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Conditional Receipt and Waiver of Mechanic's Lien Rights <br />Dated: j / iTt';�5 <br />Up(In roceipt by the undersigned of a check from 1y in the sum of <br />$47 72, G% and when the check has been properly endorsed and hasficen paid by the <br />bank upon which it is drawn, this document shall become effective to release any mechanic's <br />lien, stop notice, or bond right the undersigned has as follows: <br />Check Only One <br />1) ❑ as partial payment for labor, skill and material furnished or to be furnished. <br />2) ❑ as payment for all labor, skill and material furnished or to be furnished (except the <br />sum of $ retainage or holdback) <br />3} �Kasfull and final payment for all labor, skill and material furnished or to be furnished <br />tofollowing described real property: <br />Owner Name: 4r !` <br />Street Address 1: <br />Street A ressl <br />City: �em PI`llf State: MN <br />Zip: 5S117, <br />And for value received hereby waives all rights acquired by the undersigned to file or record mechanic's <br />liens against said real property for labor, skill or material furnished to said real property (only for the <br />amount paid if Box 1 is checked, and except for retainage shown if Box 2 is checked). The undersigned <br />affirms that all material furnished by the undersigned has been paid for, and all subcontractors employed <br />by the undersigned have been paid in full. <br />(Note: if this instrument is executed by a Corporation, it must be signed by an officer and if <br />executed by a partnership, it must be signed bb�y�a partner.) <br />Company Name;, <br />Signed By: <br />Title <br />Street Address: <br />City: State: MN Zip: <br />FOR SUB -CONTRACTORS <br />