HomeMy WebLinkAbout06-5825
CITY OF ZEPHYRHILLS
5335 - 8TH STREET
(813)780-0020
BUILDING PERMIT
5825
Permit Number:
Permit Type:
Class of Work:
Proposed Use:
Square Feet:
Est. Value:
Improv. Cost:
Date Issued:
Total Fees:
Amount Paid:
Date Paid:
Work Desc:
5825
MECHANICAL
AlC CHANGEOUT
NOT APPLICABLE
Address: 4735 R LLlNS ST
ZEPHYRHILLS, FL.
Township: Range: Book:
Lot(s): Block: Section:
Subdivision: CITY OF ZEPHYRHILLS
Parcel Number: 14-26-21-0000-00200-0000
5,265.00
5/24/2006
60.00
60.00
5/24/2006
AlC CHANGE OUT
Name: WOODBURN, CHESTER
Address: 4735 ROLLINS ST
ZEPHYRHILLS, FL. 33542
Phone: 813 783-6531
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REINSPECTlON FEES: Reinspection fees will comply with Florida Statute 553.80 (2)( c) when extra inspection
trips are necessary due to anyone of the following reasons: a) wrong address b) condemned work resulting
from faulty construction c) repairs or corrections not made when inspections 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.
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 permits required from other governmental
entities such as water management, state agencies or federal agencies.
The payment of inspection fees shall be made before any further permits will be issued to the person owning same
"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."
NO OCCUPANCY BEFORE C.O.
~~
TRACTOR SIGNATURE PERMIT OFFI
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
813-780-0020
City of Zephyrhills Permit Application
Building Department
t-aX-l:ll::l- ( l:lU-UULI
Date Received
Ro j ),(15
S/,
Fee Simple Titleholder Address I
!j73)'
t/Jrf15
51
JOB ADDRESS
Owner Phone Number
Owner Phone Number I
Owner Phone Numb~r I
I
I
I
I
LOTt#
PARCEL ID# I
bOOO
Ch~( IJvf- .. . .
BUILDING SIZE I . SQFOOTAGE I I HEIGHT I . I
I I I I I I I .. . . I I . . I .. .. I . , . . .. . . . . . . . . .. . . . . . . : . .. .. .. . .. . .. .. .. . .. . .. .. . .. . .. .. .. .. . .. .. . .. . .. .. .. .. .. . .. I . .. , . .. .. .. . . , . .. . .. . . .. . . .. I . . . .. . I . . .. I .
SUBDIVISION
I
B'
o
o
ADD/ALT
REPAIR
COMM
FRAME
WORK PROPOSED
E1
D
D
I Ak
NEW CONSTR
INSTALL
SFR
BLOCK
PROPOSED USE
TYPE OF CONSTRUCTION
DESCRIPTION OF WORK
I
I
I
I
o
1
SPECIALTY D
FLOOD ZONE AREA
o BUILDING 1$
o ELECTRICAL 1$
o PLUMBING 1$
o MECHANICAL 1$ .S)....& 5'. e>c
o GAS D
FINISHED FLOOR ELEVATIONS I
o
o
o
'4 - C).LP,-';:)\ - ODOb:" Ob260--
(OBTAINED FROM PROPERTY TAX NOTICE)
SIGN D MOVE 0
DEMOLIsH
OTHER I
STEEL D
I
I'
I
OTHER I
VALUATION OF TOTAL CONSTRUCTION
AMP SERVICE
t=J
D
W.R.E.C.
PROGRESS ENERGY
VALUATION OF MECHANICAL INSTALLATION
ROOFING
OTHER
DYES
DNO
1"""""""""""""""""""""'1"""'"""""'1"""""""""""1""""';""".""""",,"""'1""""""""""'"
1111111111' I' 11111111111111111111'11111111'11111111111111111111111111111111111111111111111111111111111111111111111111 i 1111111111111111111111111111
RESIDENTIAL Attach (2) Plot Plans; (2) sets of Building Plans; (1) set of Energy Forms
Minimum ten (10) working days after submittal date. Required onsite, Construcllon Plans, Sanitary Facilities & 1 dumpster
COMMERCIAL Allach (3) sets of Building Plans; (1) set of Energy Fonns.
