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Before me. the undersigned authority, personally appeared 1,.~-[~....~`..... ~ • • ~ ~ ~ - !
who, being duly sworn, says that is the lienor h ein or the agent of tM ti,,enor,~Mrein.
,.~.~~~~~-1~~.., .
.
- _ (lienor's Name)
whose address is .,/~.~t~....... ....,~iLP........... .(~G/ .-:~1.~; ..~J-CI.L~.G~..... ,
(Lienor's Address)
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and that in pursuance of a contract with PLL~./f t~ -..~6,.J..e~'7. ~ ~~.~!Y~-~ - • • • ~ ~ ~ ~ .
lienor furnished labor, services or materials consisting of: (Describe specially fabricated materials separately)
d~ ~ x y
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on the following described real property in ~.L/.. L~~ ......................................County, Florida:
(Describe real property iciently for ide tification, including street and number, if known)
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_ 3
of a total value o .,(/L~.•~~..d'~~.~`. . ~!L~isJ.-/.~la!..v1~[~(~Fit~'~..... dollars (S -.-~..rf-.o3..~ -.~.v....)
of which there remains unpaid S...C~~ ..,~1...3.~-..,3.Q for which amount he claims a lien on the above
described real property.
He further says that lienor furnished the first of said labor, servicens
or materials on .~,yQ7.`...
, 19~L.~ and the last of the same o~--~JGtr1LJ.. pt.~. _ , 19.(v/~_/ ,and (if the lien
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is claimed by one not in privity with the owner) that the lienor served his notice to owner on
................19.........,b ,
y...........
(Metho of Service)
and. (if the lien is claimed by one not in privity with the contractor) that the lienor served a copy of his notice to
owner on -
~ (Contractor)
on _ . _ _ . _,19.._....,by..........._... .
(Method of Service)
and additionally, (if the lien is claimed by one not in privity with the subcontractor) chat the lienor served a copy
of his notice to owner on
(Subcontractor)
t
~ _ _ ........_..19........bY .
on _
1 - (Method of Service)
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BY......._ y~.~7~:.:~.~...:..... _ -
Agent ~ ~ ~ _ .
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Sworn to and subscribed before me this _E~~ _ _ .._......dsy of 4~~-. vh'.f ti..1 ~
.f~:~.-,~,r,
Notary Public
This Inrtrumr~nf pr~~parr~d b~•: C_ ~t~tr Luc ~t st-.: ~ f 4~
~~r~rlrr~ss Shot,t•Y 41, W ~Si(~v E,r~RES I1 19~~
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e ~ 1101~fp twtu ~N, v+oERwtlti~
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