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Befon n». th~ und~rsi~d authoMY. P~rsonally appear sd l~ y/ C~-S' S'r'
I wlw, b~in~ duly sworn, s~y: thd h~ is th~ l+enor herein or ~he a9en~ oF ~he tierwr herein,
3 the attorney ~
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(Li~ s Name)
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(lierwr s Address)
and that in purwsnc~ of a oontrad with ~ U C CJ .._.~l~1C [.~_l~ f~C?/L ~4 i'~' c1 ~
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~ k~nor furnished labor, sKViots or matsrials oonsistin9 of: (Describa specially Fabricated materials s~paraf~ly)
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( Se t 1~Rc ~ rQ~'ss
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.s~ 7"h ousA ~v d F~ V~ N k~,~ 2 r= dollars IS 7,~ ~•3 7,J
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h f h ere remains unps i d s~~`~~• ~ s ~ , for w h i d~ amount h e da~ms a 6en on t he f
d bwiry
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(Describe real prop~rty wffiwNly for identification, induding slreet and numb.3r if known) f ie ~~M r'h`
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~ IlSo~c t~? $ 9~~~' ~qs r~ts" ur tn rh a~ p r. ~ n~. ~iy: rhrnr r'~~n, I,~u~~.~ S~•~c rh
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5q;d ae~pEety cL/~o bt'~w~9 ~/cs~~I?.AeV C~,`' ~e/lr.~.;" /~cr j%~ln~v rhe:
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Fle (urther says tha~t lienor FumisF~ed the first of said labor, ser~~ces or ma~er~als on b
19..---, a~d the lasf of the same on .~l(.: hl ti= . / 4~ , 19 1 and (if the lien
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~ is daimsd by one not in privity wifh the owner) lhat the lienor served h~s notice to owner on ~
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•~r~.•~883 : ~ (Method of S~rvice)
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