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SPACE A~OYE TM16 UME FOM ?iIOCfS51N8 QI1TA iI1lCf A~WE TINi lN1E f011 11E001~0~19 MTA
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Beforo me. the undsrsi~ned Notsry Public, personally epps~rsd ~ ""'~""r
who was duly sworn and says that hs is (th~ li~nor h~rsinl Iths ~y~nt of th~ lienor heroin)
(DEIETE ONE)
T~.IC:t'Y',.:ec~.- E • ~P...1"~.-
tlienor's Name)
whose address is ~//~~'C...~~iJ~~~~~` 'v~ . ~ "^"~P~ ,
3(~cJ2 (lienor's Address)
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and that in accordancs with a contract with ~~~1~~ ~~C.GcJ( -i'"'~' .
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{ienor furnished fabor. services or materials consiscing o(: (~escribe specially labricated materials separately)
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~ on the following described real property in ~ County. Florida:
~ (Describe real property suf(iciently for identification, inCluding street and number, if known)
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i ~ ~lQ~_ G_._"11L~ ~ 1~ ~t oL
, ~-4-~(~- t~~~~-I~ ~~.f~~ 02~- S~ 1~.~~J~
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~ awned by ~Q ilY c~ ~
f of a total value of Nl~ dolla~s (S i
of which chere remains unpaid S`A ~-t Q.. • . snd turnished the first of ths itams on
1 , 19 ~0.. and the last of the items on ....L./(_.v , snd (if the {ien
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is claimed by one not in privity with the owner) that the lienor served his notice to owner on
f
~ ,19 .by •
(Method of Service)
and, lit requiredl that the lienor se~ved copies of the notyce on ths cont~actor on jv~7~'
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by _ , snd on the subcontractor. ~
(Method of ServiCe) ~ •
on ~IJ ~Z~ . 19~~. by ~ .
COUI,/T lMothod erv~ce)
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cfFC~UNTY.E~~ Agent
Sworn to and subscribed betors me th~s day oi 19
oouca~s axorj, c~aK u~, s~
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BOGA 67~ PAGE 049 7`" ~~~~^l
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