Change Order No 1 & PCA - Edison Well #3A Rehabiliation Proj No. 119-097 - Peerless Midwest, Inc.

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AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of St. Joseph SS: James R. Williams _ being duly sworn that helsbe is the _ eneral Manager (Name of Officer) (Title) of Peerless -Midwest, Inc. having contracted with City of South Bend Board of Public Works (SubcontractorlSupplier) (Contractor) to furnish certain materials and/or labor as follows: Labor & Materials for Edison Well 3A Rehabilitation (Description) for a project known as Project No. 119-097 Edison Well 3A (Natne of Project) located at Edison Well 3A and owned by City of South Bend De artrnent of Public Works (Owner) and does hereby further stata on the behalf of the aforementioned subcontractor/supplier: (PARTIAL WAIVER) that there is due from the Contractor the sung of Dollars ($ ❑ receipt of which is hereby acknowledged, or ❑ the payment ofwhlch has been promised as the sole consideration for Ibis Affidavit and Final. WMver of Lion wlkh. is given solely with respect to said amount, and which waiver shall be. effeective onlyup6n w alpt of payment thereof by the undersigned; (FINAL WAIVER) that the final balance due from the contractor is the sum of Sixty -Two Thotu5and Three Hundred Fifty Dollars _ ($ 62,350.00) ❑ 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 an the aboye desod0ed,prgporty acid improvements thereon #A ac oW ofiabor or material or bothfpMisliod b the alders# 00 thereto, subjaot to Jitrtitatiaifs or cont(ltions .t*xpressed, herein; if any; aiid furlhsr certifies! the# no, other; party bag ogy c1&itit mright to a Nit on account_o f any Wpo k perfQrtned .ar M terld flihiish©d tb'the undersigned for said project, Arid Wt# is pe of tlils f iflavit $tid Waiver of Lien, // Peerless -Midwest Inc. (Finn) (Aitthnrixed Representative) STATE OF INDIANA } SS: ST. JOSEPH COUNTY ) Before tne, the undersigned, a Notary Public, in and for said County and State, personally appeared dames R. Williams and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN WITNESS WHEREOF, t have hereunto subscribed my name and affixed my of ci l seal he , z 1% day of April 200 20 CAlHY S. I ANCENotary Public gnature F'7 " , Notary Public, State nS Indiana MyComnmissionExpires: 06,012fl u`°:, 5t. Joseph County Ft�nty` \t 4Tn.�vly Commission uxpirqr; Cathy S. Lance Notary Pdblic _ �t^;• -�. Residing in Indiana Crj ;��; 4�. err ne O6 2023 r