HomeMy WebLinkAboutInv# PAY APP 2 - IMS CONTRACTING, INC. - 03/25/2022 (2)WAIVER AND RELEASE OF LIEN UPON PARTIAL PAYMENT
The undersigned lienor, in consideration of the partial payment in the amount of ____________
hereby waives and releases its lien and right to claim a lien for labor, services or materials
furnished to City of Dania Beach on the project of _______________________ to the
following described property:
100 W Dania Beach Blvd, Dania Beach, FL 33004
Dated on: 3/28/2022
Lienor's Name:
Address:
By:
Printed Name:
___________________________________
___________________________________
STATE OF MICHIGAN
COUNTY OF ____________
The foregoing instruments was acknowledged before me by mean of [how the individual appeared; check on]. □physical presence or □online notarization this _____ day of , 20___, by
(name of person making statement).
Signature of Notary Public-State of Michigan
Printed Name
Personally Known ______ OR Produced Identification _______
Type of Identification Produced_______________________________________________
NOTE: This is a statutory form prescribed by Section 713.20 Florida Statutes (1996). Effective
October 1, 1996, a person may not require a lienor to furnish a waiver or release of lien that is
different from the statutory form.
$71,056.96
Dania Beach Pier Replacement
Industrial Maintenance Services, Inc.
1920 20th Ave N
Escanaba, MI 49829
Kayla Martinucci
Delta
28th March 22
Kayla Martinucci
Tammy M. WilesDelta