HomeMy WebLinkAbout17-18568 , � � CITY OF ZEPHYRHILLS
5335-8TN STFtEEi"
(s�3)7so-ooz0 185,6r8'��
BUII.DINC PERMIT �/
PERMIT INFORMATION � • LOCATION INFORMATION
Permit Number: 18568118433 Address: 5939 GAI.� BLVD '
Permit Type: SIGN . ZEPHYRHILLS, FL.
Class of Work; WAL� S1GN Township: Range: Book:
Propased Use: NOT APPLICABLE Lot(s): Block: Section:
Square Feet: Subdivision: CITY OF zEPHYRHILL�
Est.Value: Parcel Number: 10-26-21-0020-00000-OQ50
Improv. Cost: 7,900.00 - OWNER lNFORMATlQM
Date Issued: T/2612017 Name: ZEPHYR I( LLC
Total Fees: 172.50 Address: 7162 READING RD STE 730
Amount Paid: 172.50 CINCINNATI, QH 45237-3845
Date Paid: 7/26/2017 Phone:
Work Desc: 1NSTALL WALL SIGN HARBOR FREIGHT
CONTRACTOR S APPI.ICATION FEES
ATLAS SIGNS HOLDING SIGN 112.5Q
ATLAS SIGNS HOLDiNG ELECTRICAL FEE sa.ao
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Ins ections Re uired
F OTE
E�ECTRICAL RCfUGH
FINAL
REINSPECTION FEES: (c)Wifih respect to Reinspection fees will comply with Florida Statute 553.80 (2)(c)the
local government sha11 impase a fee of four times the amount of the fee imposed for the initial inspection ar
�irst reinspection,whichever is greater,for each such subsequent reinspection.
NOTICE: In additiort to the requirements of this permit,there may6e additional restrictions applicable to this praperty 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#a owner: Your failure to record a notice of commencement may resuit in your paying twice far
irnprovements to your property. If you intend to obtain financing,consult with your lender or an attorney
before recarding your nofiice of camrnencement."
Complete Plans,Specifications Must Accompany Application. All work shall be performed in accordance with
Ca Codes and Ordinances. NO QCCUPANCY BEPQRE C.O.
NO OCCUPANCY BEFORE C.O.
CONTRACTOR SIGNATUR PERMIT OFFI R
PERMIT EXPIRES IN 6 Mt�NTHS WITHOUT APPROVED INSPECTIDN
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
� PRUTECT CARD FROM WEATHER
� s��-�eo-oozo City of Zephyrhills Permit Application Fau-813-780-0021
` Building�epartment
Date Received S" � phone Contact for Permitting —
Owner's Name Owner Phone Numher
Owner's Address � Owner Phone Number
Fee Simple Titleholder Name Owner Phone Number
1
Fee Simple TlUeholder Address
�I JOB ADDRESS � LOT# �
SUBDIVISION PARCEL ID# � " G,,� � � �� ,
(OBTAINED FROM PROPERTY TAX NOT1C�
WORK PROPOSED e NEW CONSTR e ADD/ALT � SIGN � Q DEMOLISH �
INSTALL REPAIR
PROPOSED USE Q SFR Q COMM 0 OTHER
TYPE OF CONSTRUCTION Q BLOCK Q FRAME � STEEL Q
�
DESCRIPTION OF WORK •\ � �
BUILDING SIZE OOTAGE HEIGHT
�BUILDING �l VA ION OF TOTAL CONSTRUCTION
v V
QELECTRICAL AMP SERVICE 0 PROGRESS ENERGY Q W.R.E.C.