Minimum ten (10) working days after submillal date. Required onslte, Construction Plans, Sanitary Facililles & 1 dumpster
All commercial requirements must meet compliance.
SIGN PERMIT Attach (2) sets of Engineered Plans.
....PROPERTY SURVEY required for ali NEW construction. .
111111111111111111111111111111111111111111111111",111l'I.IIIII.lllllllllllllllillllllllliiilllllillillllili1IIIIilillllillllilllilliiliiililiillii
Directions:
Fill out application completely.
Owner & Contractor sign back of application, notarized
If over $2500. a Notice of Commencement Is required. (AlC upgrades over $5000)
Agent (for the contractor) or Power of Attorney (for the owner) would be someone With notarized lelter from owner authorizing same
OVER THE COUNTER PERMITTING (Front of Applicallon Only)
Reroofs Sewers Service Upgrades AlC Driveways Fences (PloUSurvey/Footage)
BUILDER
SIGNATURE
COMPANY
REGISTERED
Address
ELECTRICIAN
SIGNATURE
COMPANY
REGISTERED
Address
PLUMBER
SIGNATURE
COMPANY
REGISTERED
Address ~
MECHANICAL- \"~
SIGNATURE ~
Address I P D P:> o)i.. \ '5 '::>0 6<f5
OTHER I
SIGNATURE
Address I
I
COMPANY
REGISTERED
--"IrA-'
~0
I
COMPANY
REGISTERED
Y/N
FEE CURRENT
Y/N
I
I
I
I
I
I
I
I
I
I
License #
Y / N FEE CURRENT
Y/N
License #
Y / N FEE CURRENT
License # I
I ~\-tt I~Q ~..IL
. Y / N I FEE CURRENT
License # I
Y/N
Y/N
Y / N FEE CURRENT
Y/N
License #
, .
NOTICE OF DEED RESTRICTIONS: The underslgn~d understands that this permit may be subJect to "deed;' restrictions"
. which may be more restrictive than County regulations. The undersigned assumes responsibility tor 'compliahce with any'
applicable deed r~strlctions. ..,. , .
UNLICENSED CONTRACTORS AND CONTRACTOR RESPONSIBILITIES:' If the owner has hired. a contractor or
c<<;>ntractors to undertake work, they rriay be required to be licensed In accordance wltli state and local regulatiohs. If the
contrac~or Is not licensed as required by law, both the owner and con~ractor may be cited fQr a misdemeanor vlolatton
under state. law. If the ,?wner or Intended contractor are uncertain as, to what lI<<?enslng reqUlrement~ may apply ,f~r the .
Intended work, th~y are advised .to contact the Pasco County Building Insp~cUon Divlsloli-Ucensl~g Sectloh at 727-847-
8009. Furthermore, If the oWner has hired a contractor or contractors, he Is advised to haVEdM contraotor(s) sigh .
. portions of the .contractor Block" of this ~ppllcation for which they Will be responsible. If yoti, as the owner sign as the. . :
contractor, that:rriay be an Indication that he Is not properly Ucensed and Is hot entitled to permlttlhg privileges In Pasco .
County. . . .
TRANSPORTATION IMPACT/UTILITIES IMPACT AND RESO~RCE REOOVERY FEES: The undersigned 'understahds
that Transportation Impact ~ees ~nd Recourse Recovery Fees may apply to the construction of heW buildings, chahge of
. use In. existing bulldlngs~ or expansion of existing buildings, as specified In Pasco County Ordinance hllmber 89-07 and
.' '. 90-07, as amended. The undersigned also understands; that such fees, as may be due; will be Identitled at the thne tif
permitting..1t Is further ,-:,nderstood. that Transporiatlonlmpact Fees and Resource Recovery Fees must be paid pi"lof to
. receiving a .certlficate of occupancy" or final power r~lease. If the project does hot Involve a certificate of occllpahcy or
filial power. release, the fees must be paid prior to permit Issuance. Furthermore; if Pasco CountY. WateriSewer Impact
, fees are due, they must be paid prior to permit Issuance In accordance w.ith applicable Pasco County ordinances.
