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fIORIpA STATUTES . • ; OREW'S FOlM M 120~J~ Manu{~Clyr~f~~Or T6~ H. i W. Dn~r Co~tpany
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~at~te of...----._~'laris~::.~-----------------~-------,~------ .14()27',1
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CLERK
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._INDIAN_ RIYER._.SEPTIC__TANK__SERVICE, TNC. & ROOFING SF~'tVIC~
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(Name of Lienor)
.P~Qs__~nac._1.,7.3.7.~--_Yer~__.8~a~h.,.__F~.or.~.d~.,
(Residence or Business Acldress of Lienor)
bc~ing duly sworn says that in pursuance of a contract with .___I.,ewis_.Industriss:_jWilliam.
_~tiS~Q.~-Ge~!~x~~l..Sex_~.1npm.e~n.t~..~nr~z,,,P~_.._.5:~~...~1~C7.e,.~'._R_._..$Qx. ~$$~.,Melbourne, F1z.
{Name of Lie.nor's EmploS~er ar person with whom he contractedj
~ performed la6or and
hP ~urn:shed } the f ollowing services and (Here describe the labor or seruices performed or
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materials furnished. Describe spec.ially~ fabricated materfalsseparately)
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to thc value of-----------$3~,.-OQ-------------------------------
( State contract p; ice )
on tjFe f ollowin~ dc~scribed real property. (Describe ~eal property su~iciently f or identi ficatian, giv-
in street a~td nu~rtber i known Lot..ll__._Block._5$-__ 701._~~lag _Ave.
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owned b}'----~-------------•--------••----~-------------•------------------
(1Va~rte of ozuner a5~inst whose intc:rest lien is claimed )
zt~hnsc~ intc'rc~st z~t sucft real property is--------------------------------------------------------~-----------...--------~-------=----------
(State owner's interest, as f ee si~nple, ti
f e e~tate, lease-hold, i f known )
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He f ttrther sa}~s that the last itena of ~ ~as~ perfo~~ on the.= .~::,~l,~~='':~~..::.:
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da}~ of_____S~.ip~smker___________________________, 19..~5._, and, of the contract ~rice stated; t~ier~'~is ~~aid
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the antount of- -------------------~~-9' ~Q----...-------------------------------------------------------------.._..'.`.._-'-:~---__---'----•----=----
(Statc a~noccnt unpaid)
for zt~/tich amottnt he clai~rrs a liere on the rcal prop~rt?~ h_ rein cl~sc~;;b,ed, ~~~~~,~'r;~~uj~~,~r~G.
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(~'igtl~~u ~ ~ of
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.S'ubscrib~d cin%1 swurn to bEfore rne this...___~~ of_____________ .`.`~i. 19.__..___
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.~ty Com»azssion °~iir,~, . ~s-+ (County) ~
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