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~t~ ~tis ~EtN~H~c• , RAMCO FORM 120tiS
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Be(ore me, the undersigned authority. personally appeared
~ who, bein duly sworn, says that he is the lienor hArein or the agent oi the lieno~ herein . .....1~.................
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(Lienor's Name) S~ C~~C~
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" whose address is .
. (tienor's Address) -
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~ and that in pursu nce oi a contract a~ith..?..C~~~{~~..... 1 .
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lienor furnished labor, services or materials consistiny oi: IDesc~ibe specially fabricated materials seperately) _
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ors the following described real property in.....~.. ~ ~~''`e' ........County, Florida: - •
~ (Describe real property sufticiently for identification, in luding street and number, if icnown)
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awned by . . . - _
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~ S~~fi ~~.r~.c~..a~,dL_ ~'~'~.,c~.~ ~ 3 c~, o0
af a total value of dollars iS
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of which there remains unpald S...L?. tor which amount he claims a lien oR the above
described real property. ~ - ~ ~
He further says that lienor furnished the (irst of said la~or, services or materials on u-t''~.____.~~....._.._
. 19.~'~°and the last of the same on.. 5~~~._..~.~~.....:.... .'19D..Z; and (if the lien
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~ is claimed by one not in privity with the owner) that the li~nor served his notice tc owner on
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5.,..~-.~ _ /5" - g'Z- 5~~.~~c~e_
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. (Method of Service) ~
and, (if the lien is claimed by one not i Frivity with the contrar•tor) that the lienor served a copy of his notice to
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ovvner or
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` ^ " J (Contractor) -
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. on:_...J.~'.'r~'-...,.~~--~-~--...-._--~ 19.~~ by.... ...../..`.............-•---~...~'.~.~:~C~................... , .
_ . (Method of Service) ~
and additionally, (if the lisn is claimed by one not in privi2y with ths sub~~ntractor) that the iienor served a copy Y
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~ of his notice to owner on -
I (Subcontractorl
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, ~ _ ~ eth f Service)
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Swo~n to and subscribed before me this.......... f.~ ................da ot .
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1~ Notary P iic i .
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No~Fary Pubbc, Sfato of Florlda a~ Carge T~ ~.,f ~V
- I ~l~lr r•.. ~ My Commission Expiros 11pri1 19~ 1485 ,
~ - aa?a 3~2 t~ ~61 . . . -