HomeMy WebLinkAbout08-7283
CITY OF ZEPHYRHILLS
5335 - 8TH STREET
(813)780-0020
BUILDING PERMIT
7283
Permit Number: 7283
Permit Type: COMMERCIAL
Class of Work: AD DIAL T COMMERCIAL
Proposed Use: COMMERCIAL
Square Feet:
Est. Value:
Improv. Cost: 11,000.00
Date Issued: 3/06/2008
Total Fees: 87.50
Amount Paid: 87.50
Date Paid: 3/05/2008 Phone:
Work Desc: GROUND WATER REPLACEMENT EQU WI ELECTRIC,14X22 REPLACE FENCE
Address: 6026 GALL BLVD
ZEPHYRHILLS, FL.
Township: Range: Book:
Lot{s): Block: Section:
Subdivision: CITY OF ZEPHYRHILLS
Parcel Number: 03-26-21-0010-12800-0000
Name: HESS
Address: 6026 GALL BLVD
ZEPHYRHILLS, FL. 33542
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DELGADO ELECTRIC INC
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2ND ROUGH PLUMB
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SEWER
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ELECTRICAL FINAL
PLUMBING FINAL
REINSPECTION 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 our property. If you intend to obtain financing, consult with your lender or an attorney
before recordin y ur notice of commencement."
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CONTRACTOR NATURE PERMIT OFF I
PERMI EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
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I "IS CERTIFIEDundertbe-provision.,of cbi489 1!'S;
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HCC Environmental Services Inc
Groundwater Remediation Construction Ser:nces .
Earl R. Hatch, Jr.
President
352 473-9801
CSLL.- 351.-2'>""0 - '1"".'5"""
~aQ8r 1 006 S89 2715 Fax 352 473-9841
340 S.w. Jasmine Ave. Keystone Heights, FL 32656
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MAR-05-2008 WED 03:01 PM FEDERATED CPU
FAX NO. 15074557828
P. 02/02
PROOUCl!Il
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03/05/08 \\l
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
_ COMPANIES A'=fORDING COVERAGE
COMP-.NY FEDERATED MUTUAL INSURANce COMPANY OR
A FEDERATED SERVICE INSURANCE COMPANY
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FEDERATED MUTUAL INSURANCE COMPANY
Home Office: P.O. Box 328
Owatonna. MN 55060
Phone: 1 -888-333-4949
Home Office: Owatonna, MN 55060
DELGADO ELECTRIC INC
POBOX 151054
TAMPA FL 33614
041-115.7
COMPANY
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THIS IS TO CERTIFY THAT THE POLICIES OF INSURANce ~ISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ADOVE FOR THE POLICY PERIOD
INDICATeD, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY DE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORceD BY THE POLICIES OI:SCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIC?,NS AND CONOITION.~ OF SUCH POLICies. .!:,IMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CD TVPll OF INiURANCE POUCV NUM8E11 POUCY EFFEcnVE POlJCV EXPIRATION UMITli
LTll DATE IMMIDD/VVI DATE (MNlIDD/VYI
GENI!l'IAI. UABIUTY GeNeRA~ AGGftEG-'TE 2 000 000
COMMEnCIA~ GENERAL ~IABILITV PRODUCTS - COM PlOP AGG 2 000 000
A CLAIMS MADE [K] OCCUR 9001316 01/22/08 01/22/09 PERSONAL" APV INJURY 8 1 000 000
OWNER'S III CONTRACTOft'S PftOT eACH OCCUftftENCE 1 000 000
FlftE DAMA!,!E IA~V Dn" 11rol 100 000
MEP EXP (Anv lIIl' pOl1lCln,
AUTOMOBlllllJA8IL1l'Y 8 1.000,000
X ANY A\frO COMPIIIlECl SINGLE LIMIT
ALL OWNED AUTOS BODIL V INJURy
A SCHEOULEO AUTOS 9001316 01/22/08 01/22/09 (Pd/ PO/dOll)
X HilleD AUTOS BOOILy INJURY
X NON-OWNED -.lJTOS IPa/ aoeldon'll
PROPERTY DAMAGE
GAIlAGI! UAIIUTY AUTO ONl.Y. Ill' ACCIDENT .
