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Home My WebLink About23-6663City of Zephyrhills 5335 Eighth Street Zephyrhills, FL 33542 Phone: (813) 780-0020 Fax: (813) 780-0021 BAR-006663-2023 Issue Date: 07/24/2023 REINSPECTION FEES: (c) 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 subsequent reinspection. Notice: In addition to the requirements of this permit, there may be additional restrictions applicable to this property that may be found in the public records of this county, and there may be additional permit required from other governmental entities such as water management, state agencies or federal agencies. 111�1111! 1111 � � � ':!� 1 1 IKITIF11117! 11411 111111 i 1 Irrinin I I I I : : mmmm=� Complete Plans, Specifications add fee Must Accompany Application. All work shall be performed in accordance with City Codes and Ordinances. NO OCCUPANCY BEFORE C.O. NO OCCUPANCY BEFORE C.O. 4 PE I CONTRACTOR SIGNAT4 T OFFICE PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED PROTECT CARD FROM WEATHER 813-780-0020 City of Zephyrhills Permit Application Fax-813-780.0021 Building Department Date Received 77 r Phone Contact for Permittin - 1 Owner's Name V,6 - Owner Phone Number i / Owner's Address I Owner Phone Number Fee Simple Titleholder Name Owner Phone Number �s Fee Simple Titleholder Address JOB ADDRESS2epANv2A,'LLS LOT # SUBDIVISION'., s� PARCEL ID# (OBTAINED FROM PROPERTY TAX WORK PROPOSED B NEW CONSTR 8 ADD/ALT 0 SIGN a DEMOLISH INSTALL REPAIR BUILDING SIZE SQ FOOTAGE HEIGHT ® BUILDING $ VALUATION OF TOTAL CONSTRUCTION =ELECTRICAL $ AMP SERVICE PROGRESS ENERGY = W.R.E.C. =PLUMBING 1$ =MECHANICAL $ VALUATION OF MECHANICAL INSTALLATION =GAS ROOFING Q SPECIALTY = OTHER FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA =YES NO BUILDER COMPANY SIGNATURE REGISTERED Y/ N FEE CURREN Y I N Address License # ELECTRICIAN COMPANY = SIGNATURE REGISTERED Y / N FEE CURREN Y / N Address License # C �� PLUMBER COMPANY SIGNATURE REGISTERED Y / N FEE CURREN I Y / N Address License #�� MECHANICAL COMPANY SIGNATURE E REGISTERED Y/ N FEE CURREN Y/ N Address I License # L— OTHER COMPANY SIGNATURE REGISTERED N FEE CURREN Address - license # fii#i�lltilii�I;QiF�#iif�f�itli�#�f¢��if#tf#tilil�##i€iifaliilE#i�i1#![ei RESIDENTIAL Attach (2) Plot Plans; (2) sets of Building Plans; (1) set of Energy Forms; R-O-W Permit for new construction, Minimum ten (10) working days after submittal date. Required onsite, Construction Plans, Stormwater Plans w/ Silt Fence installed, Sanitary Facilities & 1 dumpster, Site Work Permit for subdivisions/large projects COMMERCIAL Attach (2) complete sets of Building Plans plus a Life Safety Page; (1) set of Energy Forms. R-O-W Permit for new construction. Minimum ten (10) working days after submittal date. Required onsite, Construction Plans, Stormwater Plans w/ Silt Fence installed, Sanitary Facilities & 1 dumpster. Site Work Permit for all new projects. All commercial requirements must meet compliance SIGN PERMIT Attach (2) sets of Engineered Plans. ****PROPERTY SURVEY required for all NEW construction. Directions: Fill out application completely. Owner & Contractor sign back of application, notarized If over $2500, a Notice of Commencement is required. (AIC upgrades over $7500) ** Agent (for the contractor) or Power of Attorney (for the owner) would be someone with notarized letter