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` n~ 1911 1AESH~N+cs RAMCQ FORM 1201's t
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' ~ Before me. the unde~signed authoiity. Pe~sonally Appea~ed
wt~o, being duly sworn, says that he is the lienor hetrein o~ the agent of t e lienor her in. .
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whase address is -
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and that in pu~sua~ce of a cont~act wcith ...................t.......................................................... .
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lienor turnishad labor, services r materials c nsisting af: (Describe specially fabricated materials separately) _
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~ . on the foifowing described real property in ....................................................................................County. Flerida:
j (Qescribe real property sufficientiy for identification, including street and ns~mber, if knovvr~~ •
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~.~i1.0. ``p~ .t..~~!~,....h~'....... ~'...~.~..~....f............ anna?S ~s ..~._~...~.f.. ~.'..G.~........~
of a total vafue of .
d-~~ . tor which amount he cl~ims s lien on the above
of which there~rornains unpaid S•.:••~~••••••-••••-•-••••-•••••••••-•-•-••• • ~
desc~ibed real property. ~ - ~ .
He further says that lienor furnished the first of sai~ labor, services or materials on .
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...~.~!h~-..:.._~n........ . 19..~r
and the last of the same on..~-t?~•~.••...~'/...:..... . 19..~.~.~.`~., and (if the lien
~ ~s claimed by on9 not in privity with the owner) that the lienor se:ved his notice to owner on "
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. ~hllethod of Service)
and, ~if the lien is claime by e n t in privity wiih the contractorl that the lienor served a copy of his notice to ~
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P«.~,.._.~_._.. .
o-::~ea .
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~ 19~~.., by<.:......... fJ~?f`'.`~...:..~
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on J.Q
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and aciditionally, 1if the lien is claimed by one not in privity vorith the subcontractor) that the lienor sorved a c~py
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of his notice to owner on
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- lSubcontractor) . `
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` - . 19..:..---.., by .
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~~s~~ (Met of Service) _
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- ~987 ~G I $ Pil 7 ~ " " "
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~t;.,C et~C'~~~.~~::~.;:• r Lienor 5.~. _ -
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- CtEEK ~i'r.~.'J;s E:~ _ By ....:.......................................................•...-•'i3rss~~i,`.~ ~
<< . _ ~ F'rl'" . Agent • .
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. Sworn to and subscribed before me this ......:.......day of . . ' i:_.~';19.4 • ~ • - •
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_ . Notaty PubliC ; • ~ ^ ~ ~
~ I~Iti•l~r•~rrr~rt~•nl ~?r~~/fn?~•~l l,~~: N~~FaryPublic, ats of Florida a}~L'r_tQri -
I~/rl~~~•• My Comm~ssion Expires Ap~il 19~ i985 ~ - ~
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