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KARL R SHORTER <br />. MY COMMISSION # FF976849 <br />EXPIRES April 01, 2020 <br />0i1511 kD153 wicsxoni , <br />Blue <br />Goose <br />Construction <br />Heavy CMU (Underground Utilities! 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 />15t Street & 43rd Avenue, Indian River County, Florida <br />Lienor's Name: <br />By: <br />Print Name: --Er-; A n <br />Carr Construction <br />Title: D', ref <br />Dated on: \?..- I)4201 8 <br />State of Florida D 'n <br />County of: `1cki e <br />9 acknowledged11 day ofDCC WOU, SUR <br />The f�Qreyoin irtstrtunert before me this <br />By bi(1CU(I.'CYlidl� who is personally known to me or who produced <br />as identification. <br />Notary Public <br />My Commission Expires: l+/ /c93— <br />Note: <br />This is a statutory form prescribed by Section 71320 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 34979-4709 *Ph. (772) 461-3020 *Fax (772) 468-4669 <br />70 <br />