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201202405 <br />Claim of �ien <br />........................................................................................................................................................ <br />State of /V � � /' G�S �(� <br />County of �i� I � <br />Before me, the undersigned Notary Public, personally appeared �if'!e ���S o7 E� �.�.��C <br />who duly sworn says that he is (the lienor herein) (the agent of the lienor herein) whose address is /395� A�d o� �!^� <br />./'t o s �r � �.,,,,,r <br />andthatin <br />sepa <br />with a contract with <br />lienor furni� <br />, , n <br />�va� Kiv��^ (� � � v�'� . <br />labor, services or materials consisting of: (Describe <br />.1.. , ,• � 1.• .� <br />�.� <br />on the follow described rea property in Hec, / <br />State of /Y/P 4`aS�P� <br />(Describe <br />for identification, including street and number: <br />� y C-�.� .,. a <br />. <br />fabricated materials <br />. , <br />�� i. <br />County, <br />,, <br />by of a <br />total value of � 9 alJ �8ollars ($ �� • ) <br />of which there remains unpaid �� o s R io o Dollars ($�. 4�'�� 9� ), <br />and furnished the first of the items on ��f f� , 20�_ and the last of the <br />items on �r.� �J7 � , 20 and (if the lien is claimed by one <br />not in privity with the o ner) that the lienor served his notice to owner on ` , <br />20 by ° <br />� <br />(Method of Service) ° `" "°' <br />And, (if required) that the lienor seroed copies of the notice on the contract on , <br />20 , by , and on the subcontractor <br />(Method of Service) <br />on 20 , by , and (if known) on the <br />lender , on , by <br />(Method af Service) <br />Page 1 <br />www soaates.com � 2004, Soaates Media, LLC <br />LF136 • Rev. 04/04 <br />