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...................~~~Y~~s~.!.s..~ain~...M.~.k~~!~~~:~nB.. ~~.P.B??3~,...Inc,
( ame of Lienor)
......................:..~Z.~_..~T.~QX~..AY~xi1L8 ._..........._..BQC~~.4
~&~...---Fa.S2~
(Residence os Busineu Addreu of Lienos)
~ being duly sworn says that in pursuance of u contract with .T~1Q..~Qn~3~]Ct~~~Ox1.. ~0.~ ~
...._...12_.._s.~~:~e~._ 4~~x.enua---....F~.....Pl~~ca~...F~.Qx~,~~
(Name of Lienm's Emplvyer os person with whom he contracted)
f pesformed labo~ and
he t furnuhed } the f
ollowing scrvices and (Here describe the la6or or services per
f
ormed or
materia~s
materials furnished. Describe specially fabricated materialssepa~ately)_. _pQint.,~ ~Suppli~es__
. ........:........~.------•------------•-----__......__........_....__...._.._.._.-------..._....-----...8t~
C
~ ~ .D.
-------•----•------------------------------------------------------------•------•--.__._._..~_.....---.._~._REC,p~qp-~+'~ ta--•-•---...--
- :'lS~~~-------=.._...---
JAN 23 AM 8 i q2
-•--._.-•--------....._.......---_..__._....~..._.__-------..RDSE$.~ ....~~~~or~~~
to the value of_..~~.].23...?.9_._ ............................................_-----~i•ERK CIRCUIT
(State con#~act price)
me the f
ollouring described real p~operty. (Describe real property sufjficiently f
or identi
jication, giv-
ing street and number if knoum) :_..a,].Q~k._~_
o~_l~~s~.~tlnd..Qnix...Dne__An~o~c~iing....._..._..
to the plat_.there . o~._~~cQ~dgd.__~~_._p~~t~oQk..~o~.. 1~_ .Pa,ge_.30 '
,__of _ the . ~?b~~ ~ ..:'i~~o.~:~~ _.Q#:..~~~_..~!~~~~ _.GQ~~Y_ .~~o~~d~!....----- -
h'
oumed by._.._.Edg.ewater _/~part}~ents..._~nc. ;
(Name of oume~ against whose interest lien is claimed) i
whose inte~est in such ~eal Qsopest~ is... J.,.__J, _Sambatero-.Trio. Construction_.Co ~
- - - -t-
_ (State owne~'s inte~est, as f
ee simple, li
f
e estate, lease-hold, i
f known )
r
He f
u~ther says that the ~~st item o
f r~ii~s was{ fu~ ~ on theH~.n~b_________________
~n+~eria~- ~
_day of_.~ovember______________.__._____________~ 1g66___~ and, of the conhact price stated, there u unpaid
the amount ot---~?,.~?3._7.4---------------------------------------------------------.....--------------._..-----------------....--------..._
(State amount unpaid~.
f
o~ which amount h'e claims a lien on the real prope~ty herein described. ,
8lchard+,~ ai t u act in~ o '
~ ~ - ' ~ In c;
, >
atu~e of Lienor)
:
Subscribed and swo~n to be ore me this....../rf'~ ~
1 ay o _ 19G~ ~
~~~.a.tti~i~~f~~~~~~ .
; '
G~ A ~ ~ @Fyif ,
~~,C~~'~~'~'1'~,ys.,;;;;;: 4 (Notasy Public)
' C -'t C;~-~ ~ ~ % ~.cn = • ~ ~II ~it. Sttto cf flcr..'.m a rp,~
` ; _ :-a=~~~; .fM Commissiao E,~;u ~q. i~t iSG9 ---,~~~ll-~~
......................•-----•~iCr?.~.l.~~.---
= : rMy Co~rt ~..,P.~~1if6~S~.b_~?..ac.. r.. ~ ck..~, (County) (State)
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