ANY AUTO OTHER THAN AUTO ON~Y;
EACH -.CCICleNT' 8
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_EXCESS UABILn'Y EA8:!.~CCUAREIIICE . 2 000 OQ!L
A X UMBRIiLl.A FOftM 9001317 01/22/08 01/22/09 /,GGREGATE . 2 Q.OO 000
OTHF.ft THAN UMBRELLA ~ORM
WOllKERS COMPPlSATfON AND X WC S'fll'l'U. OTH- -
R_-' :.;"
EMPLOYEIIS' UABILrrY 'L E-.CH ACCIDENT 500 000
A THE PROPRIETORI tNCL 9000174 01/22/08 01/22/09 EL DISEASE - POUCY UMIT 50QI.OOO
PAftTNEflSJEXECUTIVE
OFFICERS ARE: X EXCL E~ DISEASE. IiA EMPLOYEE 500 000
OTHER
DESCRIPTION OF 0"IlRATlON8/LOCAnONSNEHIC~ESISP~1AL ITEMS
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~111157 CITY OF VEPHYRHILLS 283 SHOULb ANY OF THE AIDVE DESCIllBED POUCles BE CA...Cllu.ap BS'OIIE THE
5335 EIGHTH STREET l!l(1'tIIA'l'ION DATE THEllEOF, THE ISSUING COMPANY WlL&. I!NPEAVOft TO MAIL
VEPHYRHILLS FL 33542 ..10_ DAY& WIIrT'TEN NOnCE TO T"~ CERTIFICATE HOLPER NAMED TO THE LEFT.
11IT FAlWIIE TO MalL SUCH NOTICE SHAU. IMPOSE NO OBU"'l'IOIII 011 LIAllIUTY
OF ANY KIND UPON TIE COM!! S OR REPRBSENTATIVES.
AUTHORIZED I\EPIIEBENTAnV
,t~t.l:;;~.r"'~)"W':"'.O""":"~~~:%'*$!~:"1;l~~~~':rt.f.W~:;:~*'~f$:~)!j':~~*;*~~iMf;:i$i~!l;~~;~!li'lJ'W.~S:.~*W!H(#.~~~l!W:~~1P:f."511l . ~ .~~~~;l;l~~~~mm.,
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HAR-05-2008 WED 03:01 PH FEDERATED CPU
FAX NO, 15074557828
p, 01/02
Date
FEDERATED MUTUAL INSURANCE COMPANY ~~lJ~"~EfP
FEDERATED LIFE INSURANCE COMPANY
FEDERATED SERVICE INSURANCE COMPANY
HOME OFFICE: OWATONNA, MN 55060-2401 INS URAN C E ~
FACSIMILE COMMUNICATIONS COVER SHEET
Number of pages sent ~ (Including cover sheet)
03/05/08
To: Name
From: Name CLIENT CONTACT CENTER.
Company CITY OF VEPHYRHILLS
Fax No.
Fax No. 1 813 780 0021
Ext. No.
Telephone No. (888) 333-4949
NOTE: If any of the pages are not legible, or you do not receive all the pages. contact Federated at the above telephone or fax number.
Account Name:
Account Number:
DELGADO ELECTRIC INC
04.1-115-7
Contact Info:
Message:
MM-29(c) Ed, 5-90
Printed 1/'1 U.S.A.
, ,.
