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~M 1l/l MkINANIC• pAMCO FORM 120~~i
, 1UN lAW f5 ~1~0~
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8elore me, the undersig~ed authority, personelly appeared . ~~~~ ~~~
who. being duly sworn, says that he is the lienor herein or ths agent o1 the lienor herein, .
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(Lienor's Name)
whose address is ~ V ~~~ti 4 ~~~~• ~ O ~ 7
(lienor's Address)
and that i~ pursuance ot a contrect with ~~GCT~~9 ~'l~-7'~'~~ ,
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~/
,
lieno~ fu~nished labor, services or matsri~ls consisting of: (Describe specially iabricated materials separatelyl~
a `~ ~ ' ~ ~u a~--.~ w ~Q,(%
on the foliowing described real property in ./: .-S ~- • J~ ~ l.t•C~- . County, Florida:
IDescribe real p~operty sufticiently fo~ identification, including street and number, it known-
S~'R,E;F T~' o~ cF c! S- ~. W c~.--~ /~ /Hd •
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owned by ~` y Li~~~~'''~ . , .
'~ , ~~l~~~/;n ~ /~ ~`_° ~ vv
of a total value oi 1 '~`-~~ yl.~~tiR~4" £ ~ /~N-t., ~(~ars (S ~~ ~S - )
1 L~
of which there remains unpaid S , for which amount he claims a lien on the above
described real property.
He ~urther says that lienor furnished the first oi said labor, services or materials on ~ a+'`- ~/
. 19 C ~ and the last of the sam~ on ~~- /`l , 19 G~,-and (if the lien
ll
~ o? 1
is claimed by one not in privity with the owner) that the (ie~or se~ved his notice to owner on
.19 a ~.. . by .
~ iMethod of Service) ~
and. (if the lien is claimed by one not in privity with the Contractor) th~t the lienor served a copy of his notice to
owner on
(Contractor)
on .19 .by ,
(Method ot Se-vice)
and additionally, (ii the lien is claimed by one not in privity with the subcontractor~ that the lienor se~ved a copy
of his notice to owner on
on
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Ig61 ,f.':'~ 29 P;? i2- ~ 3
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Sworn to and subscribed betore me this
19 , by
(Subcontractor)
(Method of Service)
~~v~ ~~~
Lienor
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•:~~LyS _r:~'~';; .y~. :. Agent
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~~ :x:.,~~ ~1~J #.= Notary Public
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