from owner authorizing same OVER THE COUNTER PERMITTING (copy of contract required) Reroofs if shingles Sewers Service Upgrades A/C Fences (Plot/Survey/Footage) Driveways -Not over Counter if on public roadways..needs ROW 813-780-0020 City of Zephyrhills Permit Application Fax-813-780-0021 Building Department 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 properly 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 Agriculture and Consumer Affairs. If the applicant is someone other than the "owner", 1 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: 1 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 performed to meet standards of all laws regulating construction, County and City codes, zoning regulations, and land development regulations in the jurisdiction. I also certify that I understand that the regulations of other government agencies may apply to the intended work, and that it is my responsibility to identify what actions I must take to be in compliance. Such agencies include but are not limited to: - Department of Environmental Protection -Cypress Bayheads, Wetland 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 & 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 W" 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 permitting 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. OWNER OR AGENT Subscribed and swom to (or affirmed) before me this Who is/are personally known to me or has/have produced as identification. Notary Public Commission No. Name of Notary typed, printed or stamped CONTRACTOR 7 Subscribed and sworn t (o me this Who is/are personally known to o as/have proJuc6a as identification. i —Notary Public Commission No. 1 Name of Notary typed, printed or stamped Notary Public State of Florid7 Ak Frank Thompson xT!�w4 rKWltt( Expires 8 Karilyn Meck R15gjq S ULL FC I :T% 16.13 S30941 Last Revision Date: 0918 Page 3 of 6 [] Loan docs signed Paper docs NOT signed at Size Inspection Paper docs signed at Site Inspection ; H NnT d;H ., c;n, I-nerfi— E docs sinned at Site Inspection L. '2023 Date Approved: - --- ---------- - Tuesday, May 2,2023 Date Measured; My Florida Safe Home No 1 Date Inspection Schedulded For Wind Velocity in MPH 137 S30941 Ap�jicant Karilyn Meck Frame Type � On NOC M on Loan Rid 1E 71992 Applicant Phone/Email (864) 887-1607 iML= Exterior Siding Co icant, Douglos Meck Year Built Co -Applicant Phone/Email Bucking Req Contract Date & EOR 4/29/2023 5/04/2023 Color ff Home Address City, State Zip 6458 Brentwood Dr -----_------------- -------- Zephyrhills, Fl. 33542 Grids Frosted County Pasco Impact Sales Rep Aaron Harding Non -Impact Phone Number (407) 508-8285 Window Shields Job Phan No NN=MEC=O001NEM31EO=MKM=N=O= Door Shields A Phase: I mmmm�� No Cust. Init '6KJ1A1__ customer agrees to the above 1 1 3na) T, q9, -75 �1 � 2 �jd'/v a, f 3(, sj�s 3 lma 5E�c 4 73, �m i 7, 75 iP OA'e 6 7 10 11 12 13 14 15 16 17 18 19 zo 4� Customer signature: Date: /3 Do you have an HOA: (Z�)' or No (Please circle one) Do you live in a Flood zone: Yes or No (Please Circle one) Measured By: 0 1,} Iq Date Measured: 23 Last Revision Date: 0918 Page 1 of 6 , Page 11cd 27 HOME PERFORMANCE ALLIANCE, INC. | Phone: (800) 472-5449|Fax [727) 538-4217 ' Customer Service Hotline: 800-472-5896 � 178O1O2ndAvenue, Suite 5O0.St. Petersburg, FL33716 � vvww.hpewindovva.com ^ Email: He|p@HPAwindovvo.rom |� � � S30941 � KarikmMeok 864-887-1607 Date: 04/29/2023 0458Brentwood Dr juat|iu1en322@gmai|.com HR4Rep: Aaron Harding ZephyrhiUaFL33542 Office: (8O0)472-5440 ' General Description ofWork ; Home Performance Alliance, Inc. (HP/) will furnish & install windowo, sliding glass doors and/or entry doors, which are further described inthe Specification Sheet attached hereto aaExhibit ''A^ & initialed bythe parties, HRAwill remove 8dispose ofall � debris from job site. Price below includes bui|dingpermits & Inclusive Limited Lifetime warranty (see sample vvarr�an�. � Project Price: $15,500 Initial Down Payment: $ Form of Down Payment: Cash Balance Due: $1549 Form ofAdditional Down Payment: Cash Balance Due Upon Substantial Conmp|et|nn:° $15.40 �Form ofBalance Due Payment: Ceob� °"^' "^',r- r-%''=''""^''^'C-1-^'' =`'`^'°r-`^"^'Mr'%IA1C1 ^^'""""r)" ^'"-r "=`="-rJr- r'^'^' ="",~,'°^' Bring 311 due is to be paid upon the completed installation of the windows and/or doors. Final inspection by the city or county occurs post- installation and is not related to payment being due. On finance jobs, all finance terms are contained in separate paperwork between you and your finance company. HPA is neither a broker nor a lender. Any minor post - installation items will be discussed with you (such as plugs and trim, possible stress cracks, extra sealant) and is subject to coverage under your written warranties. You Have the Right To A Dedicated Customer Service Hotline. Call: All work will be completed in a professional, workmanlike manner meeting or exceeding standard industry practices. Any � alteration or deviation from the above scope of work involving extra costs will be set forth in a change order agreement � between HPA and you. Unless otherwise specified, all labor carries a one year limited workmanship warranty. ! � Page 5 of 27 CONTRACT EXHIBIT A HOME PERFORMANCE ALLIANCE, INC. Phone.: (800) 472-5449 - Customer Service Hotline 800-472-5896 - Fax (727) 538-4217 1780 102nd Avenue, Suite 500, St. Petersburg, FL 33716 www,myhpa.com - Email: Help@myhpa-com License# CGC1 508826 ® CBC1 258017- CCC1 333840 Karilyn Meck 864-887-1607 Date: 04/29/2023 6458 Brentwood Dr justlisten322@gmail.com Rep Name: Aaron Harding Zephyrhills FL 33542 Office: (800) 472-5449 HPA ROOFING SYSTEM SPECIFICATIONS al HPA to install Peel and Stick Waterproof Membrane on entire project area. It is agreed and understood by and between the parties that this exhibit, along with the Custom Roofing System Agreement and the Additional Terms and Conditions, constitutes the entire understanding between the parties, and there are no verbal understandings changing or modifying any of the terms. This exhibit may not be changed or its terms modified or varied in any way unless such changes are in writing and signed by both parties Buyer(s) hereby acknowledges that Buyer{s) has read this exhibit. Additional Information Gutters in front and bank of lanai,, Karilyn Meck 04/29/2023 Date Page 18of07 F *Single Hung windows, top iufixed & bottom opens. Tilt !nN/4. �. *Company is NOT responsible for painting or staining.