HomeMy WebLinkAbout93-3107
BUILDING PERMIT
Permit
_ 3107M
,3 -.:l3 -9:3
CITY OF ZEPHYRHILLS
(813) 788.6611
N~
Property Owner:
Job Address:
Parcell.D. #
E~/ P~-'
CY5-7!~1:H~ GVJ'
c.-P-D-
MECHANICAL
Date
~.
Sewer Conn
Water Conn:
Water Meter:
T.I.F."s:
Zoning:
Description of Work
FINAL
DATE
NO OCCUPA
Complete Plans, Specifications and Fee Must Accompany Application. C.O.
All work shall be performed in accordance with City Codes and Ordinances.
Inspector
Li ucJ
&0'-
c
City License Aegls..atlon # to 5" '7 '-~.l-~:.
State Certified License# (/
P~rmit Fee~()' ~---
Signature ~~
Company
Address
Telephone#
Valuation or
Contract Price
B~G
ELEC~'L
---
PL~
-
~~~-~JJa;;
MECHANICAL
Breakers
Ducts Insl.
Compressor
Final
SLB
Tub Set
Water
Sewer
Final
Tp. Servo
Rough In
Meter Can
Const. Pole
Pool
Pre-Meter
Final
Ftr.
Pre SLB
Lintel
FRM.
Insul. CL
WL
Driveway
REINSPECTION FEES: When extra inspection trips are necessary due to anyone of the following reasons, a
charge of Fifteen and 00/100 Dollars ($15.00) shall be made for each trip for each trade:
a. Wrong Address
b. Condemned work resulting from faulty construction.
c. Repairs or corrections not made when inspection called.
d. Work not ready for inspection when called.
e. Permit not posted on job site.
f. Plans not at job site.
g. Work not accessible.
The payment of inspection fees shall be made before any further permits will be issued to the person owning
same.
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CONSUI\...IER AGREEMENT
'~'''''IICd'> PInpoint!. IIIC, Box 965, Vdlley Forge, PA Hl4lJ2 ("The Comp,lIIY'") and ______.__.
_n_ fl.4_!'f".J: t{-?tt2.Iy. 4 ~LOWIJ61.S________ ____ _______________
SS7 ~_I/G:ttu... .-f!,/ VIJ> - --~"y~JJ..J./i -----*--~---;n.sztL- ___ _ ,_______ ("Consumer");
(c,'y) (~ldte) (LIp)
\ ~;ll '~ld.1 I\tld! tl":>}
__(!4~_fI.l1:r___
lrl ClJll~l(h.:rdtlon of ttJu rnuludl j.Jrollll~t~t) III Ihis dYI lJelllt" jl_. Tho COl"i1pany and the consumer agree thdt:
0:1 the followIng' list, ;;nd tho Consumer agrees to pay
TIl" consumer req"esls thu insldllalion of tile propane storage and related equipmenl
I tlt-) CUfIlpdny lhu chdr~Jt.:s fOI 1I1~ equipment and reldtell Sf:rVlce:j as listed.
EQUIPMENT AND CHARGES
IJI :.(_.IIII'rIOtJ()f ~.>r()HI\r..,d: ^NNl:J^l
,~ 'II 11\ r III LCiU'I>MLl~ T HLNT Al
(?).__.t20__~G--_,___
INSTAll AIION
CHAHGL
ANNUAL
MINIMUM
---~----J!!____
.-f'J
-------- - - ----------- --- 'If:--------------. --------
'3)1;5UJ.ozLl!111Lt..c~~8/fQ,-OO C!.'f- A.!2._____ ;11'
--_.~.-,-----~-- ."."------_._--~-- -.--------.. ... --~_.-.-'--'----_.,-,~---
_._----'---,---~,~---,-- --_._------'_._._--_._~----_. -,-- -~--'
Fees, Renj,t'b, Installation Charges, Lease Charges, Etc. Are N01 Refundable.