CONSTRUCTION LIEN LAW (Chapter.713, Florida $tatu~es, as amerlded): If valuation of Work, Is $2,500.00 or more, I
certify that I, the appUcant, 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", I certify thl1lt 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 compllam~e with all applicable laws regulating construction, zonlhg Bhd land development. 'AppllcatlOr1 is .
hereby made to obtain' a permit to' do work and Installation as Indicated. I certify that ho work or !nstallatlon has
commenced prior to Issuance' of a permit and that all Work will be p~rformed to meet standards of all iaws regulating
construction, County' and CitY codes, zoning regulations, and land development regulations In the jurlsdlctloh. I also
, . certify that I understand that th~ 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. S,,:,ch agenples Include but are hot limited to: .
Department of Environmental Protection-Cypress Bayheads, Wetland Areas and Environmentally Sensitive .
Lands, Water/Wastewater Treatment. . . .
Southwest . Florida Water Management District-Wells, Cypress i3ayheads,' Wetlahd Areas, Altering
Watercourses. . . . '.
Army Corps of Engineer~-Seawalls, Docks"Navigable Waterways.. ....' .' .
Departm'ent of He~lth & Rehabilitative SerVices/Environmental H~alth Unit-Wells, WasteWater Treatment,
.' Sep~lc Tanks.. . .. . . . .' .
US Environmental Protection Agency-Asbestos abatement. .
Federal Aviation Authority-Runways.
I understand that the folloWing restrictions apply to the, use of fill:
Use offill Is not allowed in-Flood Zone "V" unless expressly permitted.' . .... . .
If the fill material Is to be .used In Flood Zone "A~, It 15 understood that a dralnag.e plan addr.essing a
.compensatlng 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 "N In connection With a permitted building using stern wall
. construction, I certify that fill will be used only to "fill the ar~a within the stem wall. .
. If fill. material Is to be used In' any area, I certify that use of such fill will hot adversely affect adjacent
properties. if use of fill Is found to a~versely 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 fo~h In
this affidavit prior to GommEmclng.constructlon. I, understand that a s.eparate permit may be required for electrical wor~,
. ' . plumbing, signs, wells, pools, air conditioning, gas, or other installations nQt 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, c.ancel, alter, or
set aside any provisions of the technical codes, ~or shalllss~ance of a permit prevent the Building Omclal froi11,t~e~ea~~r
requiring a correction of errors In plans, CQnstruction or violations ,of any code~. Every permit lssu~d shall b~come Invalid
unless the work authorized by such permit Is commenced within six months o.f permit Issuance, or If.work authorized by
the permit is suspended or abandoned for a period of six (6) months after the time th~ Work Is commenced. An extension
may be requested, . in writing,' from the Building omclal for a period not to ex~ed hlnety (90) days ahd Will, dem~nstrate
justifiable cause for th~ extension. if work ceases for ninety (90) consecu~l\le days, the job Is considered abandoned. . .
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAy REsuLt IN.:V~UR.
. PAYING TWICE FOR IMPROVEMENTS TO VOUIt PROPERTY. IF YPU INTEND. TO. O.BTA~N F~NANCING; CO....SL T
ITH YOUR LE DE OR AN ATTORNEY BEFORE RECORDING VOU .,NOTIC OF COM ENCE E T; .
. FLORIDA JURAT (F.S. 11?-03)
OWNER OR AGENt .'
Subscribed and swom to (or affirmed) before me this.
. '. by' .
Who Is/are personally known tb me or haslhave produced
as IdentlflcaUon.
CONTRACTOR ". ' .
Subscribed and sworn to (or afilrmed) before me this
. by'.
Who Is/are personally known to me or haslhave produced .
. '. as IdenUflcatlon.
Notary Public
Nolarj Public
Commission No.
Commission No. .
Name of Notary typed, printed or stamped
. . .
