HomeMy WebLinkAbout15-16743 r`
f CITY OF ZEPHYRHILLS
= 5335-8TH STREET
�sis��so-oo20 167 3
BUILDING PERMIT
PERMIT INFORMATION LOCATION INFORMATION
Permit Number: 16743 Address: 6437 BRENTWOOD DR
Permit Type: RE-ROOF ZEPHYRHILLS, FL.
Class of Work: ROOF REPLACEMENT Township: Range: Book:
Proposed Use: NOT APPLICABLE Lot(s): Block: Section:
Square Feet: Subdivision: BRENTWOOD FIRST ADDITION
Est. Value: Parcel Number: 04-26-21-0030-O0000-0060
Improv. Cost: 11,250.00 OWNER INFORMATION
Date Issued: 11/13/2015 Name: GREGG WILLIAM G & LOIS � (� �
Total Fees: 95.00 Address: 6437 BRENTWOOD DR --
Amount Paid: 95.00 ZEPHYRHILLS FL 33542-0622
Date Paid: 11/13/2015 Phone: 813-469-3153
Work Desc: REROOF SHINGLE
CONTRACTOR S APPLICATION FEES
G VIN ROOFING REROOF RESIDENTIAL 95.00 �
I 1 �. � �s_
���
�
Ins ections Re uired
DRY IN ROOF INSP
TAPE JOINTS ROOF INSP
FINAL I(^2 �(^( ��
REINSPECTION FEES: (c)With respect to Reinspection fees will comply with Florida Statute 553.80 (2)(c)the
local government shall impose a fee of four times the amount of the fee imposed for the initial inspection or
first reinspection,whichever is greater,for each such subsequent reinspection.
NOTICE: In addition to the requirements of this permit, there maybe additional restrictions applicable to this properly that
may be found in the public records of this county, and there may be additional permits required from other governmental
entities such as water management, state agencies or federal agencies.
"Warning to owner: Your failure to record a notice of commencement may result in your paying twice for
improvements to your property. If you intend to obtain financing,consult with your lender or an attorney
before recording your notice of commencement."
Complete Plans,Specifications Must Accompany Application. All work shall be pertormed in accordance with
City Codes and Ordinances. NO OCCUPANCY BEFORE C.O.
NO OCCUPANCY BEFORE C.O.
�
CONTRACTOR SIGNATURE PERMIT OFFI R
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
a��-�eaoo2o City of Zephyrhills Pecmit Application Fax-813-T84-0421
' B+�ilding Department
Date Recelved Phane Cantact far permittin —
pwner's Name ` � —C�'�. Owner Phone Number
Owner's Address � ����� Owner Phone Number �~ - �
F�e Sfmple Titlehoider Name � � Owner Phoae Number �� �
Fee Stmple TiftehoSder Address
.�oa aoo��ss � ,��.'G,�t/1"1�lm�r� �.oT� ��
suaoivisiaN S'��.�/�i2 � p�lS� Pattce�ia�
(OBTAINED FROM PROPERTYTAX NdTICE)
WORK PROPOSED NEW CONSTR ADD/ALT � S1GN' Q Q DEMOLISH
� e lNSTA�.L 8 REPAIR
PR4P4SED USE Q SFF2 � COMM � OTHER
TYPE QP CON$TR!lCTION �BLOCK ' C] FRAME [„� STEEL Q
DESCRIPTION OF WORK P�" � �/�f� �.J� � �t���G�
BUILDING S12E � � SQ FOOTAGE C��1 HEIGHT ���
UILDING $ // ��O VALUATION OF TOTAI.COIVSTRUCTIQN
l�
QEI.ECTRICAL $ ��— AMP SERViCE Q PROGRESS ENERGY [� W.R.E.C.
QPl.UMBING $ ' �^��
�� ` �
OMECNANtCRt. $ VALUATlON OF MEGHANICAC IiVSTA�LArION �
QGAS [�'"�F2QOFING Q SPECIAI.TY � OTHER
FINESHED P�OOR EI.EVATtONS �� FIQOD ZONE AREA QYES. NO
BUtLDER � COMPANY
SIGNATURE REGISTEREp Y/ N FEE CURREh Y/N
Address LtcBnse# �" � �
EtECTRICtAN � COMPANY
SIGNATURE REC,{SiERED Y 1 N FEE CURRE� Y/hl
Address Licensa# 4 ���
PIUMBER � COMPAMC
SIGNATURB REG157ERED Y 1 N FEE CURREh Y/fU
Address License# �� �
MECHANiCAL - COMPlWY
SlGNATURE REGlSTEREd Y t• N �EE CuttREt� Y!N
Address License# C �
aT�t�� ��,l.;, � coMQ�wx �-$��1� �d d1'i�'�
.
