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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 two thousand two hundred sixteen & 40/100 dollars ($2,216.40), payable to: <br />Killmer Electric Co., Inc. <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. [Q 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 />Co., Inc. <br />B <br />Printed Name�� <br />Title Cz� <br />Address S ► 11 1 V-'- l� <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 />