*Window Color Options (Exterior/ Interior): White/White, Bronze/White � i 3Lite Rollers (1/31/31/3)|74X5O � Window .1 � Location Front Quantity 1 Window Brand Duraahin|dX Non -impact Window ' Window Style 3 Lite Rollers (1/3 1/3 1/3) Size 121-132 Ul Standard Mullion Included Exterior/|nter|orCo|or White/White Grid Style Colon ia|/BrittanyGrids � Half Round -77OOSeries 130X19 Window # 2 Location F Quantity Window Style 1 Half Round -7708Series Window Brand Size Ouraahie|dXNon-impact 54-7301 Screens Full Exterimr/inbariorCu|or White/Whitb --------- Grid Style Colon ia|/BrittanyGrids 2Lite Rollers -77UOSeries |�2�50 . � | Windowe# 3 Location front room Quantity 1 Window Brand Duruahie|dXNon-Impact Window Window Style 2 Lite Rollers 7700 Series Size 124-133 U| Screens Grid Style Full Colon io|/BrittanyGrids Ex±erioo/|nteriorCo|or White/White Double Hn -770OSeries |37X 50 WMdow # 4 Location Quantity 1 Window Brand VVindovv��y|� Double Hung ' 77OO8erieo Uunaohie|dX Non-|mpact Windows Exferipr//nbariorCoior White/White Size Grid Style Colon 3Lite Rollers (1/41/21/4)-77OQSeries 88X 50 Window� 5 Location Master Quantity 1 Window Brand Ouraohie|dXNon-Impact Window Style Size 134-143 Ul 3 Lite Ro||ers(1/4 1/2 1/4) 7700Sories Exterior/|nteriorCo|or White/White Screens Full an4mMeck 04/29/2023 wa��i�-oe'com�u/5, A ORDER: 1250. ORDER DATE: 0 ORDER CONTACT: SHIPPING INFORMATION HPA St Pete House Account SHIP VIA: 1250338 1 7/7/2023 1 s30941K MECK I KARILYN MECK 1 7700 DOUBLE SLIDER 1 71 1/2 W X 48 3/4 H WHITE REPLACEMENT ACCESSORY TRACK FILLER INSIDE TIP TO TIP LOWS/ARGON/CLEAR TEMPERED ALL GLASS BREAKAGE WARRANTY LIFETIME GRID STYLE{FLAT COLONIAL=[2V3H]} FULL SCREEN FIBERGLASS 1 VENT LATCH FLORIDA BUILDING CODE APPROVED PRODUCTS=[R35-(84X54, RF=E2, GS=DS) FL16092.9] ESTAR CLIMATE ZONES=[NC, SC, S,] SOLAR HEAT GAIN=[0.18] U-FACTOR=[0.29] VISIBLE TRANS MISS ION=[0.41 CLEAR OPENING HEIGHT=[43.5531 CLEAR OPENING SQUARE FEET=[9] CLEAR OPENING WIDTH=[29.7561 2 7700 DOUBLE HUNG 1 36 1/8 W X 49 141 ' WHITE REPLACEMENT ACCESSORY TRACK FILLER INSIDE TIP TO TIP LOWS/ARGON/CLEAR GLASS BREAKAGE WARRANTY LIFETIME GRID STYLE{FLAT COLONIAL=[2V1HD FULL SCREEN FIBERGLASS BALANCE TRACK COVER FLORIDA BUILDING CODE APPROVED PRODUCTS=[LC45-(40X52, RF=NO, GS=DS) FL15819.81 ESTAR CLIMATE ZONES=[NC, SO, S,] SOLAR HEAT GAIN=[0.18] U-FACTOR=[0.291 VISIBLE TRANS MISS ION=[0.421 CLEAR OPENING HEIGHT=[16.8891 CLEAR OPENING SQUARE FEET=[3.6271 CLEAR OPENING WIDTH=[30.9281 7/7/2023 11:19:13 AM 1 of 4 1250338 1 7/712023 / e30941KMECK 3 77OOEND VENT SLIDER VVH[7E 1 88VYX48 7/8H � ' REPLACEMENT - ' ACCESSORY TRACK FILLER INSIDE [ TIP TOTIP � 1/4-1/2-1/4 END VENT LOWE/ARGON/CLEAR �. � GLASS BREAKAGE WARRANTY LIFETIME � HALF SCREEN FIBERGLASS 1VENT LATCH | FLORIDA BUILDING CODE APPROVED PROD CT3 132X54.RF=E2.GS=DG. 424)FL16002.10 EGTARCLIMATE L3NE8=[NC.SC, 8] � SOLAR HEAT GA|N=0.21 i U-FACTOR=[029] i VISIBLE TRANS MISS |ON=045 ; CLEAR OPENING HBGHT=[43.G78 ' � ' CLEAR OPENING SQUARE FEET=[6.141] CLEAR OPENING VV|DTH=C20,2451 � 4 77UOEND VENT SLIDER 1 73 10YVX49H | WHITE REPLACEMENT ACCESSORY TRACK FILLER INSIDE TIP TDTIP 1/4-1/2-1/4END VENT �. LOW EN.R8DN/CLEAR GLASS BREAKAGE WARRANTY LIFETIME : ` KEEPER GRID GTYLE{FLATCDLDN|AL= [2V3H]} � LOCK GRID STYLE(FLATCOLDNiAL=[1V3H]} HALF SCREEN FIBERGLASS � 1VENT LATCH � FLORIDA BUILDING CODE APPROVED PRO UUCTG UR4 132X54.RF=E2.G8=D8. � 424)FL10082.10] | ESTARCLIMATE ZONES=[NC.SC, Sj ~ SOLAR HEAT GA|N=0.10 ; U-F8CT0R=0.291 V|G|BLETRANSK8|SG|ON=[0.4] CLEAR OPENING HBGHT=[43.8U3] � CLEAR OPENING SQUARE FEET=[5.O27] � CLEAR OPENING WIDTH=[16.5271 7/7/20231119:13Aw 2or4 Rg EST WHITE HALF