SIGNATURE � __^_,_,,,_,,_� REGISTERED Y I N FEE GURREh Y I N
Address "� �� � (�� �" � Ltcense# �1�.."'��YD�y� �
REStDENTiAl: Attach{2)Rlot P.lans;(2)sets afxBullding'Plans;(1}sef of Energy�Forms;R-t�W Pertnit for new canstruc�on,
Mintmum�ten:.{1.0):working"days aftec subrritttal date. Requlred onsite,Gonstructian Plans;Stormwater Plans wt Stit Fence fnstailed,
SaNtary Faciiities-�1;dumpster,,Site'Work•Rermit for subdiVislonsllarge proJects
CONlMERCIAL Attach(3)camptefe sefs af Buitdirig Plans plus a Life Safety Page;{1}set of Energy Forms.R-O-W Permit for new construction.
Minimum ten(1 Q)working days after submlttal date, Required onslte,ConstrucUon Ptans,Stormwater Pians wi Siit Fence instailed,
Sanitary FacilfUes&1 dumpster.3ite Work Pertrrtt for all neinr projects.All cammercial requlrements must meet compliance
SlGN PERMiT Attach"(2)se#s of Engineered Plans.= ,
•«'•PROPERTY SURVEY required for aEi NEW constructlon.
Direa#tons: � , • �� ,
F{N aut appticaUon compietely. 't, . ' ' �
Owner&Contractor slgn back of applicatlon,notarized•� �'� ' ` ' _ _ � � '� °" ` �
If over$25p0,a Not�ce of Commencement is required. �(AJC upgr8de�over$7500) "� " , - .��� 5 �,
'" Agent(far tiie aontractor}or Powec af.Attorney(for the awner)would be someone w(th notarized letter from owmer authorizing same _ r _ ,
dVER THE GOUNTER PERMIT7ING ' (Front of ApplicaUon'Only�.,°?' ,;;�� ' � �"
,.,,. .
Reroafs if shingles Sewers Servide llpgrades�'AtG`�°�� ,:Ferices(PtatlSurveylFoatage} , � , .,' � �• ,:':t Y=
,. � ;� �� . :;:, ,: .,� - .�. . ,. . , .. .
Drivewaya-Not over Counter if or�iputilic.roadways:.needs'ROW� , � '~ : ' ' ,� _ . , _
NOTiCE OF DEED RESTRICTIONS: The undersigned under�tands-�.th�t,this:�.�r:mit 4may_be.,subject to°deed"restrictions" .,
which may be�more';rest�ictive�than Gounty�regulations.'�The undersigned'as'sumes'responsibility#or�compliance"�with�any
appflcable deed restrictions. _ �. ,,. . � -
UNLICENSED CONTRACTORS AND CONTRACTOR RESPONSIBILITIES: --If•the owner-has,hired�a �contractor or
contractors to undertake work,"they may be=cequlred�:to�be;licensed In accordance.wlth state.and�loca,l,rsgulations. If the�
contractor ts not flcensed as requlred`tiy law, both the owner and conUacta��iriay be-cited=for a��misdemeanor violatton
under state law. If the owner or Intended�contractor�are uncertain as to what.Ilcensing.requlrements:�may�.apply for..the •
intended work, they are advtsed to contact the Pasco County Bullding Inspection DI`vlslon-l:Icensing�Section at 727-847-
8009. Furthermore, if the owner'has"hi�ed a cont�acto� o� contractors, he is advised�to have the contractor(s) sign
portions of the "contractor Block" of.this,application for which they will be r.esponslble...:if.you,.as.the owner sign`�as"the
contractor, that�may be an indication that-he�is not.properly licensed and�is not entitled to"perm`itting_privlleges in Pasco
County. '
TRANSPORTATION IMPACTIUTILITIES•IMPAC7�ANb�RESOUItCE RECOVERY FEES:��The undereigned�understands
that Transportation Impact Fees and.Recourse Recove.ry Fees may.:�apply;to°the construct(on,of new_buildings,�change of '
use in existing buildings,�or.expansion��.of�ezlsti�,g�buildings, as speclfled.in Pasco�County Ordinance number 89-OT and
90-07, as amended... The undersigned also:understands, thait:such fees�,as,�nay be�.due;,:wlll.-be identlfled at the`time�of • '
permitting. It is iurtFier understood that Transportatlon Impact Fees and Resource Recov.ery'Fees..must be paid prio�to
receiving a °certificate.of�occupancy" or flnal powec.release. :If�the project-.does not,involve�a.certificate of occupancy.o� '
final power release;,the#ees�must be paid prior to permit Issuance. F�tthermore;�if Pasco County�Water/Sewer�Impact
fees are due,they must be�pald prior to,permit-Issuance�in accord"ance witli applicable Pasco County ordinances.