Name of Notary typed. printed or stamped
05/11/2006 10:16
8133934247
SHIP IAMt-'A
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Nama . - .U(L
Address: C1"....7~y RHcU.S St.: /Fir Zip: ~~,~
lIWe the awnera af the prem.... cIoecrIbed ~, he.......ftwr ...femMI to .. "PUn:ntIIN,- Ofl'er to c:ontrlICt wlth Sea,. Home 'mprovement
Prock.cts a Services henllnaft8r ref9mK1 ID a. "SHIPS-, to fumiSh. deIhlIN'. and amanao fer ......1IlIion of ... materlBle ~-V to
Impnw., .,. ~Ises ,oceted 8t:
(~J
AJ,II! VBIT ANDlDA CHlllIIPX-
USE li!)(ISTIfIIQ veNT OR CHlMNSY 0 AePL~e FLUE: 0
lNSTAL.L NEW CHIN",EY LINER 0 SIZE ___
SYBTBM RATING 1hV'B COOUNG _ SEER
~~MWNT-' "8: ~ -~l'r ~__LI)
I"URNACElAIR HA~ ,,"'- t"-r~TAr &XISTING 0 NIIW .. ~
CONDt!N8eJ1t UNIT. COOLER .. _
AtoClVIOIi UNIT. BOlLE'" .
EvAPOAAT'OFl COIL. OTHER." __
.......-1310: 1I.,1:lt!I~ Ar ~
FUFlNACelAlA HANDU!!A exISTING 'Ji3l:vlIT -
CONDENSER UNIT EXISTING CI NEW 0
evAfOOAAl'OFl COIL EXlBTfNG 0 NEW 0
LINE S&T EXIS"l'lNCD NEWO
(CiIV) .....) (ZIp)
PVC VIiNT PI~E FOR HI-e FURNACE HOfq CJ VERT CI
COMBUSTION AIR CJ exISTING Cl MODIFY 0
, PIPE 'N8TAl..I..ATION CJ 2 PIPE INSTALLATION 0
HE<<nNG AFue.
..~~...
HUM'OI"'&R EXISTING 0 NEW .
AI'" CUiAI'ltIl'l SClSTINB Cl NEW ..
DUCT CLl!ANING VE!.S 0 NO CJ
DUeT~...
use ExI8nNO S"ST~ 0 AOO TO I!XlSTINQ D
INSTAWNG NEW SYSTEM 0 SEE s~~ JNS'Tf'YCT1ON9
REGISTERS uCE EXISTI"'a D NEW 1lJ'" u....'r .,-0
'AET\JFIN.AlA 0 EXISTING 0 MOOIFY CI I-io
~~~rti~~~~ ~ TSTIf-
-..pAcJ.c ~ ~ ,"'T .
CONTJltACTPAICe $_-S-~;:....~. ...00 ~ec;J -f.o .Cr.ecJ,';t- (!.l(~ r-
.00 #tVI!2- S'q/~"""'A C9/( ~CL.5r-
.aQ
.gQ
AEMOV& OLD IiQUIPMBNT F.:..o." SITE ~ ON SITE 0
DFlAINUNE ~O NEW
CONOENS.t(f& PUMP IOOSTING Cl NEW Q ___ .::2 I 1'\..
SLAB EXlSTlHCiD NeW~ SIZE ..,~. J
OI'MliR exISTING CJ NeW a
.. ..~.a. .
CONNBCTTO EXISTING MNEI.D 1NS'1*..1. N~ec: OJ
INSTALL NEW 0 AMP 9EAvICE 0 ~ "f"At'!e
SAMe LOCM'IOPil 0 NEW 0 ADDITIONAL waR
STlIIITE SALES ~
t~ ......,~,
.
DOWN PAVWENT
s:
8ALA.NOE OUli
s
S~~
TO BE FINANCl!D ~ CAsH ON COMPLETION 0
CONTRAcToPl
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A_1IIIIlWMl ....&~
TNle -- __ _ _IITOS 1OIIIU. Bll OISTUouIev IN TN"
~~_.U__T"""'_CTlDH"" CON11I~OI'IOTHE"S.
