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P1~OJSCT ACCdIJNT - FOR PRIVATS WORK•'QA IMPR4VSMBNTB ' :
OWN!!RS NO?t'ICS OF CO~II~lBNC,SMEN'~' OF I~SPROiVSMSNT OF RSJ1I. PR~Ura~ ' ~
(FT,ORZDA STATt?TES 84.131) ~ - :
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A. Deecription of real property `
Street addres~e f a ) ~ ~ / ~
Leqal= ~ ~
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8. ner Deacr' tio o e Imp , nts_ _ ~ ~
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C. Ownera nams and address: e' ~
His i~tereat in the described property: _ ~
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D. Naine and addrees of the fee simple title holde= (f f other tt~an ~
above cwner) ~ f
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Contractor'e N a dreae:
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F. Nam~e and Addrese o~ burety on payr.~ent bond ~if any) ~ .
Amount ot T~ond:, _ ~
t~. ~1"he name and aZdrese within the etate ~of a person other than hfm-
self who may be designated by the awner ae the person upon who:
notices or other documents may be eerved:
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H. ~fame ~nd address of other peraon to xeceive copiee of lienore'
uotices pureuant to 84.061 (2) (b) Florida Statutes: ~
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I. Name and addres p~ Purchaser (our custo~ner) ~
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J. pame and Addrea6 of rnty (if required)~,_. ~
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' R. Job No. Approx. Matoriale $ r. 000- ~-d _ Sxpeeted ,
~ Completion _ -
~ L. Architect Name and Addre~se: ~ . •
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M. Dodge Report: (Check one) Attacl~ec~ Not Availabie: ~
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