CONSTRUCTION LIEN LAW(Chapter 713� Florlda Statutes,as amended): If valuation of work is$2,500.00-or moce, I
certify that I, the applicant, ,have-been provided with- a copy� of the mFlorida Construction� Llen.L'aw—Homeowne�'s
Protection Guide" prepared by tFie Florida Department of Agriculture and Consumer�Affairs. if the applicant is someone
other than the"owne�", I certify that I h�ve,obtained'a copy.of.the;above.:descrtbed document_and:p.r.omise�in.good faith to
deliver it to the.`owner",pdo�to=commencement: ^-• - � . ' ,
CONTRACTOR'SIOWNER'S AFFIDAVIT: I ce�tify<:that;ail.the,l�formation.in�this appllcation is accurate and that all work
will�be done in complfance with all appl(cable"laws regulating construction, zontng and�land development. Appifcation (s
hereby�made to obtain..a.permit to do woric�and .installatlon as indicefed:�:.'I certify-tFiat�no work��or installation has
commenced p�(or to Issuance`of a perm(C and that�:all work will be perFormed .to meet standards of all laws regulating�
construction, County and City codes, zoning regulatiQns, and land development cegulatlons-in the�jurisdtction. I al'so
certify that I understand thatlthe regulations of other government agencies may�apply�to the intended work, and that it is
my responsibility to Identify•rivha�;actfons I must take.to be=In_.cotrlpliance: Such agencles-inalude but-are.not Ilmited to:
- Department of E�vironmental�Protection-Cypress.'Bayhead�, Wetland Areas and Environmentally Sensitive
Lands,Water/Wastewater Treatment. �
- Southwest Florida Water Management DisUtct-Welis, Cypress. `Beyheads; Wetland Areas, Altering
Watercourses.
- Army Corps of Engfneers-Seawalls� Docks, Navigatile Waterways.
- Department of Health�'8 Rehabilitative Services/Environmental Health Unit-Wells� Wastewater�Treatment,
Septic Tank"s. � _
- US Environmental Protection Agency-Asbestos abatement.
- Federal Avlatton.Authorlty=Runways. �
I understand that the following.restrictions apply to the use of flll:�
- Use of fill is not allowed in Flood Zone"V"unless expressly permttted.
- If the fiil material-is to be used: in-�Flood Zone. "A", It. is understood that a drafnage plan addressing a
"compensating volume" will be submitted at time of permitting which is prepared by a professfonal engineer
Iicensed by the State of Florida:
- If the fill material is-to be used in Flood �one °A° In�connec�ion�with.a permltted building using stem wall
� construction, I certify that fill�:will:b.e used only.to.fill the area wtthin the�stem•wall.
- If flil materlal is to be used in any area, I certify tfiat use. of such flll will not adversely affect adjacent
propertfes. If use of fill Is found to adversely:�ffect adJaeent�propertles,.the owner may be cited for vlolafing
the condiiions of the�building;permit Issued under the attached {�ermit application, for lots less than one (1)
acre which are elevated;by flll; aR engineered dralnage plan is required. .