QPLUMBING $ �����
QMECHANICAL $ VALUATION OF MECHANICAL INSTALLATION � ������S
QGAS Q ROOFING Q SPECIALTY 0 OTHER �`�
FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA �YES NO /� `
� � v�
BUILDER COMPANY � �
SIGNATURE REGISTERED Y/ N FEE CURRE� Y/N ^
�d�� C
Address License#
� � � . ��.6��
� ELECTRICIAN I r COMPANY S � �i��
� SIGNATURE REGISTERED N f5 cuwtEn Y/
Address License# E b
PLUMBER COMPANY
SIGNATURE REGISTERED Y/ N F�cuw�n Y/N
� Address License#
MECHANICAL COMPANY
SIGNATURE REGISTERED Y/ N F�cuwx�n Y/N
Address License#
OTHER COMPANY � �
SIGNATURE REGISTERED / N URRE� Y/N
Address p License# � �
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RESIDENTIAI. Attach(2)Plot Plans;(2)sets of Building Plans;(1)set of Energy Fortns;R-O-W Permit for new construction,
Minimum ten(10)working days after submittal dale. Required onsite,Construction Plans,Stormwater Plans w/Silt Fence installed,
Sanitary Facilities&1 dumpster;Site Work Pertnit for subdivisions/large projects
COMMERCIAL Attach(2)complete sets of Building Plans plus a Life Safety Page;(1)set of Energy Fortns.R-O-W Pertnit for new consUuction.
Minimum ten(10)working days after su6mittal date. Required onsite,Construction Plans,Stormwater Plans w/Silt Fence installed,
Sanitary Facilities 8 1 dumpster Site Work Permit for all new projects.All commercial requirements must meet compliance
SIGN PERMR Attach(2)sets of Engineered Plans.
""PROPERTY SURVEY required for all NEW construction.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Direetions:
Fill out application completely.
Owner&ConVactor sign back of application,notarized
If over E2500,a Notice of Commencement is required. (A1C upgredes over E7500)
•• Agent(for the contractor)or Power of Attomey(for the owner)would be someone with notarized letter from owner authorizing same
�
OVER THE COUNTER PERMITTiNG (copy of conVact required)
Reroofs if shingles Sewers Service Upgrades A/C Fences(Plot/Survey/Footage)
Drlveways-Not over Counter if on puhlic roadways..needs ROW
NOTICE OF DEED RESTRICTIONS: The undersigned understands that this permit may be subject to"deed"restrictions"
which may be more restrictive than County regulations. The undersigned assumes responsibility for compliance with any
applicable deed restrictions.
UNLICENSED CONTRACTORS AND CONTRACTOR RESPONSIBILITIES: If the owner has hired a contractor or
contractors to undertake work,they may be required to be licensed in accordance with state and local regulations. If the
contractor is not licensed as required by law, both the owner and contractor may be cited for a misdemeanor violation
under state law. If the owner or intended contractor are uncertain as to what licensing requirements may apply for the
intended work,they are advised to contact the Pasco County Building Inspection Division—Licensing Section at 727-847-
8009. Furthermore, if the owner has hired a contractor or contractors, he is advised to have the contractor(s) sign
portions of the"contractor Block"of this application for which they will be responsible. If you, as the owner sign as the -
contractor,that may be an indication that he is not properfy licensed and is not.entitled to permitting privileges in Pasco
County.
TRANSPORTATION IMPACT/UTILITIES IMPACT AND RESOURCE RECOVERY FEES: The undersigned understands
that Transportation Impact Fees and Recourse Recovery Fees may apply to the construction of new buildings,change of
use in existing buildings, or expansion of existing buildings,as specified in Pasco County Ordinance number 89-07 and
90-07, as amended. The undersigned also understands,that such fees;as may be due,will be identified at the time of
permitting. It is further understood that Transportation Impact Fees and Resource Recovery Fees must be paid prior to
receiving a`certificate of occupancy"or final power release. If the project does not involve a certificate of occupancy or
final power release,the fees must be paid prior to permit issuance. Furthermore, if Pasco County Water/Sewer Impact
fees are due,they must be paid prior to permit issuance in accordance with applicable Pasco County ordinances.
CONSTRUCTION LIEN LAW(Chapter 713,Florida Statutes,as amended): If valuation of work is$2,500.00 or more,I
certify that I, the applicant, have been provided with a copy of the "Florida Construction Lien Law—Homeowner's
Protection Guide"prepared by the Florida Department of Agricuiture and Consumer Affairs. If the applicant is someone
other than the"owner",I certify that I have obtained a copy of the above described document and promise in good faith to
deliver it to the"owner'prior to commencement.
