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n• 1!7) MLCMANIW NAMCO FORM 120',
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Before ma, the undersignsd authority, personelly appeared . C~/l,~~l~~
who. being duly sworo, ssy~ that hs is the lie~o~ herein or the agsnt of ths lisnor her~in.
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(Lienor's Nams)
whose address is -~ ~ . .. : .. GL~ . . ~. ~!'~. . . !~. p. . ~ ~. ~
(Lisnor's Address)
and that in pursuance of a contract with . .. .. . . . .. . • ~ . ,
,9 ~l .
~ • . . . . .... ... _ . . ,
lienor iurnished Iabor. services or msterials consisting of: (Describe specially (abricated materials separately)
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, on the following described real property in ... .. ..~. ~.~.'~'~:C'L~ ... County, Florida:
IDescribe real property sufficiently for identi(ication, including st~eet and number, if k~own)
/,2 90 S w !3H ~
Lot#! f3~ ~:37 ~•a~-
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owned by . . ~
~ Q ~f ~,~
of a total value of ~jLC, £ .~ .,~/r~ . ~dollars (S / / .d` / ' 1
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of which there remains unpaid S .../ l d` 7 , for which amount he claims a lien on the above
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described real property.
He furthar says that lienor furnished the first of said labor, services or materials on
p(~ p,,~ 1
~-l~i ~. . 19 D~, and the lest of the same on ICY-~~.. ~ ~ . 79 ov and (it the lien
is claimed by one not in privit~ with the owner) that the lienor sarved his notice to owner on ''~ U'+'~- ~~ ~
. 19 ~ by . . ii.~~s~u~ •
(Method oi Service) ;
and. (if the lien is claimed b one not in rivi with the contractor) that the lienor served a co ~
y p ty py oi his notice to
owner on .
IContractor)
on , 19 , by . ,
, ' f~t. ,~ ' (Method of Senrice)
and additionafly, (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
ss~~s
on
19~1 J<<=+ 29 ~ :2- ~3
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Lt_:-Pk C:~f'C"~ ~ ( :~//
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(Subcontractor-
(Method oi Service)
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.;,,~,__ _ Lienor
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Swom td and subscribed before me this ~- ~-.p..='..d~y~. ,~
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anrnc PAGE 1~0~ .
,19 .by
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Notary Public , ~
:
NOTA1tY PU~U~ S*ti7E pF Ft~RIDA AT ~ • ~
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