Sts. & Hy. Code, § 5626

The superintendent of streets may file in the office of the county recorder of the county in which the parcel of property is located, a certificate substantially in the following form:

NOTICE OF LIEN

Pursuant to the authority vested in me by the Improvement Act of 1911, I did, on the ____ day of ____, 19_, cause the sidewalk, curb, or park or parking strip, bulkheads, retaining walls, or other works (as the case may be) in front of the real property hereinafter described, to be repaired and improved, and the legislative body of said city (county, or city and county) did, on the ____ day of ____, 19_, by Resolution No. ____ assess the cost of such repair upon the real property hereinafter described, and the same has not been paid nor any part thereof, and the said city (county, or city and county), does hereby claim a lien on said real property in the sum of ____ dollars ($____), and the same shall be a lien upon said real property until the said sum, with interest at the rate of ___ percent per annum, from the said ____ day of ____, 19_ (insert date of confirmation of assessment), has been paid in full and discharged of record.

The real property hereinbefore mentioned and upon which a lien is claimed, is that certain piece or parcel of land lying and being in the (name of city, or city and county) the county of ____, State of ____, and particularly described as follows:

(Description of property)

Dated this _____ day of ____, 19___.

Superintendent of Streets