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<br /> 2 Tbt psoan aQeiaot who�e intee�est in the real edate tlte llen is doimed i�: ...I"'�•�j,...'t „Q,��eC_
<br /> 3. '17�nan�e�nd adde+e�of We daimant ia: �P�� r�;,L'''Z 2,Z�' ��
<br /> �'�cd,.1��Pe ad h�d p��.z.
<br /> �. Ths n�me and�ddr+e�of the peraau with wMm the claimant oan�i�
<br /> 1 7 ��y_�i�DiIY � �Ar � l SLn��_��t �03
<br /> 6. A general deaaiptlon of the claimant's aerv[cee performed to, be perf� r materiala ed or to be
<br /> tlunished for tbe ia�provennent and the contract pcioe is: +��o:•- T�,. c,��
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<br /> e. (Complete one of the foUowjng)
<br /> . The amaunt uapaid,w�sther due ar not,to the claimant far the servic�ea a�materids�e 3��8
<br /> The unpeid emount is not fix�d by the oontrad, but a good faiih eBlimate in the annouat of� . � `
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<br /> 7. (Complete ane of the foUowing) .
<br /> The tirtae the laet servlces or mateodnls were fumiehed was 3 ���'9 3 • �
<br /> The tic�ne the laet servioea ar ma4arial� were fumiehed has not yet �ecurred but i� eetimated to oocur `
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<br /> Suberibed end sworn to before me thie �� da of \ —, 19�.
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<br /> G .���.,�,�r.y..r`C�'��'!�•Z�� Notary Public �
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<br /> (b�147.3ee 82•148 for amendment;b�148 for aesignment;b2•1:3'i far recordinR tune;b2-154 for diarhar�e or releasel. I
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