If I am the AGENT FOR THE OWNER, I;�promise in good faith to fnform the-owner of-the permftting conditions set-forth tn
this affidavlt�prior to commencing constructlon. I understand thet a�separate permlt may be requtred for electrical work,
plumbing, signs, wells, pools;. alr condltioning,.gas� or othec install�tlons nol•spec.ffically included in the application. .A
permit Issued shall be constcued to be a Iicense to�proc�ed with the work and not as:authorily to..viotate, cancel, alter, or
set asfde any provisions of�the technicai codes; nor shall issuance�of a.permtt.prevent the Bulidirig Offlcial from thereafter
requiring a conection af errors in plans, constructlon or violations of any codes. Every permit issued shall become invalid
unless the work authortzed.by such permit:{s-coFnmenced�withln six months of permlt issuance. or If work authorized by
the permit is suspended or.abandoned for a perfod of six(6)months.after the tirne the�wotk�ts commenced: An extension
may be requested, In writing, from the Building.Officlal for a period.not to exceed nine�ty(90) days and wlll demonstrate __
_ _justifiable_cause_for_th�extensio�:–If-work-ceases.for ninety(90)consecutive-days,..th�)ob-ls-considered aba�doned.
WARNING TO OWNER: YOUR.FAILURE�TO,RECORD A-NOTIGE OF�COMMENCEMEI�T MAY RESUlT IN YOUR
PAYING TWICE,FOR IMPROVEMEPI�S TO YOUI�PROPERTY.-I�°YO.U�1�1�'FEND`T�OBTAIN�FIIeFANEING;�ONSULT
WITH YOUR LENDER.OR AN ATTORNEY�BfFORE�RECOR�DING_�YOUR'NbTICE:OF�`COMIIiIENC�EIIAENT:
FLORIDA JURA�(F.S.117.03) _ " �
OWNER OR AOENT___�_���� I CONTRACTOR �,C1��
Subscrlbed and swom to(or aflirmed)before me this Subscribed and'swom=to(ow afflrmed)�before me this
by �by �
Who Islare personally knovm to.me or has/have produced Who.ls/are personallyknown•M me or-haslF�ave�produced •
as Identlflcatlon. as IdenBflcaOon.
Notery Public . � Notary Public
Com sslon No � Comm s n No.
"'�^'v' JOEL E.BACON '*'eva�• JOEL E.BACON
=2����F: ��i�'' �`�: #FF 137073 !,
Name of Nota ,,,t �(e� � ,2018 Na of Nota _ p '�tg�g�@8,
�''�� F F��P�` 0onded ThN T Fein Insw�nce 80038&7019 �'.;� F fl°:' 0onded Thm T�oy Fain Insurance 800385-7019 �
A;, �m' A�
�
� � I Il�I(�(I�li��l�i 1l�ll�11�11���!19II�►1�f!�ll�l lllil�l�!1�11�
,
2�155�2�34
Permit Nq. Parcel ID No � l �{g `�/""Q�,,�(J '�J,�����'�(r'(l� ���,�n��
�., • �
� � �, to.
NOTICE OF COMMENCEMENT � �*'m"
�,,, � ; �..• �
State of ������� Gounty of �J�� ' ���
� � �
, t11 �
THE UNDERSIGNED hereby gives notice that improvement wiil be made to certain real praperty, and in accordance with Chapter 713,Florida Statutes,. � � �
the foitowing information is pravided in khis Notice of Commencemre/nt: / 1 ,�p/� .
1,' Descripkion of Property: Parce(Identification No, t�Y ` �fZ �! ����� �����'" t�F�YI� � �r;
�// ��.p � -��R3
Street Address: �7 c�=G7 �/y /��-�' 3 �--- � ��
2. General Description ot Improvement /�-�' /��e�� � `(.�.✓ �� ' �g u�+
C7 �c�
� �
c� t9
K �
3. Owner Infortnation or Lessee information if the�essee c�o'�acted for the improve.ment: ' n
�E� ,� � /l��" ,�' G',Jle,�.i,�rYt ���� .- m
��,�"��G���'���0 2��/�!/'�h�i�,�.�' �=�_ ', �
Address ,�9 - / City � State
Interest in Property: y/�/V�� �"�S�°'"
Name of Fee Simple Titleholder:
{If different fram Owner listed above)
Address /?�r/f.) ���` 'p� City State
4. Contreckor ll� i.� i�i ���
Name�t''7 ��b'� ��i� �!�/� �l� �� �/
� Address - City Sta^ t��.SGJ�'
Cantractar's Tsiephone No. �1.s���J '—��3�
5. Surety:
Name �,,.,..--
Address City - State � �:.D
Amount of Bond: $ f� Telephone No.. � p ��
� ���
w�,
6. Lender: -'�� � N�
Name �-•
@ -
z
Address City State �t3�
Lender's Telephone No., �/ � ��S
7 Persons within the Stake of Florida designated by the owner upon whom notices or other documents may be served as provided by ���
Section 713.13{i){a)(7),Florida Statutes:�-. p� �
� Ei
O
Name �..�- ,C F,�
z
Address ��„ City State `, ���
Telephone Number ot Oesignated Person: �t.�.
