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~ountp ot
~1f1?sD IIL=IOH
(Name of Lienor)
5109 Ooral 1~~ns~, Ibrt ri~ro~. llsMda -
~Residence os Busineu Addreu of Lienos)
being duly sworn says that in pu~suance of a contract with H~...=• sOI+T+IT~i
(Name of Lieno~s Employsr o~ pe~son urith whom he cont~acted)
labor and
he { p~ } the f
ollowiag services Qd (Here describe the labor or services per
f
o~med or
~
materials f
ur~euhed. Descsibe specially f
abricated materials sepa~atelY) ~l.. ~~~~t~6.
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FILEB AND RE~Op9Es
OZ_ laa~~_ ..............~T. !.l~JCIE CAU~tZY,..Rt.~?~..-._. ~
RECORD VERIFIE9 t
. _.....w----------.._._....__..------.-----------------------...._......-----.._...._.._~4~"~'l.1 ~
------_.~_..------------'66--AUG--- ~ s---p~----~_:.34.
i
. ..~D~~~?'~~bITRAS-------------....
to the value of
"_""OZE ?HOIIS,ITD _ ?OII~_ H~lDiBZD _ ?Il~T~~~_ ~1~D1i~MIR~=--._
(State cont~act psice)
on the f
ollouring described reol p~o y. (Describe ~eal p~o erty ~~~~tty fo~ ~~n~~:~, giv-
~ S~} o! th~ ~ oi 8~} (l~~s 1.53 acr~• o~~a
in street and number i
f knoum _$odss--i~-t~4~tkaf?at--oo~~~-- ~--SN~1-o~--}3Y ~o~-
~h~p 35 eo~ths ~a~ ~EI ~a~t. 1ZO~FlI~a th~rts~os t~at pa~ct oi eaid la~ai•
' ~i~~riti~..la.. tha..~st~~•.3~w1--lsrs-,Eyaen~--8aw~a~sa-aad--~ta~--It~l~?--8a~a~~s~,
hi• ~rii~, to soti~rt I~~ aai Svui• l[o~ilt~ Iw~, lsi• wil~, reoerdt~d ii
! ~•~..~e~~Ic..~Q u~..os__#~h~a_.H~t... b.~es.._~ooan.t~ -.~.aor~a.-....~LSa.~LO=esu~
~ 5~.---~--- L
Bloel~ 2 oi =h~ ~pio~ BaD~iri~loi.
' owned B._..t.._SOLLI~Ji..a~b-PBAiLIS.-33~iIrlYli~--l~is--~iis,--------•-------------
; ~ (Name of oumer against rnhose intesest lien is claimed)
. . • ~
whose :nte~est :n ~uch seal~~
y u...----
(S~stt oume~s inte~est, as f
ee simple, li
f
e estate, lease-hold, i
f known ) ~
labo~ rp~formed 17th
He ~urther says ! e latr ite~re of sesvices wasi ~~~on the-----------------------------
~
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da o ~ ...-.-.~--,19-- 6~, a~, of the cont~act price stated, there is unpaid '
~ y f-------------------- . ~
the amount of.--------- ~
(State amount unpaid) - - ~
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fo~ which amour~t he clainis a on the ~eal p~ope~ ein described. i
x , .
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i
~ " ' ' ' ' '
~ _ (Signatuse of Lienor)
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. 19_~t6.. :
S.u~scribed and swo~n to befo~e me this......_.~ th:......_.day of 1 t '
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~ ~ . " ~ ( tary Public ~
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~ :.iP...i~-----=-- - (County) (State)
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