ROUND REPLACEMENT [ ACCESSORY TRACK FILLER INSIDE �| TIP TOTIP ` LOWBARGDN/CLEAR GLASS BREAKAGE WARRANTY LIFETIME FLATSTARBURST=[3] � SILL EXTENDER BEND ONLY WHITE �| PROFILE BENDING FEE � SILL EXTENDER BEND ONLY WHITE � PROFILE BENDING FEE i FLORIDA BUILDING CODE APPROVED PRODUCTS=[LC50-(6OX60.RF=NO.GG=DS) � FL15818.131 �| ESTARCLIMATE ZONES=[N. MC, S8. S] � SOLAR HEAT GA|N=0.21 U-FACTOR=020 VISIBLE TRANS MISS |ON=[0.47] G SILL EXTENDER VVHXF12 5 7 Structure Mullion parts 1 73 1/8VV C � ` 8 Structure Mullion parts 1 73 10VV AM77STRUCTURAL MULLION COVER � WHITE � 9 Structure Mullion parts 2 � FULL BRACKET � 10 Structure Mullion parts 2 C'CL|p 7/7/2023 11:19:13 AM 4 of 4 INSTR#2023130899OR BK10856 PG2307 Page 1 of 1 07/24/2023 09:42 AM Rcpt: 2606730 Rec: 10.00 DS: 0.00 IT: 0.00 Nikki Alvarez-SaWles. F q Paso County Clerk & Ctam troller Permit NO. Parcel ID No 04-26-21-0030-00000-0070 County of Pasco THE UNDERSIGNED hereby gives notice Out Improvement will be made to certain real prop", and in accordance with Chapter 713, Florida Statutes, the follonving Information is provides in this Notice of Commencement 1. Description ofProperty: Parent ldenfiftMionNo. BRENTWOOD PB29 PGS86-89 LOT 7TRACT Q stmet,dd,aaa:. 6458 BRENTWOOD DRIVE, ZEPHYRHILLS, FL 33542 z General Description of improvement 3. Owner Information or Less" information if the Lessee contracted for the Improvement: HARVEY DOUGLAS & MECK KARILYN 1229 YARDS DR WESLEY CHAPEL FL Address City State, interest in Property; 1002/0 Name of Fee Simple Titleholder. (If different from Owner listed above) Address city state k Contractor. HOME PERFORMANCE ALLIANCE N AVE 1780 102 ND N SUITE 500 ST PETERSBURG FL Address city state Contractor's Telephone No.: (727) 538-4140 5. Surety: Address City state Amount of Bond: $ Telephone No.: 6, Lender: Name Address City state Lander's Telephone No.: 7. Persons within the State of Florida designated by the awrler upon whom notices or other documents may be served as provided by Section 713.13(1)(a)(7), Florida Statutes: Name Address city State Telephone Number of Designated Person: & In addition to himself, the owner designates Of to receive a copy of the Lienoes Notice as provided in Section 713. 13(1 Xb). Florida Statutes. Telephone Number of Person or Entity Designated by Owner. 9, Expiration date of Notice of Commencement (the expiration date may not be before the completion of constrwion and final payment to the contractor. but will be one year from the date of recording unless a different date is specified): WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OSTAII WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF *nder penalty of perjury, I declare HIM I have fead the foregoirV notice of commencement and thall Me facts stated therein we true to the best of my lincroledge and belief. STATE OF FLORIDA COUNTY OF PASCO Oi SighaTure of Owner or Lease% or Ownees or Lessees Authonzed Officadrector/Partner/ManeW 1-1 lzuAgA� Signatory3 TItle/Office The foregoing instrument was acialowledge d before me this 2_,s, kgn1w YVI f" Personally Known El OR Produced ldenftficaficnx� 'olary Signature 15M Type of Identification Produced Name (Print) 10, M).00 - 5o6o 9 -o N t r P jpli wpdataMcsinoficeomm"encmnent—pcD$3048 LU W < I-— ( ) U� V) Uj , — X 0 0 LiLL 90 0 2: ('Q o :r < 0 LD ALL' LL 0 u- 0) z _173 eu cc, c) < :z t_U ,lu ta J_ W 0 z co