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salon ma. tM undarepned authority. PersoeeMY appeared
who. beano duly swore. ssys thst he is tM lienor hiMein a the a~+t of the lianor hNein..
.........................:.........................................e~:... ~......:../..~w.t~
lLNnor's Name1
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whoseaddrassts.......t.~lP.~/..~f~.....Z........~4.x:..~~.r..v ::.....:.:.:.:..~r.~:..~/c.-e r.....T.,~!~:... -
lt,ierar'e Address)
and that M pursuance of a contract with..... C./~ 4l.~t!t.... ~P..4.~!!~~r ...!!...,~d.~:~f 1~....~1.1.s6~r1.~~... .
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Manor fwnished labor. services a materials oo~no a: lDeax~a spadally fabricated materiab separately),
~iwG ~6.r andc~i.~s h~/e~ Psficisre~~ a~/ •
d yi I~ ~ NG A?i a ,ti G/ -
on the labwino described rani property in ~ i0'G ~s.'...•--•--•--..........~...........Coartll? l:brMa:
lOescribe real Property sufliderrtly for identification. itw~ludino street and number. if known)
St' G • 3f' - 39 - Sb~ e ,liEjijr a b~ Qt, SdN• lo.. o f S d'~'~
o ~E j4 rv >r S• yL /'et f e^?c a ki ~ ~ /.~e o.7 ~tef y~L To rt/
of to Poirot ~i+3.os- PPC~ .~o.rtS e ~ fe~~.- d~' S«tio~,~
t/jL~.~ • /V ,t~ • or fps ~~G,+c s r Yo Pai3 - - w ~ i fit t ~o r
rods ~„~t cc+r~ / if/w
owned by ...........U..~[s.~d~..... D....S~P..tJ.1! r ......~.~.~........J~.d.Ca!
~.....:.~.~t r7~s .....~~~!'~~.r
r,g tci~s
.........y...
a s total valve a .~s~a~...bra.~~~xa.P...Zvi...~trrrdcerd....~.~f~f~~~s/+~oaa~ is 7 F
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a which tf~era rrmains unpaid s......~s ~ .7 .for which amourK he claims a lien on the above
t
described real property
He further ssys that lienor famished the first a said labor, services a material on ~j~r••••
p
........18..71!.... and the last a the same on......s`J.~c,~.~.d.!,1..... , t8..~~.. and tit the lien
is claimed by one not in privity with the owner) that tM lieeor served his notice to owner on ~ !
,Q / _
(Method of service)
and, to the lien is claimed by one not in privity with the eornractorl that the tieaor served a copy of his notice to
owner on
(Contractor)
on .........................................................................1 s........... by......................:.................................................... ,
(Method a 8ervics)
and additionally, lif the lien is chimed b1? one not in privity with the subcontractor) that the lierar served a copy
of his notice to owner on
lsubcontractorl
..'75164
1 qr, . ts.........., by...........................................
(Method of serviwl
t9~0 f~6 -5 AK 55
511!
G~~MTYI.~FIA. «^or
RO POITRAS
CIfRK ClRCUR ~~IjRjJ
Mt~~~'uu' RECORD V~81FIEt!_ y Agent
_
~~us `A'ry',,.
(~f.
before m• thh L day of ` t 8
='f: t,,, d. ~ ~ , Notary Public .
•,,r ' ~itl prrpernd bv: A~ atlN.it AA7E aF fl.!~ItIQA AT tNIGE 7
t • ~ • s ~~{J ~ MY COMAUSSION E~IRFSr ST?T .12 198 ' a -~~r~
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