2. The I'-'nll of tlus dqlt!elHe"t willl.Je _~_ ,"d'S ~Iom lhe dale 8. The COl1ltJi,ny is not responsible for turnishing fill, resurfacinq or
IJII wt,icll It IS ~,fUlhKj by ttlt.: COI1~AJlller d,H.l Ybdr to year tll~;r'-~d~tl.:r, unl....ss drld resta:111!! COflsuln..:r's prenllsus to Its previous condition when any equipment
unlll hUlllindtud ;)::j providl1cJ hL:n:.~ln. Consumer will purcl'idst: alll)f the propane is renll.ved by The CompDny.
bUill nh: C(J/nrkIIlY Hktt is r(:qutred fc" use at the dddff":s~ ;:' Hli~ d9,eUIllcIlt
Ill' tile tehll of ttll~ .,lfjlt.:l:nJt:ltt. Ollly (Jrop':'lrlt;~ sulci by The Company ShLl1I b(:
u~~(:ll willi Lilt:: abuve equipment.
J< Cun~;ulllur ,Hlfl:(;S to PdY The COlllpanY'$ rLltes ..md eht:HUes due under
tlll:---; ltJII)t:IIII..,:llt pn~Vi.llilllq ilt tnu lIme uf sdle Wltt)j'llllu P(!cu lurfltory est,lulisllC,d
tlY r IIU CllIlIjJ.lI1Y Wlthlll JO ddY~> ,dttH lIu! iJdlll)~1 ddlu dl ttll~ colluctlOIl olticu
lju~,j{llldlt'd by I hu CUlllp,UlY, lll'o" (;ump;'lIY IIlolY rlldke dlllHldl ddJLI~.hTlUllh to
till': It.'lll,11 tJllllle t:(IUII,HIH~IIIIi~,tcd !1.'i,vl:.11 !!J~: Cunt>.U1I,.ur ";rl~.'~ I dY i:.U.lY dlll~~lllt
."...,jlt~11 due, TIlt: CtJlIl[ldllY Slldll dC;I; d Lite chwqe of ---f't-"t:~---- tu .III pdst
ilth.' :1~11,lIlU;~> <Hid ',11.111 tJU (HIIltli.,j lu l(a'C'Vt.:r lh, rt~,I~i'_HI,:E)h: CO~.l~.. ul C{Jl.
l'IIHAI, IIw1whllq dtt(IIIIL'y'~ ft.:(...~,. If thu (;ruull of the CorbUtller sh,1I1 tJL'
lh-;'llll.'d l'II"dlht.Il~I(J/Y hy Ttll: Cl)lllpdllY lur tlllY CdlJ'.t:, Itll: Cl.lll1pdny 11l;IV
l'CljlJilI: p.,Y'II,;rlllll "UVdll(,U !ILluf\. 11,.II-'dll~lllllltlt..'1 ~.tltpllll:II!:'
COllsuuwr dUI(;~t:~; to PdY imy license, permit or insnectlon fees or
l. 1''' C:1 11I1PW,vd UPOIl tilL: equlpllh.:llt 01 tile !r("I~>dLlujn i1uret:t1 to ill thiS
..~ jf l~t..:lllt~lll, II COf"l::,UI1H}1 U~t~:., plUpillll-:: f(Jr ,my tdxdblf: pi Jfp(J';;L:~.; 1101 ruquilll\q
(l,ilcdltJII t)y lhl: COlllpdJIY CUII:,UflH.:r ~jhdll repurt ;,I.,J ,JdY ttl(~ ldX to 1I1L"
t.j.IIII~J .juilluntJ(;~, TI-lt: CUlllp,my ff:::'l~rVt:S tile 11~.Jhl 10 "cqulrl! COnSUrlH:r tu
1);J',1 d Cd~,1l d(:pu~.il .IS ~t::cu'lIy fur till: paYlllenl uf dllY SUPl whIch IlhlV tlL'
l ~\H: 1lI Illt:l It ll~, ~j(.JJL'l;IIII~IIl. 'lllj~j dUf--'()~,11 II'dY be '-lppJlcd i ,')1 Tlll~ CUIT'lJdny o.)t dflY
tllll"_~ ,1\ '..\II~)IL: ur III pdd 10 drlY ~JUfIl~ owed by CUf1~JLlf_I(,1 10 nit: CUJllfXlrly.
