Change Order No 2 & PCA - Mishawaka Avenue Traffic Signals at Fire Station No. 9 Proj No. 117-120A - Pemberton Davis Electric, Inc.

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Final Waiver of Lien State of Indiana, County of _ SS: being duly sworn that he/she is the (Name of Of -Boer) (Title) Of AC - )04-'-4 having contracted with City of South Bend --- (Contractor) (Owner) to furnish cettain materials and/or labor as follows: (Description)for a project known as M13�"0.^^t 4r sti 9 '^ y► (,Name ofPrgject) located at ► "�� s'Vt`' AL, cLJ`��t„ �boS2. JQN and owned by ON of South Bend (Owner) and does hereby further state on the behalf ofthe aforementioned subcontmact"Aupplien (,PARTIAL WAIM) that there is due from the Contractor the suns of Dollars ,. ❑ rccoipt of which is hereby owfodged; or ❑ the Payment of which has been promised as the sole consideration, for this Affidavit and Final Waiver of Lion which is given solely with respect to said amount, and which waives shall be effective only capon receipt ofpayment thereof by the undersigned; (I'INAL WAIVER) that the final balance due from the contractor is the urn of it j ot, n ac i V� " ❑ receipt of which is hereby acknowledged; or ® ilia payment of which has been prom isod as the sole consideration forthis Affidavit and Final Waiver of Lien which shall became effective only upon roceipt of such payment. THEREFORE, the undersigned waives and releases unto the Owner of said promises, any and all liens or claims whatsoever on the above-deserlbed property and improvements theroon a& account of labor or mnaterial or both, hunished b time undersigned thereto, subject to limitations or conditions expressed heroin, if any; .and f%tthor certified that no other party has any claim or right to a Ron on account of any work perfonned or material t rrnishod to the undersigned for said project, and within the scope of this Affidavit and Waiver of Llem (F) thorxod nalvo STATE OF IDIANA Am SS: ST. JOSBPH COUNTY ) Before me„ the undersigned, a Notary public, in and for said County and State, personally appeared TQA, and acknowledged the oxemidon of the foregoing Affidavit and Waiver of Lien. IN W1T, 'l3SS 1tSOF, I have hereunto subscribed my narne and affixed my official soot on e _ 11,7W day of 201 Nq Pu I c Sigrreturo My Commission Expires: Residing in County, r �rtr ub loCaaro u o s , ea g, My P xpr re s �r�rvuasw,i;�u i�aw tixaaa.