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/lA. IY67 LAWS AAMCO MORM ~ap1~
FS 71J.00
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d~fon m~, fh~ und~rsi~n~d suthority, P+~sonally appear~d.....
. . ~ the a9ent ~
who, b~n~ dul~r sworn, says thaf h~ is tFw lienor hsroin or of the li~rwr he~ein,
th~ attorney
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................CQ....~u...:.~v...~ Da-F..~.Yv~.
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(li~n« s Name~ 33 9 S/
W~,~. ~~:5'. ..-s.,...~_ ..5~~,~R ~v a._ . .,.R?-~ . F;c
cu.nor : Address) 1~ .
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and that in pursuanos oF a conhad with . . ~ . . ~/T •f . ,
. . . . . . . . _ _ ,
li~nor fumished labor, servioss or materials oonsis~iny of_ (Describ~ specially Fabricatsd materials separat~ly)
Ro o-~ ~ n~~- ~-T~~ ~s ~ ~~~~o R
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of s tolal value of._ . . _ ~4._ . _ . _ _ (ars (S 0 )
G oe
oF which thero remains u~paid S / ~ , for which amount he daims a lien on the folbwin9
described real propsrty S~. C~~ C o v K/T co~~ry, Florida:
(Desvibe real prope~ty wfficiently for identification, induding str et and nu r if known)
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l NOY
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tT.lUCIt COUN1r.Fl~.
itO~ER POItN~S
~ ClE1tK CtRCU1T CQtlft
~ , RECORD YE11{FIED
, ~223~2
owned br. ......D~C.'D....~ ~~S ~ U~~ ~ fv 1 w0
Fb further says that (ienor Furnished the first~ of said labor, services or materials on G~ e~~
19.~Q., and the last of the same on j~~.~ 8. 19 l.Q, and (if the tien
is daimed by one not in privity with the owner) that the lienor served his notice to owner on 3O
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l~Ryu~ ,~e~ d
_ . . . ~9. . , by ~ v P r ~e
(Method of Service)
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. Lis
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~By ? ~
" Ayent or Attorney
Swom to and subsaibed before nw this._ .._...day oF ~O!/ - 19/ _ .
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