CONTRACTOR'S/OWNER'S AFFIDAVIT: I certify that all the�information in this application is accurate and that all work
will be done in compliance with all applicable laws regulating construction,zoning and land development. Application is
hereby made to obtain a permit to do work and installation as indicated. I certify that no work or installation has
commenced prior to issuance of a permit and that all work will be pertormed to meet standards of all laws regulating
construction, County and City codes, zoning regulations, and land development regulations in the jurisdiction. I also
_ certity that I understand that the regulations of other government agencies may apply to the intended work,and that it is
my responsibility to identity what actions I must take to be in compliance. Such agencies include but are not limited to:
- Department of Environmental Protection-Cypress Bayheads, WeUand Areas and Environmentally Sensitive
Lands,Water/Wastewater Treatment.
- Southwest Florida Water Management District-Wells, Cypress Bayheads, Wetland Areas, Altering
Watercourses.
- Army Corps of Engineers-Seawalls,Docks,Navigable Waterways.
- Department of Health 8� Rehabilitative Services/Environmental Health Unit-Wells, Wastewater Treatment,
Septic Tanks.
- US Environmental Protection Agency-Asbestos abatement.
- Federal Aviation Authority-Runways. .
I understand that the following restrictions apply to the use of fill:
- Use of fill is not allowed in Flood Zone"V"unless expressly permitted.
- If the fill material is to be used in Flood Zone "A", it is understood that a drainage plan addressing a
"compensating volume"will be submitted at time of permitting which is prepared by a professional engineer
licensed by the State of Florida.
- If the fill material is to be used in Flood Zone "A" in connection with a permitted building using stem wall
construction,I certify that fill will be used only to fill the area within the stem wall.
- If fill material is to be used in any area, I certify that use of such fill will not adversely affect adjacent
properties. If use of fill is found to adversely affect adjacent properties,the owner may be cited for violating
the conditions of the building permit issued under the attached permit application,for lots less than one(1)
acre which are elevated by fill,an engineered drainage plan is required.
If I am the AGENT FOR THE OWNER,I promise in good faith to inform the owner of the perrnitting conditions set forth in
this affidavit prior to commencing construction. I understand that a separate permit may be required for electrical work,
plumbing, signs, wells, pools, air conditioning, gas, or other installations not specifically included in the application. A
permit issued shall be construed to be a license to proceed with the work and not as authority to violate,cancel,alter,or
set aside any provisions of the technical codes,nor shall issuance of a permit prevent the Building Official from thereafter
requiring a correction of errors in plans,construction or violations of any codes. Every permit issued shall become invalid
unless the work authorized by such permit is commenced within six months of permit issuance,or if work authorized by
the permit is suspended or abandoned for a period of six(6)months after the time the work is commenced. An extension
may be requested, in writing, from the Building Official for a period not to exceed ninety(90)days and will demonstrate ,
justifiable cause for the extension. If work ceases for ninety(90)consecutive days,the job is considered abandoned.
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.
FLORIDA JUR,4T(F.S.1 . )
OWNER OR AGENT CONTRACTOR
Su cri and swom t or f e e t i Su c' and s om ( d)befo e
by y
Who is/are p onall n to m o as/have produced Who is/are p n known to me r has/have produced
as identification. as identification.
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Commission N . Commission No.
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City of Zephyrhills
BUILDING PLAN REVIEW COMMENTS
Contractor/Homeowner: __ ���`� �
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Date Received: �r--�� �
Site: ���3 �,�1-L� �(��
Pernut Type: �,Y�,( � �`jf�
Approved w/no comments: Approved w/the below comments: ❑ Denied w/the below comments: ❑
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This comment sheet shall be kept with the peimit and/or plans.
Kalvin itzer Pl s Examiner D t Contractor and/or Homeowner
(Required when comments are present)
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CALIFORNIA ALL-PURPOSE ACKNOWLEDQMENT CMI.GODE§1189
A notary publ�c ar ather offlcer completmg th�s certrf�cate ver�hes only the�dent�yr of the�ndividua(wha s�gned the
document ta which this certificate�s attached,and not the truthfulness,accuraay,or valid�ty af that document.
