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ri~ isn M[cH~a~cs . RAMCO FONM 120'h
UEN IAW. fS 717 W
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Betore me, the undersigned authority, peraonally appeared ~A/l ~~L...,. yQ. S../...
who. being duly sworn, says that he is the lienor herein or the agent of the li nor herein, .
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(lienor's Name1
whoseaddressis.__. _ . .~GO ~~~~(~/g ~_.._...~~..~...1.~~....~..~..T.~.~.
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(Lienor's A~dress)
and that in pursuance oi a co~tract with . ~~t........V1/ ~--.1.~'~.~..5.
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lienor furnished labor service5 or materials consisting oi: Describe specially fabriCated materials separately)
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I~~~ G S~^'~ ^f~'Li C~ ~i /~CC02~~4 ivcC~ Gv~~/-l~
~l~s - ,~;~-~..~~,~-y s.~.,;~~ , . .
on the following described real prope?ty in _ _ _ _ . _ County. Florida:
(Describe ~eal property sufficiently for identification, including st~eet and number, if known)
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cE ~,Ue,~~- ~ o F T~~ E, y v f SecTioi~ 8~
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H~ /~'~9h e'~`~ ~A~~ S?~. Luc./~° C
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L e ss. e x~ s 7~ iti?, s •~c r. g G~ o F...~ y~er F.~sr-~i~,q.+~T-- ~
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owned by:..... . t' J~'~.~'"~../~ ~
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of a total value~of . ~kJ~QH /~~L!~c,~¢C . . . . ..~/'~'s!_ ~lars (S ..~9?a 3 ~ "
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of which there remains unpaid S..../.:/.. ~.o?..~. 3_Q..... for which amount he claims a lien on the above
described real property. ,
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~ He further says that lienor furnished the first of said labor, services or meterials an .
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` - ~ . . , 19. .S. f and the last of the same on. _ ~ r _ _ . , 19_~ and (if the lien ~
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~ is claimed by one not in privity with the owner) that the or served 's notice to ow er on .
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~ - . Z ~ . 19 by . . . . . . . . . . . . . . . ~,e%. .!t!~S~!/' . ~Lp' :
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- ~ (Method of Servic6)
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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
owner on _ _ .
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i IContractort ~ E~
on _ _ _ _ _ _ _ . 19_... , by _ _
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1Method of Service)
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 _ _ _ _ ~ . _ _ _
' ~ ISubcontractor)
~ ' 5461`~'7
~ on ' _ _ , 19_ by . . _ . . _ _ _ .
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~ ~ 23 .~i +I (M thod of Service)
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Lienor . ~ .,h• -
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~ , . " _ BY ~t~~~~fr~,
~ Agent ~ _ '1 ty~' . . ,
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~ Swom to and subscribed before me this_ . day of _~~Q'/Q . ~ti~ '
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Notary Public ~ .
l~lti. lii~lr~~i~~~~??? lii~•~~~~i~v( he . ,
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Yt COMM~iS:(~'+ E~~«ES ?aAl. I1 i9i~
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~ . ~ivpE~ ~ tiRu GEt.tiAi INS - lN~iO~FRWLTBI
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