Bend Dept. Of Public Works (Subcontractor/Supplier) (Contractor) to furnish certain materials and/or labor as follows: Cleveland Well Fimmeld Refurbishments -Well Cleaning,. (Description) for a project known as Project 118-021C Cleveland Well Field (Name of Project) located at Cleveland Well Field and owned by C i� 0 f 1i t h B l 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, _�. El receipt of which is hereby acknowledged; or El 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; HE WAIVER) that the final balance due from the contractor is the sum of 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 Marty has any claint 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. Peerless -Midwest Inc. 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 James R . Williams and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my off '4sealce 1 h day of December 200 1g CATHY S LANCE a Notary Public, State of Indiana otarnature nary tc«ter St. Joseph County My Commission Expires: "w. Z fly Commission Expires d A++un� a Residing in Cathy S . Lance �.,.�k �..., t . Joseph n a Notary Public Name