State of Califomia )
Caunty of_ E..(� �Cl£�2�.�S )
On ! � 1�11�.�� before me, rGl�l1 �. ��1,� �v ��0�l��
Date I-lere in rt Name and Trt/e of the C7�cer �
personaily appeared t����ta+nn �2��f{�'�
Name(s)af Signer(s)
,
who proved to me on the basis of satisfactory evidence ta be the persan(s) whose name(s) is/are
suhscribed to the wi#hin instnament and acknowtedged to me that helshelthey executed the same in
his/her/their authorized capaci#y(ies},and that by h�s/her/their signature(s)on the instrument the person(s), �
or the entity upon behalf of which the person(s)acted,executed the mstrument. � �
, t certify under PENALTY OF PERJURY under the laws
of the State af Califomia that the foregaing paragraph
is true anrf correct.
���OEUEUOMMI�� WITNESS my hand and fficial seal.
r :� � Com�ta�!211i�t1
, m Nonry Pu1�is•Cf�tomh ,
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. < ,� Sfgnature of Notary Pub/ic
Place Notary Seal Above �
OPT/ONAL _
i"hough this section!s vptional, comp/eting this information can deter alteration of the document or
fraudulent reattachment of fhis form to an unintended document.
Desaription of Attached Document
Title or Type of Document: l�L�h(�Q D'� _�71WIAI�!'�U}'��` Document Date: V1��`�'��
Number of Pages: _,�,_ Signer(s} Other Than Named Above:
C acPiy(ies)Claimed by Signer(s)
Sign 's Name: ' er's Name:
❑Co rate Officer — Title(s): ❑Co rate Officer — Title(s):
❑Partner ❑l.Imited ❑General O Partner Eimited ❑General,
❑Individual ❑Attomey in Fact ❑Individual Attomey in Fact
❑7rustee uardian or Conserva#ar ❑Trustee ❑ ugrciian ar Canservator
❑Other: _ ❑ Other: �
Signer Is Representing: S�gner !s Representing:
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02Q14 National Notary Associatiart*www.Nationall�otary.org•1-800-US NOTARY{1-800-876-6827} �em#59Q7 '
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at►as COpPOAATE HFJlGQUAHTERS HOATHEAST DIVISION
S I�N l NO U S T A16S 1077 Weat Blue Heron Blvd,West Palm Beach,Florida 33404 707 Commerce Dnve Concord,Narth Carolma 28026
/ � PHONE:(681)B63.8869/800.772.793Z FAX•(B61)889.4Z94 PHONE(704)7H8.3733/800.772.7932 FAX:(704)788.3843
FLORIOA i oFrr ou I �EOROIA wwwetlasalgnindustriea.us
Dear Customer:
This letter is required in order for ATLAS SIGNS HOLDINGS, INC,, or its agent, to apply
for permit(s)to install signs at your location. It must be signed by an officer(or owner) of
your company and must be notarized.
Thank you.
�� - ����' �' '�"�� � ����y-� Property owner or agent of:
�-t�Z fL����N{ �d�a.o , � �a, e��-�r � d c-� 9-�z��-
Address
Do hereby give permission to ATLAS SIGN INDUSTRIES or its agent to erect a
sign at the above location.
�w�y� � �.�
Property owner or agent(Please type or print)
i/Vl�Irr� �►�b� s--� Z - �-�-
Signature of Property owner or agent Date
'�'1(0� �f��NG P��-fl �.�3 G � Gc ti►T7 � �t-f �S2 3'�
Mailing Address
CS�3) lo�� •- �� <� .