8. In additipn to himself,the owner designates - ��- of � �
�� ta reCeive a Copy of the�ienor's otice as provided in Section?13.13(1)(b),Florida Statutes. � �
j r-
m
Telephane Number oT Person or Entity Designated by Owner: � �
9, Expirafion date of Natice of Cammenoement(the expiratian dafe may not be before the campietion ot r �t c,.tion and f+nal paymenk to the
contractor,but wili be one year from the date af recording unless a different date is specified): _____y�J G t
WARN(NG Tq OWNER: ANY PRYMENTS MRDE SY THE QWNER AFT'ER THE EXPIRATION OF HE NOTICE OF COMMENCEMENT
ARE CONSlC}EF2ED lMPROPER PAYMEt�tTS UNDEft CFiAPTEf2 713, PA12T i, SECTtON 713.13, FLOf21DA S'fATl1TES, AND GAh4
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTtCE OF COMMENCEMENT MUST BE
RECORDED AND POS7ED ON THE JOB SITE BEFORE THE FIRST INSPEG710N. IF YOU INTENO TO OBTAIN FINANCING,CONSULT
WIFH YfJUR�ENDER QR AN AITORNEY BEFflRE COtv1MENClNG W4RK OR REGORD4NG YOUR NOTICE OF COMMENCEMENT.
Under penalty of perJury,I deciare that I have read the foregoing notice af comm ent� ha e facts stated therein are true to the best
of my knowledge and befief. � �
STATE OF FLORIDA /1,,.�
COUNTY OF PASCO - r- •r �
; Signatur ;of Owner or Le ee,_o �'s essee's Authorized _ _ .,. ,
O�cer! rectorJPartner! ana
�����
Signatory's Titietpffica , �
The foregaing instrument was acknowledged befare me this�day of l�G+ � ,20�by��Q ��-�1 `r""�'�'��� /
as_�1���'� j (type oF autharity,e.g.,o�cer,trustee,atforne�acf}f� (}"�
��`Y'�� ���' �'1'1"i A N7C�� �n l�hl:k�j��f -�"`�„ `?; �! P Y > /
/ ame of ari on beh If of whom instrvment was e cuted.
� r . J ��
Personaliy Known I�OR Produced identification❑ Notary Signature
Type af{dentificafio�Praduced Name{Print) '� �" �
'�i�a�Pa,,,� ANGELA RdSE BARNETT
_� `�+% Notary Public�State.ot floJfda _
=• ••� Niy Comm.Expites Oct fi,20i8 '
=;�, �;.� Cammission�FF 166185 �
wpdatatbcstnoticecammencement_pc4530d8 ��'�+aiii••`��, $��{��pt�h�8ltd�.P�t3fyASSti. ,
e
, I IIIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIII IIII
�
2015182434
Permit No. Parcel iD No �7 2�2 ��'���J v��D�A��Q(�(/ ►+v z
��"v
. .� �-
NOTICE OF COMMENCEMENT �'�'�;:.
Slate o( �GO���'Y Counly of��✓G� N m J
(31 W
THE UNDERSIGNED hereby gives notice thal improvement will be made to certain real property,and in accordance wilh Chapter 713,Florida Statutes, � �
the following inlortnalion is provided In�his Nolice of Commencem'e/nt: �1 •
1 � Descriplion of Properly: Parcel Identifiwllon No. O Y" .c.��� �o�38 -�ooao-a�6o �.-�
. -1.�
Streel Address:
/ '��Q �!y fL 3 � •• "
3� .
