California Code, Civil Code - CIV § 8136

NOTICE: THIS DOCUMENT WAIVES THE CLAIMANT'S LIEN, STOP PAYMENT NOTICE, AND PAYMENT BOND RIGHTS EFFECTIVE ON RECEIPT OF PAYMENT. A PERSON SHOULD NOT RELY ON THIS DOCUMENT UNLESS SATISFIED THAT THE CLAIMANT HAS RECEIVED PAYMENT.

Identifying Information

Name of Claimant: _______________________________________________________________________________

Name of Customer: _______________________________________________________________________________

Job Location: ___________________________________________________________________________________

Owner: __________________________________________________________________________________________

Conditional Waiver and Release

This document waives and releases lien, stop payment notice, and payment bond rights the claimant has for labor and service provided, and equipment and material delivered, to the customer on this job. Rights based upon labor or service provided, or equipment or material delivered, pursuant to a written change order that has been fully executed by the parties prior to the date that this document is signed by the claimant, are waived and released by this document, unless listed as an Exception below. This document is effective only on the claimant's receipt of payment from the financial institution on which the following check is drawn:

Maker of Check: _________________________________________________________________________________

Amount of Check: $ _____________________________________________________________________________

Check Payable to: _______________________________________________________________________________

Exceptions

This document does not affect any of the following:

Disputed claims for extras in the amount of: $ _________________________________________________

Signature

Claimant's Signature: ___________________________________________________________________________

Claimant's Title: _______________________________________________________________________________

Date of Signature: ______________________________________________________________________________