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Blue <br />Goose <br />Construction. <br />Mealy 0611! Underground UUAtlee /Complete Site Development 'Marine <br />State Certified Licensed <br />General Contractor #CGC1517686 <br />Pollutant System Contractor # PCC056727 <br />• Underground Utility & Excavation # CUC1225110 <br />Marine Specialty Contractor # SCC131151860 <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 />lar Street & 431" Avenue, Indian River County, Florida <br />Lienor's Name: n • er Constructio Industries. Inc. <br />By: <br />Print Name: F. Scott Fowler <br />Title: Vice President <br />Dated on: December 4. 2018 <br />State of Florida <br />County of: Orange <br />The foregoing insimmentwas acknowledged before me this 04 day of 12 ,2018 <br />By F. Scott Fowler who is personally known to me or who produced <br />as identification. <br />�,,.��Y ,, STACY L. BARBER <br />0 4'0 ue`t:'_ Notary Public - State of Florida <br />Commission # FF 948930 <br />1;°,' My Comm. Expires Apr 19, 2020, <br />, nuuN oF.V Bonded throe ghNationalNotary Assn. <br />Notary Public <br />My Commission Ear es: 04/19/20 <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.O. Box 14709 * Ft Pierce, FL 349794709 * Ph. (772) 461-3020 * Fax: (772) 468-4669 <br />69 <br />