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,lA MECHANICS' - RAMCO FORM 120'.
IIEN LAW. 7170
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Before ms. the undersigned autho?ity. personally appeared ~~~~G~~ ..Q .
who, bei duly sworn. says that he is the lisnor herein or the agent of the lisnor herein,
(lienor's amsl y ~
whose address is `-J~ d..... t'~1.~4-~Cw.....~~~~l~l. ~-~.../.~rlA.. ~ }
(Lienor's Address)
and that in pursuance of a contract with............ ~ ~ ..C , ~
lienor furnished labor, services or aterials consisting of: (Describe specially fabricated materials separately) I
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on the following described real property in 1 • c~~ ...........County, Florida:
(Describe real property sufficiently tor.identification, including street and number, if known} -
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owned by ....................~.G.Q..~~..-..-- :.~...~t'.~/
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of a total value of dollars IS ~
of which there remains unpaid 5 for which amount he claims a lien on the above
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described real property.
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j He furth r says that lienor furnished the first of said labor, services or materials on ............jj............ _
~iO / ` ,19...~and (if the lien
19... and the last of the same on....
is claimed by one no: in privity with the owner) that the lienor served his notice to owner on ;
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...(/..Cpl-...............,19.~..by..........
(Method of Service)
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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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owner on +
(Contractor)
............................_.............,19...........by..................
on
(Method of Servicel
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)
Et7~~ (Method of Servicel
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FtUGFR PCITRAS
CttCK C:=CLlI? C!'L'/Ri`T~, y~~` BY t'.:.~..`, .
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....day of 19.~..
Sworn to and subscribed before me this ~ ~ ~ r"
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