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LIEw LAW. rt 71~OEi
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Betore me, the undersigned authority, Personally appeared
who, being duly sworn, says that he is the lienor herein or the a ent of the lienor herein,
C 2 (lienor's Name) /
whose address is U `..!-V..e..R..... ~..1. Q.-KJ--.....~~ V R. ~.....F..F .Q... 3 ~r...g
(lienor's Addre/s~s)
and that in pursuance of a contract with-....G.~...~..!P.f..,S..-..57.. V. ~.~-!C.R.N.-~.S.,c../.~ ,
d..o.~..-~~~ ^!.San!....C...~'..........t~"-..-Sf.....~..~.c.i..e
R...v...-.
lienor furnished labor, services or materials consisting of: (Describe specialty fabricated materials separately)
z ~ f-t K s ~ ~ o R ~ M en! ~,l ~l ~ . O O
M~4~ e~P~ ~9~ ~eR CA fi~NPISa I$• 30
on the following described real property in.. 5.~...~.C,'..C.1.l; .....................................................County, Florida:
(Describe real property sufficiently for identification, including street and number, if known)
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5-f • ,C v c i e
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owned by....~..~..R...I..S...-..~..~J..!~-..U.~~.~-Y...S.~'.-.~ .
ri • J C ~y O / /
of a total value of ~.jC...,~w,.Ll~.~..u-~.. ..5.~.~/.'.R~-..::?. ~-1.~7.~a~.-dollars (S -Gp-•~.1~•~ •~~-b•-••~
of which there remains unpaid 5...--~r-•L(t--c1~•-r-->3•- for which amount he claims a lien on the above
described real property.
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~ He further says that lienor furnished the first of said labor, services or materials on
19.........., and the last of the same on..........-.-............----:.....---- . 19........... and (if the lien
is claimed by one not in privity with the owner) that the lienor served his notice to owner on
.........................................,19.......... by...-•-•---------.....---------.......-•-•----------.....- .
(Method 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)
.19--•---...., by.-----...........-----------............-~--•-••----.....------.....-------
on
(Method of Service)
and additionally, (if the lien is claimed by one not in privity with the subcontractor) that the lienor served a copy
of his notice to owner on -
(Subcontractor)
(Method of Ssryi~dl•. ~ L I4 ,
1~~-~~.~.:-6.
ST LCC'E f.t~' ~T Y. ft r ' - -
CLERit C~"Cl'tT i:1::..b Lienor -
..:iii?..yr~'. -J~ ` ~ -
_ .
By
441633'7 Agent .
Sworn to and subscribed before ms this .................L-.....--......-..-......-...day of ......ll/.~.V........................-.-..'-,.,;.,,-,n;~8'
...4l.-..-~--l.~l.~..--
Notary Public
This lnsfninu'nf prrparr'd hv: trOTAty SIC S1ATE Of ~
Addrr•sc ~R
aQa><320 P~~E1633 ~,l?t
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