Telephone Number
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This instrument was acknowledged before me this Day ofy� , 20 � `7 � '
S-/�-/7
otary Public (Signature)
, ��'ti.l.�-r � S�LI C---,�5 5-��-�7
� ` Notary Public (Printed Name)
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' . JANETP.SELLERS Personally Known- d ,
� - Notary Rublic,State of Ohio
` � �e � My Clanmiss�on Expires Q419•2018
' � Produced Identificat�on-�
Type_ �lar� �,(�
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� a�I aS COFiPORATE HEADQUAflTERS NOHTHEAST DIVISION
i S/G N /N O U S T R/E S 1077 West Blue Heron Bbd.,West Palm Beach,Florida 33404 707 Commerce Dr(ve,Concord,North Carotina 28025
" '- PHONE:(561)863.6659/800.772.7932 FAX:(567)863.4294 PHONE:(704)788.3733/800.772.7932 FAX:(704)788.3843
FLORIDA i NorrrH cnRourw-i GEORGIA www,aUassignindustriesus
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� Date: '1 Z o[
To Whom It ay Concern:
License Holder: Jeffery Adinolfe Sta.te License: ES0000204
Fum Address: 1077 W. Blue Heron Blvd., West Palm Beach, FL 33404
Telephone Number: 813-907-8000
I hereby authorize the following individuals to act as my agent in a11 azeas of permitting
and licensing procedure with the municipality to which this is presented.
This authorization is for sign permits at various locations and to register the
contractor
X This au��a��is fo�th�(following�location: �
<�a� �3 i,�- z.�.��,��,,1 �s, �
Stephanie Arce, West Central Florida Permits
Cindy Evangelista, West Central Florida Permits
;� Ed Krauss, West Central Florida Permits
Theresa Krauss, West Central Florida Permits
Charlie Buff, West Central Florida Permits
Marshall Chmura, West Central Florida Permits
Tim Byrd, West Central Florida Permits
Date�1 � t''� Signed: �
Con a to
CONTRACTOR� SIGNATURE NOTARIZED:
State of Flori
County of y�jCf��f �
S sc 'bed befo�e me on this � day of t�(� 2017 by
�� �� � who is personally known to�e. \�����N�������b����
Notary Signature ``����N�FFR L►9F,p,!�oi���
CommissionNumb F �$�j'(m �` �,�� �'�qy��
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My Commission Expires: 7 _ �+'; �
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s ' , AFI'EP.RECORDING—ItETURN`CO: IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIII
, 2017099497 )
Rcpt:1874038 Rec: 18.50 �
PERMIT NUMBER DS: 0.00 I T: 0.00
06/23/2017 K. R. M. , Dpty Clerk
NOTICE OF COMMENCEMENT
The undersigned hereby gives notice that improvement wil]be made to certain real property,and in accordance�vith Chapter 713,
Florida Statutes,the following information is provided in this Notice of Commencement. '
�fl . �b -Z� _ OQZc - t�oocc� -
1. DESCItIPTION OF PROPERTY(Legal description of the proper[y&sh'eet address,if available)TA7t FOLIO NO.: 's
.� L 6�sa
SUBDIVISION �.►'ti Z. li"�Ol�^C� BLOCK TRACT LOT � D�BLDG UMT�L7 Z �g ��
�T
5939 Gall Blvd Zephyrhills FL 33542
2. GENERALDESCRIYTIONOFIMPROVEMENT:
Sian Installation
3. OWLYER INFORMATION OR LESSEE INFORMATION IF THE LESSEE CONTRACTED FOR THE II48R0 VEMENT:
a.Nameandaddress: �—eSS@B: H8fb0�Ff@Igflt TOO�S
b.Interes[inproperty R2t81I TOOI StOfE `:1��3�,
h ,� �+� , � �z ..��3 �
a Name and address of fee simple titleholder(f different from Owner listed above): �� �
� ��Y�C«�- � , O f�- �5L37
a. a.coxTxncrox�sNnME: Atlas Signs Holdings, Inc.
