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v•operty AppraiiKS PuON Id~ntifiCat~On (FOIiO) Numberls): 1QUr'. .::Ci:h .
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S?ACE A~OYE TNIS LIME Fpl MIOCfS51NA DATA S?ACE A~WE TltlS L1ME f011 IIEOORONlB O~TA
t~i~ttm ~.~i~n
~ie af ~lorida ~
~ountq of
Bsfore ms. ~he undsrsiynsd Notary Public, psrsonaliy ~ppsar~d Sf~~ ~ W~ ~
who was duly sworn and says that h~ is (th~ li~nor h~rein) ( i~l
(DELETE ONE)
/`~~c~~,q H<,C s' a~ N z~
(Lienor's Nama)
whose address is /S / 5 ~ ~uX 8/4d k..? Z/X K ~o ~!'L rl .
f lienor's Addressl
and that i~ accorda~ce with s contract with ~A- T~~~l CU n! 5 J`, ~ Ca,~l~iiy6 .Z n?E,. •
.
~o ~ 7 S~f,~iu 1" h u~„J ~~C,~4 .
henor furmshed labor, services or rrlaterials cons~st~ng of: (Oescnbe specially tabricated rnatenals separately)
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f~ O l~ ~ y~ ~o r/~ Ja 1R-e
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on the following des~nbed real property in ~~C !/`L v!X County, Flonda
iDescnbe real property suffic~ently for identitication. inctuding street and number. ~f known)
t, c r' a- / 5 C~"1, sr c~f 3
~y G c~ 1y u~ ~3t7 o w' ~ r; 7"w S.
~ owned by ~ d r s ~a ~ r s
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rt
R /f
; of a totel value o( T dollars (S 1
` of which thsn remains unpaid 5 d~ , and fumished the first of the items on
I ~ 9. . 19~ ~ and the last of the items o~ l J~"~ " a , and (if the lien
~ ~s claimed by one not in pnvity with the owner) that the lieno? served his notice to owner on
i
F
4
t .19 .by .
IMethod ot Serv~ce)
and. lif requued) that the l~enor served copias of the nouce on the contractor on
by 5~ L~~ , and on the subcontractor. 5/t
(Method oi Service)
on ~/~N ~ .19~fLl.by S/zG
hG~~NTy IMetnod ot Se~v~ce1
LIE~R ~
~ 'o
J ~G c~
Lienor
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s~.
` J' ~~~a tx~S`~ Q,4 BY
(GC~F COUNS'~ Agent
Sworn to and subscribed betore me this day ot ~uG~s aX~N, 19
Or4`t
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