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201108713 Claim of I.ie� ................................................................................................................................................. State of � TI� � ��, d.� � � �� -��} County of ��f_�' oc,t✓I�s/ Before me, the undersigned Notary Public, personally appeared who duly sworn says that he is (the lienor herein) (the agent of the lienor herein) whose address is and that in accordance with a contract with � �� e� C'- o�' �� '°+�.. � lienor furnished labor, services or materials consisting of: (Describe specially fabricated materials separately) � �l3v / � ,f1�� i �C. on the following described real property in ��` c°�✓�-�`( County, State of Gl�� i Sel�.�d �,�, . (Describe real property sufficiently for identification, including street and number: y� J�� rYI.G�,s� ft��! /,��(_'. vl� � `f e �ec.vi � �.. �c� e s i.�s � � ' v1 — C e+lp ��'44 � �-� Z.. � 4l tt �-$ � U�' �-� S I � 1� � t�t 1� 1 C91n � � 1n °�t�i' '�. C, i�� B'T �K,w U— by ot a total value of Dollars ($ 9�vo�� ) of which there remains unpaid Dollars ($ �i� SC� oa ), and furnished the first of the items on /(� -/.3 , 20�� and the last of the items on /D - �Cce , 20�_ and (if the lien is claimed by one not in privity with the owner) that the lienor served his notice to owner on , 20 by (Method of Service) And, (if required) that the lienor served copies of the notice on the contract on , 20 , by , and on the subcontractor (Method of Service) on 20 , by . and (if known) on the lender , on , by (Method of Service) �a�e �`. www.soaates.wm � 2004. Socrates Media, LLC LF136 • Rev. 04/04