co„o�a�corsaaa�e5s: 1077 West Blue Heron Blvd. West Palm Beach,FL 33404 b.Phonenumber. 561-863-6659
5. SURE'TY(if applicable,a copy of the payment bond is attached):
B�
a.Name and address: �C
o���
b.Phone number. c.Amount of bond:S �W D
W��
6.3 LENDER'S NAME: 7C� �
z
Lender's address: b.Phone number: - �m
,�J�
7 Persons within the State of Florida designated by Owner upon whom notices or other documents may be served as provided by !�B J
Section 713.13(1)(a)7.,Florida Statutes: /�� �
��+N�
f-' .D I
a.Name aad address: +W��
3 n
b.Phone numbers of designated persons: o,
, '�
8.a.In addirion to himself or hersel:�Owner designates of �'"� m
to receive a copy of the Lienor's Notice as provided in Section 713.13(1)(b),Florida Statutes. x
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b.Phone number of person or eutity designated by Owner: ��
�N 3
9 Fxpirarion date of notice of commencement(the expiration date may not be before the complerion of construction and final -n
payment to the contractor,but will be 1 yeaz from the date of recording imless a different date is specified): ,20_ .� �
0
r
RlARNING TO OWNER. ANY PAYMENTS MADE BY T'HE OWNER AFTER Tf�EXPIItATION OF 1T�NOTICE OF COI�4MENCEMENT m I
ARE CONSIDERED IIvIPROPER PAYMENTS UNDER CHAPTER 713 PART L SECTION 713 13.FLORIDA STATUTES.AND CAN ��
RESULT IN YOUR PAYIIQG TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE
RECORDED AND POSTED ON TFIE JOB SITE BEFORE Tf�FIRST INSPECTION IF YOU TNTEND TO OBTAIN FINANCING.CONSULT
WITH YOUR I.ENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR REC G YOUR NOTICE OF COP�IMIIICEMENT.
Under penalty of perjury,I declare that I have read the foregoing notice of com m nt d that the facts stated therein are true to
the best of my lmowledge and belief.
(Signature of Owner or Lessee,or Owner's or Lessee's (Print a nd Provide Signatory's Ti e/Office)
Authorized Officer/Director/Partner/Manager)
Sta of
County o �\
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The foregoing instrum wa�Towledged before me trus day of ,20
by T'� as
(name of perso�N�� (type of authority,. e.g.officer,trustee,attomey in fact)
for
(name of party on behalf of whom instrumen s executed)
Personally I{nown or Produced Identificarion e of Identification Produced
'-.Icitr,r'i
(5ignature of Notary Public)
(Prin�Type,or Stamp Commissioned Name of Notary Public)
Rev.10-01-11(S.Recording)
.
OR BK g5�i3 2� �1`f� �
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document.
State of California )
County of��C S )
On� 1� � �Ot� before me, I�G�tII � 1—�c� � ��''�J���'
UY1CY1 ,
Date � Here !n rt Name and Title of the Officer
personally appeared ����\O��rVI �2���l�
Name(s) of Signer(s)
,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their signature(s)on the instrument the person(s),
or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph
is true and correct.
OESORIW.I�;� WITNESS my hand and •fficial seal.
� . •�1 Commii;fon:1r21�1`;
�'�"�; ' Notary PuWle=CNNcni1��
7 , � J���O `�r'
�° ���,, Los Anpeles Couniy Signature
# �= My Comm.Expires A r 13,2020 Signature of Notary Public
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Place Notary Seal Above
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Description of Attached Document
Title or Type of Document: �V0�1(�, 0� �11Ul�Afl�'.�CUI'� Document Date: ��A��'��
Number of Pages: _� Signer(s) Other Than Named Above:
' Ca acity(ies) Claimed by Signer(s)
Sign r's Name: ' er's Name:
�Cor rate Officer — Title(s): ❑ Co rate Officer — Title(s):
❑ Partner ❑ Limited ❑General ❑ Partner Limited ❑ General
❑ Individual O Attorney in Fact ❑ Individual Attorney in Fact
❑7ruste� uardian or Conservator ❑Trustee ❑ �uardian or Conservator
❑Other: ❑ Other: �
Signer Is Representing: Signer Is Representing:
02014 National Notary Association •www.NationalNotary.org • 1-800-US NOTARY(1-800-876-6827) Item#5907
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1"HIS 15 Tc�CERTIFY THAT i ME FOREGOING IS A [oy�. n°'�
TRUE AND CORRECT CQPY OF THE DOCUMENT
ON FILE OR OF PUBLIC RECORD IN THIS OFFICE � � I�tc�oawernisr • �
JVITNESS�M�Y{HAND A OFFICIAL SEAL THIS '
_a,�`��`JAY OF 2 0/7 �` . �) �
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PAULA S O' EIL,CL K&COMPTROLLER {�a ��� �F �
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� DEPUTY CLERK "�`�� �' P'm.�`�"a`. �
BY � _ �����,�,,