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ri~ 1/77 MICNANICf RAMCO fORM 120 •',
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Betore me, the undersigned authorit~, personslly appesred ... .. ~
who. being duly sworn, says that he is ths lisnor herein or the agent of ths lisno~ herein, .. .. .. .... .. ... ..
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(lienor's Nama) -
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whase address is . ~.. ... .... ~ v~
_ . . ....... . ... ..... . .... .... .... ... ._ ... •
(lisnor's Add~ess) ~
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and that ~n pu~suance of a contract with .. . .. .. . . . . .. .. . .... ..... ... _ ` ~ .
. ............. ................................................................................................. .... .. .
lienor turnished labor, services o- materials consisting of: l~esc~ibe soecially labricated materials sepa~atelyl ~
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on the following described real p~operty in ....!. ~C ~•` . County. Florida:
. ..... ........... ................ .
(Oescribe ~eal propetty sufficiently tor identification, including st~eet and number, if known)
~o ~ ~` I 4
al oclr ~ ~ 1 a~
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owned by ~~ ....P...~Iw~i~r~ .t~.. .... . .. . _, _.. .
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ot a tocal value of . . .. ... .... .... . ... . . dollars (S . s~.~~-~ . ~
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of which there ~emains unpaid S........ _~....... .. . , tor which amount he claims a lien on the above
desc~ibed real property_ .
He further says that lienor fur~ished the first of said labor, services or materials on . ~NN~..' :/~
.19..~.Y., and,the last of the same on .. .~-~C! ~~. ... . 19. O vand lif the lien
is claimed by one not in privity with the owner) that the lisnor senred his notice to owner on
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~ (Method ol Service) .
and, (it the lien is claimed by one not in privity with the contractorl that the lieno~ served a copy ot his notice to
owner on
(Contractor!
o{~ .... . . . . . . 19 . : . bY.. ... .... ,
IMethod of Service)
and additionally, (it the lien is claimed by one not in privity with the subcontractor) that the lienor served a copy
oi his notice to ow~er on
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Sworr~ to and subscribed before me this
%'hi.. Iiix/rrrur~vrl prr/r~~r~~~l l-~~:
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(Subcontractor)
. by.
(Method of Service)
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NOTARY FUELlC ST.4 ~ E O~ tLCRI~A AT LAR3E
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B~I~K,,~~ PAGEI7~U - - ~. _ _ , . .
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