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FLA. 1167 LAWi RAMCO FORM 1i0• i~
Fi 71 J.Oe !s
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Before me, the undersigned authority, Personally appeared-.....~.ar.l....(:.ar.1.t.Qn.,....~.r... ~
who. being duly sworn, says that he is the lienor herein or the ent ~ of the lienor herein,
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~ len ~slackburn `~`ruckin~, Inc .
(lierwr
s Name)
whose address is.....`.' t.'..... ~ is o x 15 7 -A ~ . r".~Prku..~.. l.- ~.3.'l-i."v ,
(tienor s Address)
Jictory Construction
and that in pursuanos of s oontrad with _
lienor fixrahed labor, servioss or materials consisting of: (Describe specially fsbricatsd materials separately)
Fill Dirt anc: labor
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rive 1''c_ousand TNer,t;~ Five & 54,l~lars (s 50?5.54 )
of a total value of
of which there remains unpaid s - ~-v~-5 ' S4 for which amount he claims a lien on the Fdbwing
described real Prey m _ County, Florida:
(Describe real property sufficiently for identification, including street and number iF known)
SCE A~/~~~~~1 5~ <<-~-
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'J ictor;J onstruction
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Feb. 13,
fie further says that lienor furnished the first of said labor, services or materials on - . - _ - -
7 r.iarch 22 77~
19:• and the last of the same on 19.- ,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 . Fe.b.. _
Certified :ail
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....................4...............................,19.........,by...._..._ _
(Method of Service)
Glen Blackburn trucking, jnc.
V nor s
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Agent or Attorr~
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..............................................day of - t 14's:-
Sworn to and subscribed before me this.-.. ' '
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