I). /\11 f:-qUIPllk'/lt ~.,ljppllt.:d ijr In:)ldllucl by The c.:UI1lIJ';rlY whieh is not
:'tH~t'IIICdl!y ')uld \() C\j:1IUnlt.~1 will fe-IIl.1l11 thu IJI'OPl:rty ul Tile C()IllIJ.tt1Y .HH_l
~,iI.IIlIlOI tJuuJjll(~ d flxlUlt..: lJI tilt: Curl~lurller's j.llufhJrty U( .J pillt uf ltlt: relll
ll(i'!Jt./ly. C(III:,lII11\~f i.llNll~; ,011 lullHI~J. PI[JIII~J ~11l(J littln~r:-. r\(l( uwnlHI 11'1 riu:
C,-AllpJIIY dllCl I::.. :;oldy rt;~)I.H.Hl',Jt)iL; tur t1lt~Jr nld!llll:ll<lIICl':. UpOl1 It:qutJst ul
I ~lt. (:\llllpd,IY, CU(l~>urrk~1 :,I\~dl t:Xl.';~ule d ttll.U1Clllv ~,tdll:IlIl:1I1 in fU1'I1I
It_,l:'l.}j)clbly :Hdlsldclory lu Ttli:~ COlllPdflY ~md r(;turn It to Tlh; COII:pdny to,
llililij Fkq,II(\!v::Js ()f tlit: lIwfll:f:,lilp ul .:qulI)"lt.~;;t. .~~I,r\lSlJMI::.J--{ WILL N(YI
1.1;,0.1 MJY CONNLC f10!~S 01, UISCONi.iEC, ;:)"J,; Tel! HL EOUIPMiCN r
ur HI S~; WIIITI i"N 1-'EHMI"c;I(JN IS m,C'I\ic,) H1UM 1 HI, COMI'^NY
lUlhUllll,.' v.ill dHow Tht: CUJilll<IIlY fn:!.: ;){;CeSt:i lo llle jJropt.:dy whert: Hit..!
e<;L,qJllwlll I~; tu tw iU\_;lkd ,II ;dl tHlll:~i tu Ill::-.l..lll, ~.d\ll(;t; ur lemUVl~ HIt:
\;ljdljllli.'ld.
(;1 liLnf IS NO HFPflES[I~TATION OR WAHHANTY. EITHtR EX-
l'fHSS OR IMF'lILD. WITH IH.:SPECT 10 ANY PHOI'A'~l OH EOUIPMENT
~,'I\'J 011 HllILAFlEH ~;UBJLCI -r,.) THIS ^GHHMENr. INCLUDING ANY
\/J/\HIl^NI IES Of- ML HeliNJI ii/Jill: Y OH Of- f-ln.1E~;c; Ion ^N INTfNDI [)
f'UHII)C;1 ur,DLH NO C!IlCIJ'<'1.Sl,\NCES SHALL ,lit: COMPANY UE
11,~'J1 L IOH CmJ;;H)U[I~ IIAL C>d SPECI!,: DAMAGES, II~CLUDING
VlllfluU 11II>~IIArIOrJ UUSiNE~;S IN I EHHUPTIO/.J llAI,MCLS
I Ttw COrbUnlj;(" dulhOllll:~; Tilt: CompilllY tn Ic:pLclCC ib equivnenl .lit
,1I1'Y IIIlll: \Nllh no ctldll~ll.'~; III !tIt: obli~JdIIOIl~-; of Ihi', "I_lr'~'.'IIIL'Ilt. It TtJtl
l.(lilll.ltllY rl'pldcl:S tlll: (~qljIJ_Jlllt:f1t WIllI (;ql1iprllt.:n! of ddl...,"~;'ol Cdj.).IUly, 111/":
dlllhj,11Il~!ll,tl ci1dlljU::';. II .IllY, WIll tJU ddJu~tt,'d to those ,lldt dIe' I;Llt'rently tJUllq
dldf~Jl:d IUI thu t~qUJpmt..~lll '..-\lhldl I~ ~;ub'.:!:!uted. TIlt."-: CLl~l'"t"n81' dlltfJCJlilc':"
1111: C()mpdnv, Ul Ib r1j~(iltJtj(J11, lu IVlllpur;Hily remove ,I:, l,'llulpmvlil (!l/flnq
!)C;IIVd'. ul 11CJlI-.USd1ItJ t)y t1lt~ (;01 ISllfl H.:r, III WIIJC~t t.'vellt l'lV H:II1i,1 dl,jrqt..'~;. 11
,lily, will be ~USpt;lltJt.ld.