A!lIIt:~_~ Ie ~~ ._WOIIIIC. CUV1OIl1r:AIalITIIflMNIlIE ANO
MY- _____ -..- _........ 8'1IOM___._._ QrWOlllC.".
~';;;1U~EF'OI'I N~ "'1IRl!B'08 ~W1THINTtltRTY
~L ... - ~IIiL"THIS ~ UPON -ITTI!N NClTIeE 10 CUS-roMPt.
,"1_WlU.lI1aIIT~" __ww...~
CllIMI'LEnID - ~ _ ~.,.. _ _C'I' '\"0
-- fa 'I'NII'T1_ TMII ~ to HX:lII"I\nII go, _ _ ,., AN\! Cl'rNl!" 'l"lM1i
8'1 MVrUIlL -"""" ....,.....NI: I .....,~ -..- ...... . OOC.... .... Elm_II
nlt"\ -- .... I ""ILL .. 00MlI0C'1lO _ -.0 THtIll lMI'l!! TO ~ Tr<I: AGTUAl.
~ "'~ ....._~ DoIII'L
o-=: ~~&~ MA8TEI'ICA"'O" D~~ PFlI!MIER QAAO'" ACCOU~ fI ...s:.O~ q'iD I s,.rOO ~(C,
I:iHfBDE:;:A~Fril~~=NTCI~A~~ HIp) I EXPIAIlnON DRI!: ... CODE:
CASHlCHet;ft DAMEX OOTHEA . ~ _ I Dlil..AYUll BILLING 0'nE:--1---1_ -?Q
~........... ...... ,. MO. DAY VeAR C- I
SUIIMlnED 8'1" -.M. No. ll~ I ,~~" ....?WIG ___ooo""YSOO" _1:.1
THIll eaN,"-aeT_CE IN~_' p~
_ 'ffl MAST&1Il f>AOrEeTtON AGAEEMENT 0
_ 'fR REMIR PROTECTIOl\l AGAEe.....NT CJ __
,..~ Aft__.;
.~ 18 Hal' IlbPONBtB-'! _ "''''''' ~ COO. "IOl.trrIOOfe CIt _-me,,",_
~ 0/<_ DIle"rWo-. _. ~I(;AL.'-" "" ~ fOU~ _Ila...
~ ""TP4I8~." ~ 18 1Il::~ " W1L~ _.... ~_
~~=t~~Cll\e BWUJ.._ oucmiD -" -1lCM:D""1_1O"'E
CONTR.tlCT lIIlICt
"SATISFACTION
'lED"
III UIitC) ._v._II:....~ ......
1...."CiI~...... ~ Of Wlf" -A. .......---................ ~ ~....... ............ ~~.. __ _........................ MM1.......................
~~~..~ ... hMllw Of" t1II "."." 0'...... R-..- #IItI Ca.~. AI{ o.n. C_.-f!a9. ..... ft7$); AA (_ "1.07CNIK AZ_ (AOcm_); CA (&en. 1111IO- COlli..
...--55 n~ a.. l:-m): Cf (1fYAC ""1HI~); ~ (HVAt <<:M0124tl51 : G-'l (Reo. CA-1l11ttSil); HI (ClUslIMd SNc. ~1I5 c-&eLA.J: ICY (HVaC #M03912);
lot. (MIch.l8ptIC. ColItr. ft62lI); MD (MHIC 132117: ./.".,. Mlnlc:IL MVAC ; wv ("""". " ....,,11I ~~ ftGGllMnd County, NY UCllIlSed SubcontrmllfS: OR
(O""'RS~~'OS'):"Ql (ttVAC I.Ie. NOlI. TACl801ti2471! 00!IS83C.01!1l1O&C. C, 0012IC.llOIRIIC:. 01 I; VA (C.... A Cant'. "27OIMI57008): WA (e-n. Comr,
ISEA R-~~ ....,,: WI/ IGen. Bldg. SDo:c. M\IOOlJ52t1. $_ untlt:a Mid ......dDn p".ro,tItWI DJI SHlf'$ ~ om. .IIt1/tf:N ~ IIISWb1110n /lMfDtmtIfI .1' SHlP$-
~1fr1tIrt8_~; "*,,,,-tSHIP$ I~"'ID""""."",,_~
!!~CEFTHTD ~~: YOU. THE l&.YA MAY CANCa.. TltIS TllMSACTIOIII AT AIf'I TIME PRIOR TO MIDNIGHT OF lItE TlfIRD BU&INe8S
...... [1" ._...EBS DAY IN . FIFTEENTH IlUlIIEU DAY "NOATH DAKDTA IF YOU ARE AGE &5 DR OLDERJ AFTEfI THE DATE
OF THIS TRANSAlmCHI. BEE THIU" ","ACHED NonCE OF CANCB..LAT'ION FOR" FOR AN EXPLANA11DN OF THIS RIGHT.
