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(? F 010,9A0 <br />WAIVER AND RELEASE OF LIEN <br />UPON FINAL PAYMENT <br />The undersigned lienor, in consideration of the final payment in the amount of $10.00, hereby <br />waives and releases its lien and right to claim a lien for labor, services or materials furnished to <br />Johnson -Davis Inc. on the job of Indian River County BOCC (Owner), for improvements to the <br />following described project <br />Gifford Area Stormwater Project; Bid No.: 2018045 <br />Project No.: IRC -1502 <br />Indian River County, Florida <br />Dated OnQ,�� AO to <br />Lienor's Name: Mack Concrete Industries, Inc. <br />Address: 23902 COUNTY RD -561 <br />ASTATIJjLA, FL 94705 <br />By:,I i <br />�r ,' <br />i- <br />Printed Name/ Title: SA AH A JACKSON <br />Sworn to and subscribe before me this Vec <br />/l�tf <br />ignature o y Public <br />Commissioned State of Florida <br />"%<. CONNIE WILSON <br />Ojet.MY COMMISSION # 00245954 <br />%-„,,ofP EXPIRIS August 17. 2022 <br />RMhAhMN.pnn w+MAArkMM; <br />Print Name of Notary Public <br />Personally Known XX or, Produced Identification: <br />Tvne of Identification Produced: <br />NOTE: This is a statutory form prescribed by Section 713.20, Florida Statutes (1996). <br />Effective October 1, 1996, a person may not require a lienor to furnish a waiver or release of <br />lien that is different from the statutory form. <br />