Change Order No 1 - PCA - Mishawaka Avenue Roto Rooter Jetter Removal and North Shore Drive Improvements Proj No 118-069R - HRP Construction

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AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of S t . Joseph SS: Nancy Knapik being duly sworn that he/she is the secretary/treasurer (Name of Officer) (Title) of HRP CONSTRUCTION INC. having contracted with City of South Bend (Subcontractor/Supplier) (Contractor) to furnish certain materials and/or labor as follows: Mishawaka Avenue - Roto Rooter fetter Removal (Description) for a project known as MishRwska Avenue - Rnto Ronter Jetter Ri'lemoval (Name of Project) located at Mishawaka Avenue and owned by City__of South Bend (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 Lien which is given solely with respect to said amount, and which waiver shall be effective only upon receipt ofpayment thereof by the undersigned; (FINAL WAIVER) that the final balance due from the contractor is the sum of Twenty sa d Tw&1ve Dollars and 50 100 ($ ) 24,_01 2_.50 ❑ 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 Iimitations or conditions expressed herein, if any; and further certified that no other party has any claim 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. HRP CONSTRUCTION INC. (Firm) By (Authorize Representative) STATE OF INDIANA } Nancy K n a p i k SS: ST. JOSEPH COUNTY ) Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Nancy K n a p i k and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal on the 1 1 t h day of October 200 2018 d4'�4 Notary Public ignature My Commission Expires: 3 / 8 / 2 4 C, 001AI YQl1 'e-5�-e—.. Residing in S t . Joseph County, Indiana Notary Public ame