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iLA. 1~67 LAWE ~ 11AMC0 iORM 120M
F• 71~.09
(~l~tim ~f ~i~~t
~ixts o~ ~loriDa 4i~r~.i;~ilr -
~owtt~ of ST. ~.u~:~• Co~s„7Ty ~
Befor~ me, th~ undersi9~ed autlwrity, personally appeared •7~'1~1'1.+t~~ ~ G. l1~~~~, ~R.
who, bein9 duly sworn, says that he is the lieno~ he~ein or ;~he a9°"~ # of the lienor herein,
the attorney
~ . ......:..................~.a.~T~?s.~W.......,~~s.jlHit~¢A~ ~y ..=.~.?C...._.. _
~ (lienor's Name)
whoss addreu is . Q.~ ......I~•.. E.. .Q. .ST. - ~/~es~Ieo 6 ~ . /G/• VZ3 ~7' Z. ,
(lisnor's Addross)
and that in pursuance of a contrad with ~ie~aK .!Y~.he iu_... a f `~l- F
~ c~.~ 1 dcRS., ,~~ve. - ST ~ ~•?-R.~", ~
li~nor Furnished (abor, services or material: oonsistin9 of: (Desc?iba specially Fabriwted materials ssparately)
~u ~e,vi s k. ~ v~ i a1.sT•~/ 3- 7ot1 f~ ~C . LC.c~, T. ~9-~ r e.. ~
t,J - ~ o K~J ~E/e~,T, Fu~t~lwct tJlC~v,crtiet, '+/°~'t°o~ 3 Te~aJ
'Lftpqc~-Ty eool.~~ eoi/ p~ks 3'~4` ~u,~s,
y a~,r.~?' 6o~iel, lP,~
s~yo~~y ow~/~T , C~J R~'r~.~w A-i;e G,e~ ~F Rcok;,a~l~ - eo~o~«
p~,P~, d~~~~ , ~z~ ,Ex~. ~~,~s ~/uwr,;~,; 1,~yu ~s
/1 ooaQ vst7r , T-.sl~tT ~.~1r.eo/ 4~ ~.e ~ i ~e~"'r' ,r .~1fiie.QA,Jly.
~ ~fxT. 1?eF~t:G, p!pc, d~e.si~ ti eotlT~o! wi~~s .
oF a tdal vslus oF...~~R~N.t~ ~l u~tJd2e~ TC•tJ dollars (S /3 / O. t) O ~
of which there remains unpaid s~•3/O • DO , for which amount he daims a lien on the Followiny
' described real Prope~tY _ . ,S'T? ~•..t~-~'. ~ _ . County, Florida:
' (Describe rea) propsrfy wffidenfly For ideMiFication, induding street and number iF known)
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` IC o? 33, 73/c~K /l0 2, S"~~-~-~o,J. ~
i . ~ FiLEO Ah3 Q'. C~RQEO
s ~~R1 ~Ti ~L~-CiG~ S7. ~6L~IC Csoc~..u~ry S?_IUCiELQ~~h.r.FlA.
I RQG~P POItRaS '
~ c~faK ciacu~~ cou
g ~I OR ! d H• ~ECORO YERIF~ED
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~ Hs furiher says that lierwr Furnished the first of said (abor, services or materials on -
~
3
~
~ ,^~.~Qt.T_~-•--_~.v 19.7.i'., and the last oF the same on ...L~.t!.~T'. ...Z~? 19 7d~, and (iF the lien
~ 'rs daimsd by one not in privity with the owner) Ihat the (ienor served his notice to owner on
~
~ o . S. ~ ~9 ~ I ' e ~e ,erT ~ ~ e d
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~ - (Method of Service)
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= ~ SMion~ to~acid'-subsaibed before rr~ this--.........~.~. .......day of Ta.6c'~-. _ 19 ~l~Y.
~
~ NOTARY 7i7n:iC SThTE QF e~Ck~DA hi lt•k(iE ^ ~ r,
~ i~ ,
MYCONv~tlSSfGNEXFIRESOCT.51979 i L ~~~Lr%~l.C~t'1-1
y=z . iONOED JFytki C~EtrEltAl I~~S, UND~~cr~u~EJtS .Nolsry Public .
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