Notice of Intent or Lien Request------------------------------------

Notice of Intent Lien Request
Your Company Name :
Phone :
Your Name :
Your Email :
Address :
City, State, Zip :
Fax :
Job Site Address :
City, State, Zip :
Who Ordered Work:
Address:
City, State, Zip :
Owner Name:
Address:
City, State, Zip :
General Name:
Address:
City, State, Zip :
Your Customer:
Address:
City, State, Zip :
	Commercial
	Residential
	Public Works
	Federal
Amount of Claim $
County:
First Day on Job:
Last Day on Job:
Labor Materials Delivered:
Additional Comments:

Special Instructions for Lien Claims ONLY
In order to complete your lien claim we need a signed copy of this form for legal purposes. Please review the disclaimer below and upon submission, you will be prompted to print a copy. Sign on the line provided. Mail to: 24447 234TH Way SE #13, Maple Valley WA 98038, OR Fax to 425-413-8259

By submitting this form, I have read the foregoing claim, and know the contents thereof and believe the same to be true and correct, and the claim is not frivolous and is made with reasonable cause.

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