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"77464 •
ru? ~ccw?M+cr RAMCO FORM 120Yi
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Before ms. the undersigned authority. personally appearsd -
who, being duly sworn, s that he is the lienor herein or the agent of the lienor herein,
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lUsnor's Nams) ~~1l.DF~P/~'ij
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who9a eddraas is r.......... ~
(Uernor'sQAddress) / E
and that in pursuance of a contract with ~ L,7. • • • ~ • • • j~^~~'•
lienor iumished labor, services or ateriats consisting of: (Describe specialY fabricated materials separ ely)
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on the following described real property in...a~... .................:.............County. Florida:
(Describe real property sufficiently for identification, including street and number, if known)
owned by .._2..~.. ~...1--. ~`'.-..1..--- ~[l-.'^ -.r..'
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of a total value of ~.,,....~~....(t...~......... ~ dollars IS ..J.`.,~(-.D...~.•..........)
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of which there remains unpaid S-.~./..,i.-.,/-.-G£...~ for which amount he claims a lien on the above '
described real property.
He further says that lienor furnished the first of said labor, services or materials on ~ ~
s
. 19........... and the last of the same on.............................-•-•------ ,19.........., and (if the lien -
is cl>~ ed/by one not in privity wit hs owner) that the lienor served his notice to owner on ~
(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)
- (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) f
Y
k .
(Method of Service)
4'7`7464 . .
iy~0 FFo 28 ~ 2 I lienor _ f.• :
ST.LliC1E CCUYiY.FI.'.. By.---••----• .............:..................._.~..~._t .....,.~.~-..:,..._c
RJGER POITRAS Agent . ~ ~ ~ ~
CLEnI(CfRCU:i CCU?i :fit'
.
Sworn to and~ttitb'sr~Fitfett fY~~ore AS'1^IM3~~°.'2. ..............•--........day of "e ~ _ .p • ~
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Yl
Notary Public
This lnsfntntrarl prrpur~•~l b~-:
! ?+01A~y f'IMLIC sU?h a aaua? iwc~
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~ ~r,r~.Yll t!1'~~~ Mr GOMMISSIpI ~IREi MAR. q Mfi>f -