CONTRACT COpy u"." __
f'l ap1e:
::>.I:$A.K;:i li<JMH IMPROVEMENT PRODUCTS, INC.
P.O. BOX 522290
LONGWOOD, FL 32752-2290
1-407-551-5376
111111111111 1111I1111111111 111111111111111 111I11111I11111111
2006106784
Rcpl: 1001089
OS: 0. 00
OS/24/06
Rec: 10.00
IT: 0 . 00
Dpty Clerk
State:
NOTICEOFCO~NCEMENT
FLo {l,t D 11
.1/lA7CO
County:
The UNDERSIGNED hereby gives notice that improvement Will
be made to certain real prope1ty, and in accordance with
Chapter 713, Florida Statutes, the following information is
provided in this notice of Commencement,
JEO PITTMAN~ PASCO COUNTY CLERK
OS/24/06 1~:54am 1 of 1
OR BK 7002 PG 1858
! .
<.
1.
Des.cription'ofproperty: (legal description of
property, and street address if available)
'171(, R,//;YD ')1- 2cthYlh.!f5
? 35-'-/):
2.
General description of improvements: A Lt G2s-~~ ~ e(J- /.A(!B
3.
Owner information f? I
a Name and address: ~1p~
b. Interest in property: ()CJJ fJee. .
')
~ ba.nJ I ir5b i~({.ffi~SJ
ZePCf'l4tfLL5 (L, 7~-5Cf2'
c. Name and address offee simple titleholder (if other than owner):
B. .4.
~
Contractor: (name and address)
cc;,e.
5.
Surety
a. Name and address: NA .
, ~i;
b.
Amount of bond
$
6. . Lender: (name & address) NA
7.' Persons within the State of Florida designated by Owner upon whom notices or other documents may be
Served as provided by Section 713-13(1)(a)7, Florida Statutues: (name and address)
8. In addition to himself, Owner designates the following person(s) to receive a copy of the Lienor's Notice as
provided in Section 713.13(1)(b), Florida Statutes: (name and address)
ABOVE NAMED CONTRACTOR
. . .
9. Expiration date of Notice of CommeIlcement (the expiration date is I year from the date of recording unless
,z~ta~
'(' atur Owner) .
Drivers License #: W 31Cc> - {CO r 4 CO -'/33;" 0 .
Owner's Name: ~lef llJ"cs~ru ' ---'---- .
Owner's Address: 413S i(6Lt~N~ Zefr-ty tf fl L ~ fL~ 135'42
. (
All information must be typed or printed legibly to comply with recording requirements.
STATE OF FLORIDA 0,,\.c.../'\~
. COUNTY OF +/~
was acknowledged before me this 5" j'f( / IY... " by . cle.5'fe..( W~~lJ \
, I
tJ ~ Uc. . as identification and who did (did not) take an oath.
*1
"
.S! (S~gnature of person taking acknowledgement)
1 D, Fisber. . . .
. C , ,..., ... - (Name of officer taking acknowledgement - typed, pnnted or stamped)
Expires' NOll. .., :J .
BondedThruAt1an~~ Ii! ..17, 2008 (Title or rank)
IlBSh.6 Cu., Inc.
(Serial number, if any)
M9 - Rev. 08/03
,.
#1
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