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4`76960
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Before me, the undersigned authority, personally appeared . . . • •
who. being duly sworn, says that he is the lienor herein w the agent of the lienor herein...
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(Lis is Name)
whose addressis.....J L'~0....F ............................m..~~..~.....R.~^.....~T /~/F.eC'_E- ~~/f- _
(Lisnor's A~dd~ress)
....----.t! , t
and that in pursuance of a contract with.....---.~G"'~ ~.¢-''E'er '
lienor furnished labor, services or materials consisting of: (Describe specially fabricated materials separately)
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on the following described real property in.-......~ -------------County, Florida:
(Describe real property sufficiently for identification, including street and numb i known)
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owned by--~ !l - s
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of a total value of ...i~ <1~!%!'~~( . dollars lS ~~O • G ~ 4
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ttor which amount he claims a lien on the above
of which there remains unpaid 5----..-.---.•-•-------••
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described real property. }
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I - He further says that lienor furnished the first of said labor, services or materials on . ~ ~U . -
~ qq j~ ' / -
, 19.T/.., and the last of the same on...d/..-~!~r...a2 '7~... . 19..7, and (if the lien y
is claimed by one not in privity with the owner) that the lienor served his notice to owner on ....J
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19 g.Q.., by.... L.--,~. ~
t
ethod 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
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F owner on ZGi-i.R.G~Ct-...-.L.O.../.-~ . -
C Contractor)
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on__ ...............,19..........,by......-..........
(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 . _
F
`
(Subcontractor) ,
4`76960
on._ ...................................._........,19...........by--......................................
C^• ~ (Method of Service), ,,tti;,luuliii,;,
190 Ft.~ 2 4 ,
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SLLUCIE CG'•JaT'~.i Lienor ~ _ ~ ~ _ ~i
CLERK CI:'.C~~IT C~'~? ~ •
Agent rC rt ~ ,^-1; ` -
Sworn to and subscribed before me this........ _ . .....day of _ . ,19:~ ~ a
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_ _ 1\ Notary Public
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