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Form 112 <br />(W" I— miww. <br />L.. - XZ F= 100109 <br />Noticz is hereby given that, Q A t,)l 4 Q <br />intends to claim and hold u lien in the amount of t,hree %xY_o,,v fckn 'ntwr d nffei,y-vvj <br />dollars <br />��.?_492 -_OC)___ with interest thereon from the Z'_'Ja... day of lio v em 0 � r. 1q_a_6_ <br />at the rate of per cent per annum. That such amount is due and owing to the claimant <br />for (labor performed, or for skills, services, material or machinery furnished)• for the following im- <br />provement for which the same was done or supplied, to-wit _1­11 st a I d n e w 5 R_ J 5 0 36- 12, f <br />-------- ------ <br />BrVant heat. -cool un i t w th assc,- i ated., m.t.erj in . I I . -- - <br />------------- <br />------- ------ ­ ----- ------------------------------------ - ------------- _ ---- ------------ <br />The name and pastoff ice address of the claimant is Ncrtl ,qestern, Public Service <br />---------------- ---- ­ - - ---- --- ------ --------- <br />- - ---------- -- - ----------- <br />The name and postoffice address of the person for whom the work was performed or materials <br />furnished is___,'_-hu'rch_ p_f_ ,_575 -- !s1ar,_d!1ebraska <br />--------- - ------------ --------- ---- -------- ---- ------- ----- I -- ---- ---------- <br />The date when the first item of the claimant's contribution was made was the 25 t t.____-__._ .... <br />day <br />Of ---- November <br />19-. 8F, and the last item of the claimant's contribution was made on the <br />day of ive ,, <br />- m." e r -� - 19- .. <br />The following is the description of the property to be charged with the licit, to- wit:...- -- ---- ---- _ -.---- <br />L <br />3, Se i m- -s-u-b-, iv i si cin <br />. _L ---- - __ ­­__ ­­ - - --- ---- � I_- -- ------------------- ­ ------- -------- ----------- ___ ------------------ <br />------------- ­­ ....... ­ ----- - ­_­­__ ­ - -------- I -_-_ - --- ----- - I . ­1 --- ­ ­ ---------- � ­­­ __ ------------------- --- ­ ------------------ The name and address of the owner thereof at the time of making such statement according to the <br />i�) f -c� 4 , 5, 1 -5 E a s t. B i s m a r k n y <br />beat information that claimant has is - -- ------ - ---------------- ------- - ---------------------- - --------- ---- <br />David A. Valasek <br />...... ­ - -- ------------ I --------- - -- ------- -------- --------- ­ --- --- ­ ....... . <br />Following is an itemized statement of the account upon which the lien is claimed: ----- ----------------- <br />585-25036- 1 25H Br,;,-?_1t, w! I �- ­at er � a-, to I ns tal I <br />- ---------- I ---------------------------­- <br />-------------- ------- - -------- -- - - ---- ------ <br />Dated this --- - - -. - - -- day of <br />'Strike out words not applicalite. Di re- r Sel­,7 Jien Claimant. <br />STATE OF <br />County of <br />Larry L. Pi rnler being first duly sworn, <br />say that , he is <br />- 1 <br />the lien mentioned claimant entioed in 71 <br />the <br />. reg na Statement; that he has read said Statement and knows <br />the contents thereof; that he has knowledge of all the facts therein stated, and that said Statement <br />is in all respects true. <br />wez5 - e r n F­ii- I i �ry <br />is 9 2;7 <br />and Sworn to before me this Subscribed a do of <br />I I <br />NY. A <br />L <br />OIL 2k <br />-- --- -- -- -- <br />(Name of fficc) <br />STATE OF <br />County of J <br />On this - --- --- day of before me <br />personally appeared a!- r,� k <br />known to me (proved to me on oath of to be the <br />jb h <br />rl <br />k & L .11, , _t. <br />described in and exicutrd 'he within and foregoing inst—,Amcrzt, and acknowledged <br />Its me that AA— excruted the SaMr. <br />AMMON <br />UM L 6"t A' <br />NjM6*jkt2kj" Natnt <br />