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P~operty to be improved: ....._Io~.9,..81o~.~a.~..P~i-~-li~+---~?44~•~-~!!~ -
!`i1,ed in Pti?t Boo~c 10~ Page 69s Pub~lic Seooacd~ of 8t. ~aaie Cbvim~jr, Fl~oacidu . .
(descreption suf
ficitnt for idtntitication)
General description of the imp~ovement: s~
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Name and addreu of Owner: __~[r....di.ZOcca...J~e._Q.. ~?._JlrbAOC.A~ooooua-~-p!0~'~.~t..~_.Ti~t~ies
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Extent of Oume~'s interest in p?ope~ty: (f
ee simple) othes :
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Name and address of f
ee simple htle holder i
f other thun Owner : s '
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(If ownership is other than fee simple, the name and add~ess of the fee semple~ holder
also be given) Cooper ~y ~ p~
Name and addseu of Contractos: ~
••---------------------------------------•----._._--_.---•----Fbrt-Pi°•-rc-°-t.l~y_°.°~'ids
Name and address of su~ety on payment bond, if any, and amount of the bond: '
~ Amount
~ Name and add~ess, within the State of Florida, of a person other than the Oumer signing this
notice, designoted by the undersigned to receive service of noticea o~ othe~ documents_
Titlre. 8eavrit~ Coopa~t . o! .lbrt _
Pie~rce:_.20~__~.. ~So'!itb .8econd Strest,_ ~Fbrt Pie~cce, Fl,oari~s
Name and add~ess of ¢erson to seceive copy of Lieno~'s Notice as p~ovided in Sec. 84.061(2) (b) -
Florida Stattttes (Op~ionol).
------------------•-----•i~----•------____..._.._.__.____..._-----------19_ ~7..
D d rh~ -------day ~f------•---~-_...._.__._._.,
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p,~~~ B, ~ ~tu wne~ (o~ authorized agent)
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Subscribed and sworn to bef
o~e me this____._~.'._~~ ..day .l~t .,19-
My O"~ission expi~es.~l~~.~f~~d____ ~(NotaryPublic)----
,~~„~u~~,, (Add acknowledgment of Oum or authorixed agent of Owner)
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