9. Either party may terminate this agreement at the expiration of the
orin",al or ex lended term by givulg the olller party 30 days' ;;dvance written
notic". Either party may termin"tu this agreoment I( the other party fails 10
stltl:ify ,my of tile 1enns tlnd conditions of this aureem0nt. The Company may
torflllnalo thIS d~!reernent imnlodidtely if:
<I.
dbo\t.; or
Tim ConsulllOt ("il:, to pu,cll<lse the ilIlflual minimum set forth
b. Th" COI"Utnur ""Is to pay The: COlllpany amounts due under thiS
a~ln.elllellt; or
c. lilt: CUlI~IIII1t," :t.JI'lf,)Ve-:.1 or ti.llnpen.. with tllV tJtlUlpll~Lnt Installod
by The Comp,,,ry
As dny loss d"SUlg fro'n " breach of Ihls contract by Consumor would be
dlflicult to dutenl1ll1U, Il IS dqreed that in addition 10 any o~her remedies
ilci"t.'undt:r, IlqUlddlt~d rl~Hndni.;':; for ,-tny bl'edch of pHrformance will be the
(/(jllar amount set :orth above or The Company's lost profIt marqin for the
dnnudl minllllUlfl ~Jc"Jlltmdgl:. This amount IS due and pdyablt~ irnmcHiiatHly at
tilt.~ lllne of bredcil, plu~ U1tcrvst. dnd it nec8~;sdry cost.s of colleclioll to the
llliJXI/: 'um (;x kill pl~".i\jtted by li.lw.
10. ConsulII'-" 1\111 prornplly surrender 10 The Company all of The Compa-
ny's equlpmc1ll hi the CllJI~jllmer's pO:::isAssion when this odDrcemont is
k~nnllldled fur <.lilY '-Udson. Tho Company reserves the right to chi.uge a
1\.:~luLkHHJ U)drUt: for iJlckjll~J 'IP tht.: equipment and propc:me.
11. If Tile COIPp.my 'Jr C',nsunl(~r doldYS l;;!XerCislllg any of its fI(1l"lt:-) under
thl~.; agreolllent, th,lt IX" ty w,ll pul lJ(~ prevented from exereis.in(l such rights at
it leiler ddtt:. If Tl1u CUlIlPdllY or 11'le Consumer WLlIVclS any breach of this
d'l' "emenl, 1";;1 party will not be prevent"d trom enforcing its lights uncJor
tilis illJl(:fjl'1Unt a~; IllOWJ:lIlO waiveI' ~1<:.ld occurred. Tile Company is not liable
101 i.IIlY 1('~,S sustailll h j by lfk~ Consumer as d r8sult of the temporary
ej(l1<j~l::;tl)I,.)f lh..:: C:1I1slIlller's supply of propane, nor for any Injune::. to
pl:rsOII~~ 1/ property ~Irt;irl~j out..of Hie storCloe or use of propane, or the use.
Up!;:1 dtlDn ,JfHI llldlllterldHC(: 01 ropdll of any equipment or appliance stOl ing Of
utlll~:lflfJ fJrOfJ311l::. .
\
12. :ho Compar,y Slldfl nol be responsible for any dday or damages
causecl by events or circumstances beyond its reasonable control, including
Wit/lout lifllitatlon ..lets of God, fire, storms, floods, wars, compllilnce with laws
or rUHulations, or The Cornpdny's inaolllty to obt,tlll plop<.H)e from its custo~
mary ~;UPfJllers. The CompLlllY rndY sdl, t(clnster or assign this aoreement
witnuut Consumer's C(>II~Emt provldt:d the (I~Jre8Il1ent remains in full force 31ld
l:lfftct dti betWt':U'1 Hll" '":.unsul1l8r alld ~he rH~r0oll r(:pldC!nq Tl1e Company.
1:3 This ':Ufv,:,III_'nl IS Uk~- lilld! und.)rst._Hldulfj botween Tho Comp,HlY' and
tl"tu C,-,llSulllcr dlld there DIu 110 pnor fcprtj~t..:lltalions or warrunties. It any part
oj tl ilS ~lgreemnnt is i:'l'l;udqeci invalid 01' wkJnforccabk::, the remainder of thiS
il~JluumUIlL ~vill conllllllP to bu vdlid dnd enton.:eablu. This dHII~Bnl(-!nt may be
PII.)dlll'.~d or wllumlell only In vvnlillO ~i9netf by bulb lhu COlllpany and
CO'I~~lllneL
file followlllfJ altilcllrnent:; are a part 01 Ihis agreement:
Attilcl1ment I I AttJchrneni t. 'j AttachlIJr"" s ' , Attachment B
IN WITNESS WHEREOF, the ,);lrllcs hereto have duly eXHcuted 1.his agm('ment on ,1m ----21-- day 01 msJliJ.AJZr-' 19'1-1.
