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4'756'79
lns wCw~~q' 11AMC0 fO11M 120fS
urN uw. rs nsas ~
sefon f11e. tM wldersipned autll0rity. ~
who. beirl~ duly sworn. says that he is tM lienor herein a t11e agent of the Nenor herein
...............Palmer...Gonatrwctinn..Ina_......Lee...a....Palmer...P.ras........................................... -
Itienor's Nan1e1
whose addr:se is..P...O......i3~~G..6.21......P81m..Cit3/ r...F.l.ori-d8-- 3~4'90---•------•----•-------------------•----.....,
luenor's Address)
and that in pursuanw of • contract with.........Hllr~llyt.. CCt18#.xuct~On..Gor}1
...............2b~.O...Holly.woad...A.lYd........Hol].ybcoad,...Florida.- ~~.020.........:........................... .
lienor furnished tabor. servicq or materiaN caaistinp of: (Describe specially fabricated materials separately)
Labor and i~laterials to Trim House ~ ! ~ ~ ~ ~Z
4'756'79
aa:rac aaltur
on tM folbwinp described real property in.......... St LLiC,j, g„_,,,,,,_• .......................................County. Florida:
(Describe real property suffidently for identification, indudinp street and number. if known)
1657 S L. Floresta give -
LO'i• 6 BLOCK 495 ~~C . 10
Leonard Simons 250 Hollywood.•31vd. Hollywood--F-~Q~~,d~
owned by
of s total value of r^.'aur...Hundred..and•-•t eta--and-•~ xt3~ •-~i~~~l~n 1= 410•. 68-•.••.•-.--•••-.-•-.--~
of which there remains unpaid s....!~t1.0...5.8 for which amount he claims a lien on tM above
described real property.
He further says thst lisnor famished tM first of said labor. services a materiab on ep 12'111111
..S.e~atPmb$1" ~s.~9..., and the last of tM same on..~eCe~beT..lQ.........18-~~..., and (if the lice
is claimed by one not in privity with the owner) that the lienor served his notiw to owner on .i ebr31a.2'-y -..5..-•-.•
. "
i ts. 80... by........ ~.~?~:~~~.~.e~.. ~~4~~.....................................................----...........
(Method of Serviw)
E end, lif the lien is claimed btl one not in privity with the contractor) that the lienor served a copy of his notice to
i
owner on .......3urPhY....Construction_..~.4xP:......~hY~1~i.;~...Jf~lrobs...P.r~s _
lCornractorl
Februar '
on ............................y..S.................................... , te..~.Q., by......70'2a.x~......~.srtif.led-----......................... ,
(Mettad of 8ervicel
~ and additionally, lif the lien is claimed by one not in privity with tM subcontractor) that the lienor served a copy
{
t
of his notice to owner on
(Subcontractor)
i
I ~ (Method of 8ervicel
`\`\Nllfllilll~~f~~~
, ..........Pr~~.m.er...C.ons.truction...iric
~ J ,
a.J i 1~ ~ ~ sy........fee...~.....~?aLner.....P.res...
Agent
J ~ (v
- . `
SwonkQO ~ me this._~ day of ...l ...............19.8..f~..
~ ~jy~ - /
. r ..........fir..........
- Notary Public
This I
nsf rti mPn f prpparPd by: MOFJI/y ~INtK tA111! ~ lUtftiM ~ 1~
AJdrPSS ~ ~~1~4 itrOOIIM1yMON~~MC.OMM
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