PCA- Indiana Earth - Demo of Vacant & Abandoned Houses, Phase VII, Division C

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WAIVER OF LIEN 1. The undersigned labors, mechanics, materialmen, suppliers, contractors and/or subcontractors ("Undersigned") entered into an agreement ("Agreement") with the City of South Bend ("General Contractor") to famish labor, services, materials, and/or specially fabricated materials, etc., for the construction, improvement or repair of House Demolitions Project 115- 117 Ph. 7 ("The Project") located in the City of South Bend County of St Joseph , State of Indiana . 2. In consideration of $ _ 67.560.95 and other good and valuable consideration, the receipt of which is hereby acknowledged, the Undersigned hereby waives and releases to the extent of such payment and in accordance with the terms contained in paragraph 3 below any mechanic's or materialmon's lien or personal liability claims, public works claims and claims against any payment or performance bonds, or claim or right of such lien on the above -described premises and on improvements now or hereafter located thereon and which now exist or might otherwise arise because of labor, services. Or materials furnished or to be famished by the Undersigned pursuant to the Agreement, 3. This lien waiver is a partial or final waiver and release of lien as provided below: (Check One) —_ Partial release and waiver of lien X Full release and waiver of lien If this waiver of lien represents a partial waiver or release of lie, the amount of the unpaid balance due is 4. The Undersigned certifies that the materials and/or work covered by this application have been furnished in accordance with the contract documents, that all amounts have been paid by him for materials and/or work for which previous monies were paid, and the current payment shown herein is now due. 5. 1 have executed this waiver voluntarily and with full knowledge of my rights under the laws of the State of Indiana. The Undersigned is fully authorized to execute this document on behalf of the business so named. Given this 29th day of July , 2016 . (Name & Title of Authorized Signer) STATE OF: Indiana COUNTY OF: St. Joseph Signed and sworn to before me by Mark Osler this 29th day of July 2 (NOTARYSEAL) Signature: ,b Printed: Keith Stevens (Notary Public) My Commission Expires: 10/15/2023 County of Residence: Elkhart