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Before ms. the undersigned authority, personally appsared~i~~,Q. ~,1~..~.~..~~~«..
who, being duly sworn, says that he is the lienor herein a the agent of the lienor herein, .
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(Lisnor's Name)
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whose address is.,.....~~~•a......~.l~f/~Ir~l.~.~.....~~~f.~ ;
(lisno/r's Address)
and that in pursuance of a contract with ....4:.~~~...,C..,~.~~~T~~~~ 7~'lQfy
lienor furnished labor~ervicss or materials consisting of: (Describe specially fabricated materials separately)
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on the following described real property in....S~' ~~~..................................County, Florids:
(Describe real property sufficiently for identification, including atrest and number, if known)
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owned by 5~~1.--.~%~ L~/1...". SO? L
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of a total value of .............................................................................dollars IS~~~,,~i..--...~. ~
of which there remains unpaid Z..~I~.,~.S.s 2.y 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 .Cv!!t~ ~
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,19......---•, and the last of the same on...~P'..~.~......----.........:. ,19.01-d, and (ii the lien
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is claimed by one not in privity with the_ owner) that the lienor served his notice to owner on
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19...-•-----• by......../~rfc~~-rte ......~~.~x~.....-..-...........----......-----------.....---........
(Method of Service)
and, (if the lien is claimed b one not in privity w th the co rac~or) that the lienor served a copy of his notice to
owner on
(Contractor) L
on ,19.........., by.................... , E
(Method of Service) '
and additionally, (if the lien js. cl~ a by one not in privity with the ub ontract r) that the lienor served a copy
of his notice to owner on . .
(Subcontractor)
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(Meth of~S~ : ' -
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19~ .NI. ~ 8 PM. L• 5
FR.EO ~ FECORDED ;
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U4 CIETRA~R~ ~ ,
CLERKCIRCIIITCOURT_+~~ ~
RECOitO ~'ERIFIEC~_---- • +~if~,,, ~ ` `
Sworn to and subscribed before me this.........._...,1 . ........................day of 19Q....:.
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Notary Public
"/'Iris Ins?runn•nf pr.•por~•d h~•: -
• rrof~llr f~lc sTAr~ of At~wn rv _
' Iddr~•xs MI COMMISSICIN Wit3K MAR. W Nq s
BOCK 3•.~5 PACE ~ T1911 cep Ma .
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