AC#l116S',,4
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PEPAR~~T~~~~~:~-~"' ..~~,~t~~~ij~~aLBg~~LATION,lIQ~
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'., DEL~0'1 HBC'I'0a~
PE~GADO ELECTRIC INC
t~g~~r C~~~ .~VENUE FL3
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JE'S'B,gSH '
GOVERNOR
nl~PI AY A~ RFOIIIRFnRY lAW
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''sIMeNE MARSTILLER"
SECRETARY
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HILLSBOROUGH COUNTY BUSINESS TAX RENEWAL INSTRUCTIONS
Chapter 205.0535 (5) Florida Statutes requires one of the following:
FEDERAL EMPLOYER IDENTIFICATION NUMBER
OR SOCIAL SECURITY NUMBER
1. SIGN and return entire form in enclosed envelope. Your validated Business Tax receipt will be returned to you.
2. Business Tax receipts expire midnight, September 30th. Failure to display a valid Business Tax receipt after
September 30th is a violation of Hillsborough County Ordinance 95-4, as amended by 02-5.
MAKE CHECK PAYABLE TO:
DOUG BELDEN, TAX COLLECTOR
POBox 172920
TAMPA, FL 33672-0920
2007-2008 HILLSBOROUGH COUNTY BUSINESS TAX RECEIPT
EXPIRES 9-30-2008 FOLIO NO,
I FACILITIES OR MACHINES 0 II ROOMS
01 ] SEArs
o II EMPLOYEES
1011
1245
OCC. CODE
090.008
BUSINESS TYPE
CONTRACTOR-ELECTRICAL CLASS A
H, WASTE
SURCHARGE
TAX
18.00
BUSINESS TAX
DOUG BELDEN. TAX COLLECTOR
813-635-5200
THIS BECOMES A TAX RECEIPT WHEN VALIDA TED.
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BUSINESS
LOCATION
clIbR
ECrRIC IN
4820 N CLARK AVE
TAMPA FL 33548
NAME
MAILING
ADDRESS
HAS HEREBY PAID A PRIVILEGE TAX TO ENGAGE
IN BUSINESS. PROFESSION. OR OCCUPATION SPECIFIED HEREON.
4106 00124500000 000018002 000000000
11111111111111111111111111111I111111111111111111111I11111111
2008033764
Permit No:
Tax Folio No: 03-26-21-0010-12800-0010
Rcpt : 1165220 Rec: 27. 00
OS: 0.00 IT: 0.00
03/04/08 Dpty Clerk
JE9 ~ITTM?1.~ASCO COUNTj CLERK
03 04/08 . if 1 of1948
OR BK ~ PG
This Instrument Prepared By
And return to: HCC ENVIRONMENTAL SERVICES, INC.
340 S.W. Jasmine Avenue
Keystone Heights, FL 32656
352-473-9801lfax 352-473-9841
NOTICE OF COMMENCEMENT
STATE OF NEW JERSEY
COUNTY OF
The undersigned hereby give notice that improvement(s) will be made to certain
real property and in accordance with Chapter 713, Florida Statutes, the following
information is provided in this Notice of Commencement.
1. Legal description of property: 6026 Gall Boulevard, Zephryhills, Pasco County,
Florida, more particularly described in Exhibit "A" attached hereto,
2. General description ofimprovement(s): Installation of Remediation System
3. Owner information:
a. Name and address of owner of site of improvement:
HESS CORPORATION f/k/a AMERADA HESS CORPORATION
One Hess Plaza
Woodbridge, NJ 07095-1229
b. Interest in property: Fee simple
c, Name and address offee simple title holder, if other than Owner:
R
4. Contractor: HCC ENVIRONMENTAL SERVICES, INC.
340 S.W. Jasmine Avenue
Keystone Heights, FL 32656
5. Surety:
a. Name and address: n/a
b. Amount of bond: $ n/a
6. Lender: n/a
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)(b), Florida Statutes:
OR BK 7776 PG 1949
2 of 3
8. In addition to himself, Owner designates
to receive a copy of the Lienor's Notice as provided in Section 713.13(1)(b), Florida
Statutes.
