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<br /> , duly sworn,o�his oat says that the fosegoin•itemized atcour�t of wnrk,labor,skilI � _ �
<br /> '. :'.F. � �wteriols,and im�rovesuents ' true and correct: ehat same u�ere do�e and pe►formed and furnished by the undersigned : ;� __
<br /> � � - far the said G/ "e .... ..............W..........._._..._.._......._....�..�......��_____...._.............. �� . ..-
<br /> . - . 1 unde►a' n�a.2-; conerace..»..�....................�.---�.. _ .. .._.� .. .... ,�< . -_
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<br /> ' 1`.}'�' �urnished and delivered theseunde►..............� ' ���'
<br /> - ..- , :. �,�.s•... �^ts�nt�act u�as nutde and labor and nsate�ials f --
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<br /> ,` . ,• ••. ' • ` �,�� .�,�r.r.�4:�. ..was the awner of.taid prezsiues' =�.�
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<br /> , . f � That the date o f the �irat item �urnislted and detise�ed was..._..._.Q,�r........1..�r........-.�.�2�.5�.Z----...�....�atsd tite � - -"°'�'",`
<br /> .• " :�. date of the las! item was..... ��...�.Zt..�R..9..�.__...._.........�..........................__....5�.�.......................... . . ,- . -
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<br /> ,' ` �� Affiant funher states that sa� id labo�was p¢rforaned an, and materials �ue�re furnished for, delivered at, a�sd used in � ;,'„'
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<br /> aaid bsiilding os p�e�nises oa and between the dates s¢ecified. �
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<br /> �` .: . � _ . , That the prsiees charged lhetefo� are fair astd �easonablef and lhat t/sere is now d;w oss said aetount the sum of I '
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<br /> � ' �I �......�¢����-..^r.................................cla�inu a liem on the said premises fa�ehe fuft as;tot�rtt af I , �. .
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<br /> :� � Ii (rara the...�.�.�:.........day of..._�..... ._... .......... ...: .., i9....4--�,.and furthev o�an! aays rsae. �� ' . . : '
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<br /> • � . �� (See reverse side for instructions) Nota�y Pu61ic. !• , .
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<br /> ` � � &TATE OF............_............ . •.•••••••- � Entered on nurnrrical index ond &led for recozd � ' +
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