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RECEIPT AND WAIVER OF MECHANIC'S LIEN RIGHTS <br />Dated: 1 /11 /2024 <br />Upon receipt by the undersigned of a check from: <br />Bituminous Roadways, Inc. <br />for the sum of seventy eight & 25/100 dollars ($78.25), payable to: <br />Custom Grounds & Restoration Services <br />and when the check has been properly endorsed and has been paid by the bank upon which it is drawn, this document <br />shall become effective. <br />Check One Only <br />1. ❑ As partial payment for labor, skill and material furnished <br />2. ❑ As payment for all labor, skill and material furnished or to be furnished <br />(except the sum of $0.00 retainage or holdback) <br />3. 2 As full and final payment for all labor, skill and material furnished or to be furnished <br />to the following described real property: (legal description, street address or project name). <br />Arden Hills City Hall <br />Bituminous Roadways Job #2211014 <br />and for value received hereby waives all rights acquired by the undersigned to file or record mechanic's liens against <br />said real property for labor, skill or material furnished to said real property (only for the amount paid if Box 1 is <br />checked, and except for retainage shown if Box 2 is checked). The undersigned affirms that all material furnished by <br />the undersigned has been paid for, and all subcontractors employed by the undersigned have been paid in full. <br />Custom Grounds & toration Service <br />By <br />Printed Name fSgy <br />Title <br />Address <br />-D�!v L 14N -52;3z:z <br />NOTE: If this instrument is executed by a corporation, it must be signed by an officer, and if executed by a <br />partnership, it must be signed by a partner. <br />