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RCMM 3TAMff 0~[MI': tO~M M 1lOYa Mewl~dw«I ~N hr wl~ b iM N. i W. ~ Onr C~sl~f
1ecYw~i1N, FNrIM ,
' oE ~ien ~a
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~caa a~___~.o~i~n.._.__----------------------------------
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~'.ountg ot_.sx_--~~------------------------------------
--T--=-- R:.__~~Q.----••----•------------------------------------------------------------------•--•--......-----........_.....---.........------•--------
(Name o/ Lienor)
_8~16__~enrgi~A~enuer--F~rt--P3ezce,--Flosida.-•----------------------------------------------------------•----
(Residence or Br~sine.u Add~ess of Lieno~)
being duly sworn says that in pu~suance of a contract with CONCRETE MODULAR SYSTEMS,~__
-~-----------------------w__~..___.__w....-----_.__...---------------------._....._...._........._.....__..._.....__._...-------•---......---------
(Namt of Lieam's Employer o~ person with whom he cont~acted)
labos and
he d} the f
ollowing services and (He~e describe the labo~ or services pe~f
orm~d or
materials
rnaterials f
urnished. Descsibe specially f
abricated materials separately) _All__plwmhing
-i~cluding--~~h--~~--as--we~-l--as-- f ~~~,st~ed,--- i.~s~-al ~~~c~-•o€ --sew~r-----------------
-aed-~a~te~-,~-•~os~-~a~~s ;--c~i-s~--wast~er-s---a~d--gaaebage--dispoea~s,
-
~57,970.00 of which there remains unpaid ~6,085.00.
to the ualue of------_____._..---------------------
(State contract price)
on the following described senl propesty. (Describe ~eal propestysu~iciently foridentification,giv-
' ing street and numbe~ if knourn) :___See descri~tion attached hereto and made
a part hereof.
f
I
owned by_-------~QrICBE1'E_~QDIII.AR.~YS?TF.I!~iS~---I~iC..----------------------•----------------------------..._._..------
(Name of ow~eer against whose interest lien u claimed )
whese inte~est in such ~eal p~ope~ty is_ ~ee--si~mp-le--------~
(State owne~'s interest, as f
ee semple, li
f
e estate, lease-hol!~, i
f known )
labo~ r e ormed
He further says that the last item of senrices was{ p'f . } on the..__.__ ~6th____._____.
. materials ~ fu~nuhed _
day of_______ Aug.ust_____--_-------------------- 19_ 74._, and, of the contract price stated, these u unpaid
the amount of-~fr;-0$S : $E}--------------------------------------------------------------•-•----------------•-----------•----------------•-----•
(State amount uapaid)
fo~ zahich amount he claims a Jien on the ~eal property he~ein descri6ed.
- 1: ~ ~~~~~z~~--------------------
" ~ ~ r
. _ , n.~,~~y (Stgnatu~e of Lzeno )
X:`• ~ .
;-~r~ 30th
`~rlt+~e~P sworn to be~ore me this________ a o Au ust ~ jg74___
- r
~ -
•
~ ~
= ..r`r•t ' ~ • ' • L
: r: - . = = (Nctary Public )
:
~ =
'~tr~• - ; ~ ST . LUCIE , FLORIDA
; _
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~=~L~.~;~ ~~~expire.s---- _~b,l~?'_,___ --------~CountyT~--------------------------------------(State~------..
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8~oK23~. ~1430
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