Fill and Sign the Va 4 Form

This document prepared by (and after recording return to): ) ) ) ) ) ) ) ) ) ) -------- Above This Line Reserved For Official Use Only-------------Name:       Firm/Company:       Address:       Address 2:       City, State, Zip:       Phone:       NOTICE OF CONTRACT TO PROVIDE LABOR AND MATERIALS- INDIVIDUAL Code Sections 43-4.01 NOTICE TO MECHANIC LIEN AGENT FOR § 43-4.01 NOTICE Delivery by Certified Mail Date ______________ Name Mechanic Lien Agent: _________________________________ Address: _________________________________ City, State, Zip: _________________________________ Claimant Name: _____________________________________ Address: ___________________________ ___________________________ City: ___________________ State: ______ Zip: ___________ Phone: __________________ Fax: __________________ Building Permit # __________________ Date of Permit _________________ County/City Permit ___________________ Property Description on Building Permit: ________________________________________________________________________ ________________________________________________________________________ Copy of Building Permit Attached: Yes No The Claimant is providing labor and/or material for the construction of improvements on the property described. CLAIMANT SEEKS PAYMENT FOR LABOR PERFORMED OR MATERIAL FURNISHED. This Notice should be sent within 30 days after Claimant begins work. ________________________________ Claimant _____ ___________________________ Type or Print Name Notice of Contract to Provide Labor and Materials Page 1 of 2 Given under my hand this the _____ day of ______________ 20 _______ . ________________________________ (Notary Public or Magistrate, et cetera.) Notice of Contract to Provide Labor and Materials Page 2 of 2