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Blue <br />Goose <br />Constvuction <br />HeavyCtil1Underground Utilities! CompleteSite Development Marine <br />State Certified Licensed <br />General Contractor #CGCI517686 <br />Pollutant System Contractor # PCC056727 <br />Underground Utility & Excavation # CUC1225110 <br />Marine Specialty Contractor # SCC 131151860 <br />Waiver and Release of <br />Lien <br />Upon Final <br />Payment <br />The undersigned lienor, in consideration of the final payment in the amount of <br />$ 10.00 , hereby waives and releases its lien and rights to claim a lien <br />for labor, services or materials furnished to Blue Goose Construction, LLC <br />On the job of (owner of property) Indian River County , to <br />The following described property: <br />15t Street & 43rd Avenue, Indian River County, Florida <br />Lienor's Name: Mosley & Sons <br />By: <br />Print Name: D Lt/,'i/ia4-.5 <br />Title: (!P. 1l.%U? Q," <br />Dated on: 1214-I I <br />State of Florida <br />��,, <br />County of: / li- 4i r" <br />The foregoing instrument was acknowledged before me this 144 day of <br />By D z 16 44 t 7 who is personally known to me or who produced <br />as identification. <br />La° <br />to Pty, Notary Pubile :Nato c1 rte11da <br />� `� t; Nichols) Vernal <br />My C0111111190011C0111111190011G(i 00069!: <br />jor,voExpiro9 001151202.1 <br />t p621111 <br />r <br />Notary Public `k l a"t-t. <br />My Commission Expires: <br />Note: This Is a statutory form prescribed by Section 713.20 Florida Statutes (1996). Effective October 1, 1996, <br />a person may not require a lienor to furnish a waiver or release of Lien that is different from the statutory form. <br />Return to: P.Q. Box 14709 * Ft Pierce, FL 34979-4709 * Ph. (772) 461-3020 * Fax: (772) 468-4669 <br />68 <br />