TO:      650 S. Orcas St., Suite 114 Seattle, WA 98108
           Phone:  (206) 624-5877                Fax(206) 624-7327

FROM:  Name of Company:  
Company Name
Email Address
Phone Number
Fax Number
Address
City   State  Zip
 
YOUR CUSTOMER
Name:     
Address:     
City:      State:  Zip: 
GENERAL/PRIME (if different):
Name:     
Address:     
City:      State:  Zip: 
OWNER OF PROPERTY (if known)
Name:     
Address:     
City:      State:  Zip: 
JOB SITE:
Address:
City: State:  Zip: 
Plat:   
Lot: 
First Date on Job:
Type of Materials and/or Labor:
 
ADDITIONAL INFORMATION (for Liens only)
Date of Last Delivery:     
Dollar Amount:     
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