Change Order No 1 & PCA - Miami Basin Control Valve Replacement Proj No. 116-082D - HRP Construction, Inc.

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State oflndiana, County of St. Joseph SS: Nancy Knapik being duty sworn that he/she is the Vice President (Name of Officer) (Title) of HRP CONSTRUCTION INC. having contracted with City of South Bend, Board of Public Works (Contractor) (Owner) to furnish certain materials and/or labor as follows: Miami Basin Valve Replacement (Description) for a projectlmown as Miama Basin Valve Replacement, Project No. 116-082D (Name of Project) located at Maimi Street and owned by City of South Bend, Board of Public Works (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 ($ ) ❑ 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 Lfenwhich 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 Eight Thousand Seven Hundred Sixty Two Dollars and Ninety Eight Cents ($ 8.762. 98 ) ❑ receipt of which is hereby acknowledged; or ❑x 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 heroin, if any; and farther certified that: no other party has any claim or right to a lien on account of any work performed or material tarnished to the undersigned for said project, and within the scope of this Affidavit and Waiver of Lien. HRP CONSTRUCTION INC. BY (Firm) (Authorized Representative) STATEOFINDIANA ) Nancy Knapik, Vice President SS: ST. JOSEPH COUNTY ) Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Nancy Knapik and acknowledged the execution of the foregoing Affidavit and Waiver of Lion. IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal on the 12th day of October 2020, t N Public Signature My Commission Expires: 03/06/2024 Cynthia L. Vanheste Residhtgin St. Joseph county, Indiana YNTHIA L. VANHESTE Notary Public, State of Indiaw �+= St. Joseph County m Commission Number 681273 `I MY Commission Expired March 06, 2024