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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of St. Joseph SS. <br />Stephen J. Davis being duly sworn that he/She is the General Manager <br />(Name of Officer) (Title) T® <br />of D. C. Byers Co./Detroit Inc. having contracted with City of South Bend Board of Public Works <br />(Subcontractor/Supplier) (Contractor) <br />to furnish certain materials and/or labor as follows: Structural Repair and modifications to signage, traffic control, and parking stalls <br />('I?cscripts""on) <br />for a project known as Main & ColfaxParking Structure Repairs 2019 <br />(Name of Project), <br />located at 12QN. ,M4In St. $quft Bend IN 46617 <br />and owned by City of South Bend <br />(Owner) <br />and does hereby further state on the behalf of the aforementioned subcontractor/supplier; <br />(PARTIAL WAIVER) that there is due from the Contractor the sum of <br />Dollars �$ ) <br />❑ receipt of which is hereby acknowledged; or <br />❑ the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which is given <br />solely with respect to said amount, and which waiver shal I be effective only upmi receipt of payment thereof by the <br />undersigned; <br />(FINAL WAIVER) that the final balance due from the contractor is the sum of <br />:Thousand Seven Hundred Five and 73/100 dollars m_(40�705.73 <br />❑ receipt of which is hereby acknowledged; or <br />® the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which shall <br />become effective only upon receipt of such payment. <br />THEREFORE, the undersigned waives and releases unto the Owner of said premises, any and all liens or claims whatsoever <br />on the above -described property and improvements thereon an account of labor or material or both, furnished b the undersigned <br />thereto, subject to limitations or conditions expressed herein, if any; and further ccrtifip4 that no other party has any claim or right to a <br />lien on account of any work performed or material furnished to the undersigned for id projected within tl this Affidavit <br />and Waiver of Lien. <br />D. C. Byers Co./Detroit Inc <br />y (Firm)._.-_ . u .... e. _. Byv. .e <br />tltorired Representative) <br />STATE OF INDIANA ) <br />SS: <br />ST. JOSEPH COUNTY ) <br />Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Stephen J. Davis <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. <br />IN WITNESS WHEREOF I; have hereunto subscribed my name and affixed my official seal on the 20th day of <br />must 20 19 <br />to4tZillilc <br />M"April 1, 2023 <br />y Commission Expires: IT <br />Residing in Ingham .. . mw„p County, .Michigan <br />Kathy Wolcott <br />Notary Public "Name <br />..mm...� _ . <br />COUNTYKATHY WOLCOTT <br />My Colwnmion <br />Acting in the Countyw <br />.; .« r <br />