9. Expiration date of notice of commencement (the expiration date is I year from the date
of recording unless a different date is specified:
~~.?~
wner: HESS CORP TION
BY:
AS
I HEREBY CERTIFY that on this day, before me, an officer duly authorized in
the State aforesaid. and in the coun~foreiaid, to take acknowledgments, personally
appeared Doll U / d .ts:1L. / _ as
. to me known to be the persons described in and who
executed the foregoing instrument and he/she acknowledged before me that he/she
executed the same.
If11 WITNESS my,hand and official seal in the County and State last aforesaid this
db. dayof ,Feh"4q"(f ,2008. ~/ w#1Z/
,NOTARY?:-. (j".' () .\,
State ofNJ: My Commission Expires~ : 't: ~"~ ::J", ~:,~ '
\. O. J itl,:W
CAROL L. WALKER -0 ", -7 .::?J ,.5.,":>:
NOTARY ~UBLlC O~ NEW JERSEY <iJ';:,:::,~ .~/ ~ ...:'
My CommISSIOn Expires Dec. 1.2008 . OJ .;.,:'.~~','N.~ ~~ ,,'
" ;" "~;"'":'''.';t~'''
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OR BK 7776 PG 1950
3 of 3
DATE: 03/04/08 PASCO COUNTY PROPERTY APPRAISER
o N - L I N E PAR C E L P R I N T 0 U T
16:34:12
PARCEL-ID: 03 26 21 0010 12800 0010 TYPE:
SC TP RG SUB BLOCK LOT
STATUS: A
DLA: 022702
TRACK: 033002
LEG A L DES C RIP T ION:
ASSESSED IN SECTION 03, TOWNSHIP 26 SOUTH, RANGE 21 EAST,
PASCO COUNTY, FLORIDA
ZEPHYRHILLS COLONY CO LANDS
& 128 DESC AS COM AT SE CORNER
FT TH N25DG 39' 30"W 137,85 FT
S23DG 19' 56"E 135.82 FT TH
PT ON CURVE ON ELY RIGHT-OF-
ALG ARC OF CURVE CONCAVE TO
02DG 30' 02" CHDBRG & DIST
POB TH N65DG 25' 48"E 144.52
TH S65DG 25' 48"W 150.00 FT
RIGHT-OF-WAY OF US HWY 301
TO EAST RAD 1031.21 FT DELTA
N21DG 44' 31"W 165.00 FT TO
OR 3774 PG 859
PB 1 PG 55 PART OF TRACTS 113
SEC 3 TH NOODG 25' 50"W 497.30
TH N90DG 00' OO"W 177.53 FT TH
S65DG 25' 48"W 242.20 FT TO A
WAY LINE OF US HWY 301 TH
EAST RAn 1031.21 FT DELTA
S15DG 54' 11"E 45.00 FT FOR
FT TH S23DG 38' 48"E 164.82 FT
TO POINT ON A CURVE ON ELY
TH ALG ARC OF CURVE CONCAVE
09DG 10' 39" CHDBRG & DIST
POB
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City ofZephyrbills ;
"BUILDING PLAN REVIEW COMlvIENTIS
ContractorlHomeowner:
fI ('( GJ llL''y~" /YI'etJ.ckl Sl/C&e-
12~1o--67
Site: (t?u 2~ C I'!I'/ 131 rO
pemrlt Type: . .,ft'j) /Ii 1'1' r(!Juf/ tu",rk r;. td Ie hfr 't J 6 PT -boa-
Approved winD comments:~ Appro":ed w/tbe below comments: ~enied withe below comments: 0
...,
Date Received:
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This comment sheet shall be kept with the pemiit and/or plans.
Contractor andJor.Homeowner
(Required when ~ents are present)
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Fax-813-780-0021
813-780-0020
City of Zephyrhills Permit Application
Building Department
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Date Received ..