~~ ~ 10 T: ;/ I P II ~~ An,' Gas proPdne'~':l-iL
f?" . ~1..~ . >--1,__. .. I ~77(j----;;Y:--rbr~-
I), .1' , Ie jI 1~ _ _ ,';..l.,L __ ___
.",,:;.j f
~c:':~~__'-~'''''''''''''''''''''''''''_-'Cc'''----'-- - - ---- _
APPLICATI:OIiI FOR PERMIT
CI'IY OF ZEPJIYRIlILLS
BUILDIIiIG DltPAR1'HE'NT
OWNER · S MAKE
fl. tJ.. .s'ezMAAf
\\ .
t:~AFE J.-/T;C /1
PIIONE 8-/s -7~3 -(,b 7-1-
OWNER · S ADDRESS
JOB ADDRESS
~~/~ Ai.. ~IIISII~ )
LEC.AL DESCRIPTION: LOT(S)
BLOCK
SUBDIVISION
PARCEL 1. D. #
WRK PROPOSED:_l!l.!eW' Construction ---P\ddition _Alteration _Repair _Install
_Sign
_Hove
_Deaolish
PROPOSED USE:
Single FaDlily
_KIF
_' of Units
_H/H
_Co.aercial
_Indust.
_Swi.. Pool
. Other
_Restaurant Ii: llealth Deparblent Approval
BUILDING SIZE:
x
Square Feet,
Height
RESIDENTIAL:
COtIHERCIAL :
ATTACfI (2) PLOT PI.ANS Ii:: (2) SEI'S OF BUILDING PLMilS &: (1) SET ENERGY FORHS.**
A'ITAClI (3) SETS OF BlJILDDG PI.ANS Ii: (1) SET ENERGY FORMS. **
"''''COPY" OF CONTRACT RE.Qmmm.
PERnITS REOUF_"iTED
_BUILDING
$
,,0
x4/}'
Va1uation of Total Construction
_ELECTRICAL
AKP Service
Florida Power COrp.
W.R.E.C.
_MECHANICAL
$
Va1uation of Mechanical Installation
_PLUMBING
GAS
ROOFING
SPECIALTY
TYPE OF CONSTRUCI'IOIN1: _Block.
_Fr3llle _~eel
Other
FINISHED FLOOR EI.EVATIm~S:
FT.
IS P.ROJECT IN FLOOD ZONE ARE...\?
l"'ES NO
"'''''''''''''''''''''''''''''''''''''''''''*******************'''*******
CONTRACTOR SECTION
RUILDY.R
Signature
COIIfPMlIY
State Cert:. or Regist:. i#
City License Registration #
******************************************
EI.ECTRIClAN
CO'!IPANY
State Cert:. or Regist:. #i=
City License Registration f
******************************************
Sirolature
PLUKRER
COHPANY
State Cert. or Regist. #f:
City 1,icense Registration f
*******"'**********************************
Signature
MECHANICAL
Signature
CO'!IPANY
State Cert. or Regist. ,
City License Registration B
******************************************
OTHER.
l'
CO'!IPANY ~/61iS
State Cert_ or Regist. i#
City License Registration i#
.............*............................
PERHIT OFFICER.
CONDITIONS OF -PEFtl'lIT AFFID{~'v'IT
A. NOTICE OF DEED RESTRICTIONS
The undersigned understands that this perlit 'Iay ~e subject to "deed restrictions' which may be lore restrictive than City
regulations. The undersigned assu.es responsibility for co.pliance with any applicable deed restrictions.
B. UNLICENSED CONTRACTORS AND CONTRACTOR RESPONSIBILITIES
If the oNner has hired a contracto~ Dr contracto~s to undertake work, they may be required to be licensed in accorda~ce with
state and local regulations. If ttle~.t'b1<<ractor is.not~'licen5ed as required by law, both the owner and contractor laY be
cited for a .isdeleanorviolation under state law_ If the owner or intended contractor are uncertain as to what licensing
requirelents lay apply for the intended work, they are advised to contact the City of Zephyrhills Building Departlent, (B131
799-6611.
