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~u~'+rc~uw~ca~ RAMCO FORM 1204
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Before me, the undersigned authority, personally appeared
who, being duly sworn, says that hs is the lisnor herein or the agent of the lisnor herein,
(lisnor's Name)
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whose address is ...."T ~~-1...... ~.R.~'~.~~..... ~ 4~~. • `..'1.. ~ <<-~.:....i ,
(lisnor's Addre~ss)j~
and that in pursuance of a contract with.... ~~~lK......~.~...--1.. r..~Tl~~~ . ,
lisnor furnished labor, services or materials consisting of: (Describe specially fabricated materials separately)
LaboC~ t-~a~ ~ i tap ~ n , ~r~ pt~--t~~, n. ~n ;
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~a ~ t ~ ~n ~ ~ ~ d~ ~ 1 I
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on the following described real property in-........... ~~.r.... L.UG~.~-
.:...................................County, Florida:
(Describe real property sufficiently for identification, including street and number, if known)
owned by.........,~""~'.~..71.~G---~-~--/.q/II~jj
of a total value of ~~~.~..-....1.~I~.1.~....~t.1,~~....~U(Y.~C~..~U?t!1~~„{~?~ollars (S --.~~.j~ Q ~.t... U.v
----...-....1
~ of which there remains unpaid S ....,~..i..r.Q.~-..~. for which amount he claims a lien on the above
i
described real property.
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He further says that lisnor furnished the first of sai Iabor~.services or materials on :~!.v~....~~
` . 19. and the last of the same on.~.J~r...-~~...-:.----..... 19.~., and (if the lien
' 19
is claimed by one not in privity with the owner) that the lisnor served his notice to owner on yJ.
(Method of Service)
and, (if the lien is claimed by one not in privity with the contractor) that the lisnor served a copy of his notice to
a
" owner on
(Contractor)
on ,19........... by......-...-..................-..----..................................-----
(Method of Service)
and additionally, (if the lien is claimed by one not in privity with the subcontractor) that the lisnor served a copy
of his notice to owner on !
t (Subcoontractor) / G
(Method of Service)
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fgT9 Of C 28 PN 2~ 38 ~
FILEO RAG FcCGKOFU - - . . -
~ YrI~Ve7/fr St LOCI COUNTY.fIA. Lienor -
~ ROGE~ POITRAS • 4 : • .
) CLERK CIRCUIT COURT - ~ ` -
AECOItf VF .1 .[t^.._ ~ ~ ey -t~
Agent _
• ~ = ~ ,
• . J• _
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Sworn to and subscribed before ms this_......_--..-- ..._..-day of .............................;;.,-`.'...'x:.,19. ' . ;
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~otary Public
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.•lddrr~sr _ ..ntiaa iuk~c SU?TE OF ~ INGt M