Owner's Name
~AtL
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t~ DO(<[)
LOT #
SUBDIVISION
WORK PROPOSED
NEW CONSTR
INSTALL
SFR
BLOCK
PROPOSED USE
TYPE OF CONSTRUCTION
U 21 COCo
(OBTAINED FROM PROPERTY TAX NOTICE)
SIGN D MOVE D
DEMOLISH
OTHER I
DESCRIPTION OF WORK '0~~ ~~tA;";.
BUILDING SIZE I I SQ FOOTAGE I HEIGHT
11.111.'..,.....111..'.11..11..11....1111...'1111...11....11.111.....11...'.11....111......,..."'..'....11.11.11........,II..................jllll
D BUILDING 1$ ~.~
D ELECTRICAL 13eeYD
D PLUMBING 1$
D MECHANICAL 1$
D GAS D ROOFING
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VALUATION OF MECHANICAL INSTALLATION
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License #
YI N FEE CURRENT
License #
Address
MECHANICAL
SIGNATURE
COMPANY
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Y/N
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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 (3) 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.
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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 letter from owner authorizing same
OVER THE COUNTER PERMITTING (Front of Application Only)
Reroofs Sewers Service Upgrades NC Fences (Plot/Survey/Footage)
Driveways-Not over Counter if on public roadways..needs ROW
NOTICE OF DEED RESTRICTIONS: The undersigned understands that this permit may be subject to '~..:d" "'8strictions"
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 hot 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-Homeowne;'s
Protection Guide" prepared by the Florida Department of Agriculture 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 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,
, 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 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. II " .., .....
If the fill material is to be used in Flood Zone A m connection With a permitted bUilding uSing stem wall
construction, -, certify that fill will be used only to fill the area within the st~m ,^:all. .
If fill material is to be used in any area, , certify that use of su~h fill Will not adversely. affect a~Jac?nt
properties. If use of fill is found to adversely affect adjacent propertl~s, the. ow~er may be Cited for vlolatmg
the conditions of the building permit issued under the attached permit appllcatron, for lots less than one (1)
acre which are elevated by fill, an engineered drainage plan is required. . . . . .
If , am the AGENT FOR THE OWNER, I promise in good faith to inform the owner ~f the permlttm~ conditions s~t forth In
this affidavit prior to commencing construction. I. understand ~hat a s.eparate perm~t. may ?e reqUlr~d for elect~lca.1 work;
I b' 'gns wells pools air conditioning gas or other installations not speCifically Included In the application. A
p um 'tl~9, Sid shall be 'constr~ed to be a Iicen~e to proceed with the work and not as authority to, violate, cancel, alter, or
~:~~~i~~S~~y provisions of the technical codes, nor shall issuance of a permit prevent the B~i1.ding Official from the~eaft~r
re uirin a correction of errors in plans, construction or violations of any codes. Every permIt Issued. shall become. invalid
un~ess ~e work authorized by such permit is commen~ed within six months o.f permit issu~nce, or If work authorized. by
th 't' us ended or abandoned for a period of SIX (6) months after the time the work IS commenced. An extenSion
e p~rml IS s t Pd in writing from the Building Official for a period not to exceed ninety (90) days and will demonstrate
~:itfia~I~":~:e ~o~ the exte~slon. If work ceases for ninety (90) consecutive days, thll)ob is considered abandoned.
FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULTIN YOUR
~:~~~~~EO;V~:~P~g~:MENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT
WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOURN ICE OF COMMENCEMENT.
FLORIDA JURAT (FeS. 117,03) . f~
CONTRACTOR I~
OWNER OR AGENT ~~~C..Jli~Ded7and bSWyom to or affirme efore me this
Subscribed and sworn 10 (or affirmed) before me Ihls Lk- ~ _
by d ~WhO is/iarl~ersonaIlY kn(twn to m~r has/have p~odu~ed
Who is/are personally known to me or haslhave produce ~ J... ~ ~~.(. ~ as identification.
as Identification. - - -
Notary Public
Notary Public
Commission No.
~
Name of Notary typed, printed or stamped