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rIw un yECNi?Nres' RAMCO FORM 1204
l1rN IAW. rEt 71101
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Before me. tM undersigned authority. personally appeared ~ . `
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who, be' duly sworn. ys t he is the lienor herein or the sgent of the lienor herein.
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(Uenor's Nams)
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' whose address is......~.J .d..........~~"'..: ~'ln~ ~ ,Q,a, 3 3 ~
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(Uenor's Address)
and that in pursuance of • contract with......
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............5...~..~ Jam//Jy~.jx-~...
lienor furnished labor, services or materials consisting of: (DesdFibe specially fabricated materials separately)
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on the following described real property in........oL1C,r... ............................County, Florida:
(Describe reel property sufficient) for ids~fication, irtcludi street and num r if known
• . ~ ~ - ~ tel. ~~G~-~-,,:R ,
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owned b .................r......................
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of a total value of ..Y..~l..z. . dollars lS ....7y.. v.....----)
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of which there remains unpaid S ~ for which amount he claims a lien on the above
described real property.
He further says that lienor furnished the first of said labor, servic~eQs or materials on
- 4 ~ , 19..7sf., and the last of the same on.....V... ~ .19. ~.1.., and (if the lien
is claimed by one not in privity with the owner) that the lienor served his notice to owner on
.
------------,19....------• bY----•---...............----.-.....-...........
(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)
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 .
489963 (Subcontractor)
on 19.......... by..........................................................---........... .
~ (Method of Service) '
1980 JllN I7 AN ~ tl8 ~ ~
F E6 //~~NQ !!ECORItEB Lienor cc+•" •
S~IlUCIE C0171TY.ftA. ~ ~
RpG~R POITRAS - ~ '
CLERK CIRCUIT CO!!!tT ~
ey.......... - .
FtCCAB YEPIf IEC' Agent - _ -
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Sworn to and subscribed before me this......-._............ ..day of ..........19
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( Notary Public 'T"~~~'
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