2. General Descriplion of Improvement ��' �O�f � � �
O B B
� B
� m
3. Owner Infortnation or Lessee infortnalion if lRe Lessee c-ory�acled for tha fmpro�vgmenl: n
� L0 � � Mf�� �r G�J���iA•rr G�FG ;
/���Nam ip���[.li�Om.� �•��/7'{'C/C1Y/�.�.� �� F
< <� Slate
Address -/ ���y 33S Y,2
Inleresl in PropeRy ���✓��'
� Name of Fee Simple Titleholder:
(I!diRerent from Owner listed ahove)
Address �1'�/ f Ciry Sfate
4. Conlraclor: �/T[//� ����ry� //
Name �D ��'�. ���� l�i��' �lfi' �Li h/
� Address � 4 / r/ Cit� State SGJO
Conlractors Telephone No.: 3SG Sb ,--��37 ,
5. Surely.
Name _�
Ciry State �...D
t+
Ad ress `` Tetephone No. O��
Amounl of Bond: 3 �r�D
W N
6. Lender � x N o
Name � B m
Address City 51ate �U��
Lender's Telephone No. �� N�? �`'� � {4
7 Persons wilhin Ihe Stale of Florida designated by lhe owner upon whom�notices or other documents may be served as provided by ��a ��Ve e 'v �
Section 713.13(1)(a)(7),Florida Slatules-.�� d D
�3 0 �0 , �
Name n � � ��
✓� �"m @ �s ,
Cil Slate N�� �'• d . -.i 5\ o
I Address �� y
Telephone Number of Designated Person: �"� '� � � �
3 �
�— Of_ � � � 6 . � �
8. In addition lo himsel(,the awner designales • p �
J ~
� to receive a copy of the Lienor otice as proWtled in Section 713.13(1)(b),Florida Statutes. rr. �
Telephone Number of Person ar Entity Designaled by Owner � �� •,���
'�•I� ° �
g. Expiration date of Notice of Commencemenl(the expirelion date may nol be be(ore lhe completfan 1 t clton and final payment lo the � '�
contraclor,but wfll be one year Gom lhe data of recording untess a different date is speciAed): �
I WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER�AFTER THE EXPIRATION OF HE NOTICE OF COMMENCEMENT
ARE CONSIDERED IMPROPER PAVMENTS UNDER CHAPTER 713,.PART 1 SECTION 713.13 FLORIDA STATUTES, AND CAN
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROP�RTY. A NOTIC� OF COMMENCEMENT MUST BE
RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING,CONSULT
WITH YOUR IENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING VOUR NOTICE OF COMMENCEMENT. Q � W �
Under penalty of DerJury,I dedare lhal 1 have read the fore8oing notice o(com� ent a ha e facls stated lherein are true lo the best � (�
of my knowledge and belief. � W U- W w
OU—` � � S �a J U
STATE OF FLORIDA Z � F- }
COUNTY OF PASCO � U � J4 � ~
Signatur ol Owner ar Le ee, r's essee's Aulhorized Q � Q = w N � a
OKcer/l[�JreclorlPartner ana �-
[/�iJ4'�12 — �- LLl ~ Cn J �- p
Signatory's Title/OKce . O � = z J �
nn � Y 1'L-, 'G Q � r1 �- "_ � � U �
� The foregoing inslrument was acknowledged belore me this �� da of � 20�bY�/t�� �A�a 0�� �N��-�` �J � � _ � 0 �
as �l_�5�1� J _(tYDe ot authodly,e.g..oKcer,Irustee,attomey in fad)I�r Q � � }, (� �
� /
�p��,,•� ��e�Z A)fl.yA •7a��.�,�1 ti�f }'( `�'`�ajSylMame ot party on beh If ot whom i stmment was e cuted). � Q O � Q �
Nolary Signalure = V U �J
Personally Known OR Produced Identlficatlon❑ Q � �• �f-- � J
Name(Print) Q �' C� m � � U
Type of IdentiFlcation Protluce0 � w � z � J
U � � � S ¢ W��
� w O p p Z
a����L.,, �NGELA HOSE BARNETT
u" UU � / 01
3� e``� Nohry PuDlic•Stito ot FloJida � � z O �
L� .•r My Coinm.Explrae Oct 6,20f A
Commission I FF 166185 W � Q -w—� � Q
ss,? � � ��
�,°f„t�`��, goMeQthdql NmOnxl NOiarY{155n. �
wptlala/bcs/noticecvmmencemenl_pc053048 Z }
�i f-=- � O � a m