Furtherlore, if the owner has hired a contractor or contractors, he is advised to have the contractor(s) sign portions of the
"Contractor Sections' of this application for Nhich they Mill be responsible. If you, as the owner sign as the contractor,
you are indicating that you, rather than the contractor, are responsible for the work. If the contractor wishes you to sign
as contractor that lay be an indication that he is not properly licensed and is not entitled to perlitting privileges in the
City of ZephyrhiIls.
C. TRANSPORTATION IMPACT FEES AND UTILITY CONNECTION FEES
D. CONSTRUCTION LIEN LAW (CHAPTER 713, FLORIDA STATUTES, AS AMENDED)
1 certify that I, the applicant, have been provided Nith a copy of 'Florida's Construction Lien Law - HOleowner's Protection
Guide" prepared by the Florida Depart.ent of Agriculture and Consuler Affairs. If the applicant is sOleone other than the
"oNner", I certify that 1 have Dbtaineda copy of the above described document and promise in good faith to deliver it to the
"oNner" prior to cOllence.ent.
E. CONTRACTOR'S/OWNER'S AFFIDAVIT
I certify that all the infor.ation in this application is accurate and that all work will be done in co.pliance with .~ll
applicable laMS regulating construction, zoning,and land developlent.
Application is hereby lade to obtain a perlit to do work and installation as indicated. I certify that no worK or
installation has cOllenced prior to issuance of a penit and that all work will be perforled to leet standards of all laws
regulating construction, City codes, zoning regulations, and land developlent regulations in the jurisdiction. I also
certify that I understand that the regulations of other governmental agencies may apply to the intended work, ~~d t~~t it is
IY responsibility to identify what actions I lust take to be in cOlpliance. Such agencies include but are not li.ited to:
, Depart.ent of Environlental ReQulation - Cypress Bayheads, Wetland Areas and Environzentally Sensitive Lands,
Yater/Wastewater Treat.ent
, Southwest Florida Water ManaQelent District - Wells, Cypress Bayheads, Wetland Areas, Altering Watercourses
, Ar.y Corps of EnQineers - Seawalls, Docks, Navigable Waterways '
, Departlent of Health ~ Rehabilitative Services. Environ.ental Health Unit - Wells, Wastewater Treat.ent, Septic Tanks
, US Environ.ental Protection AQency - Asbestos abatelent
I also certify that, if fill laterial is to be used in Flood Zone "A" or 'A,etc.', it is understood that a drainage plan
addressing a "co.pensating voiu.e" Miil be sublitted which is prepared by a professional engineer registered in the state of
Florida prior to perait issuance.
A perlit 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 perlit prevent the Building Official frol thereafter
requiring a correction of errors in plans, construction, or violations of any code. Every per.it issued shall becole invalid
unless the Nork authorized by such perlit is co.aenced within six lonths of issuance, or if work authorized by the permit is
suspended or abandoned for a period of six .onths after the tile the work is co&~enced. One 90 day extension of tile, lay be
allowed for the pertit with fee charge of $15.00. The extension shall be requested in writing to the Building Official. An
approved .lnspection lust be logged during each six lonth peTiod, or the project Hill be considered abandoned.
WARNING TO OWNER: YuUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT HAY RESULT IN YOUR PAYING THICE FOR IMPROVEMENTS TO YOUR
PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT. JOBS UNDER $2,500 IN VALUE DO NOT NEED TO RECORD AND POST A 'NOTICE OF COMMENCEMENT'.
SIGNATURE: OWNER OR AGENT
was acknowledged
, 19 _ by
STATE OF FLORIDA
COUNTY OF
The foregoing instrument
befcll-e me th i 5
STATE OF FLORIDA
~
COUNTY OF
The foregoing instrument
befc,re me th i 5
vias acknc'vlledged
19_ by
who is personally known to me or who has
produced
as identification and who did/did not
take an oath.
who is personally known to me Dr who' has
pl-oduced
as identification and who did/did not
take an oath.
(Signature)
(Signature)
(Name Typed, Printed or Stamped)
NOTARY PUBLIC
(Name Typed, Printed or Stamped)
NOTARY PUBLIC