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~i• 1!)) MtCNAN1C~ RAMCO fOHM 120',
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Before me, the undersignad authority. personally eppeared Phyl l is Chamb~rs
who, being duly sworn, says thai9~e is the lienor herein or the agent of the lianor herein,
CHAMBERS TRUSS, INC.
(lienor's Name)
whoseaddressis 3L05 O.l~ander Bnulevard, .~.orC Pierce, Florida 33450 .
(lienor's Address)
and that in pursuance of a contract with Frank ingram, ~33. F~rnand ina , Fort Pierce,_ F Ior ida
lienor turnished labor, services or materials consisting of: (Describe saecially iabricated materials separatety)
Roof Trusses
on the following described real property in St ... l,ucxe ..Caun.t.y County. Florida:
(Describe ~eal property sutficiently for identi(ication, including street and number, it k~ow:~!
Lot 22, Block 485, Section 10,
1601 S. E. Floresta Drive,
Port St. Lucie, Florida
owned by
Frank.Ingram
oi a total value of Tweqt.y Thr~e _ Hund Xed Fort y Tt~reP and_.64/ ~O~Ilars tS 2~43 , 64 ~
oi which there remains unpaid S 2343 . 64 , for which amount he claims a lien on the above
dwcr.riF-wd real nr~nwrtv
He turther says that lienor furnished the first of said labor, services or mate~ials on
F~bruary 2b , 19. 81 , and the last of the same on February ~6.. . , 19.8I , and Iif the lien
is claimed by one not in privity with the owner) that the lienor served his notice to owner on .
.19 .bY ,
(Method o( Service)
and. (if ihe lien is claimed by one not in privity with the contractor) that the lienor senred a copy of his nutice to
owneron Fcank.Rog41.i.~o
(Contractor)
on Februar.Y 26 . 19 81 .... by.. riail.
(Method of Service) ,
and additionally, Iif the lien is claimed by one not in privity with the subcontractor) that the lienor served a copy
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of his notice to ownar on _. _ ~"
. . . ,~,T_„_, _
s•~~~~ (Subcontractor) • ~` ^ ;;~:" ~ =
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on ~9~ ~~i~ ~~z ~ti '~~= Dp . .19..... ,by . _..... _ ~ ' : .... '}~ ~-
IMeihod Of Servic~- :-: , ,, T ~: ~
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SI lUt~f CCU~~ i.t;:. CHA'iBER -TRUSS II~C. 3.^v.5 ~lea d~:;~•t.``~ie: ,~~i.
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Swom to and subscribed before me this . _ ~ _. . . day of ..... ... .~.,'.......... ~~~ .': .i~.µ . 19 O ~ .. ''
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: I~Idr~~r~.s. Notnry PuWk. fbrids, Stste st Lar~,`-. ~~, _,;;,_ ~~ yy"q` .
Mp Commisslon Exp~res trovemGer 16, 1y~4 ~ -• = ';, -
I+R 8ondad thtu Jedco Inswan;.e 11~,r~r •~'''- ~ ~~~ '~
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