Laserfiche WebLink
Blue <br />Goose <br />Construction <br />Navy Cid iUndetgrat ad UIWSUes:Comptote Sheet*lapmentiUitine <br />30.130.5*-/ LsvFb <br />State Certified Licensed <br />General Contractor #CGC 1517686 <br />Pollutant System Contractor # PCC056727 <br />Underground Utility & Excavation #.CUCI225110 <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 />1St Street & 43n1 Avenue, Indian River County, Florida <br />Lienor' Name: Ceme <br />By: <br />Print Name: tiiQrQ�s�r:, n� <br />Title: C fir' <br />Dated on: l�r o .r r' t2.0 lc�' <br />State of Florida <br />County of:�Ckrh cc. <br />The foregoing instilment was acknowledged before me this ` day of ,,,�,or;2018 <br />By (f og\n �sA.tel (who is personally known to me�or who produced <br />as identification. <br />„tY P„B�. <br />m�u„ VALERIE HUNTER <br />�,y <br />zo.—.`':. Notary Public - State of Florida <br />Commission # FF 898640 <br />.,� ri.. A:# My Comm. Expires Sep 16.2019 <br />�''FOFK?"•' Bonded through National Notary Assn. <br />1Y <br />Notary Public \ \ <br />My Commission Expires: i -16-E9 <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 34979-4709 * Ph. (772) 461-3020 * Fax: (772) 468-4669 <br />71 <br />