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HomeMy WebLinkAbout10-10797 CITY OF:ZEPHYRHILLS 5335 - 8T1 STREET (813)780- 0020 10797 • .BUILDING PERMIT 7 - z , .- ,+, Permit Number: 10797 Address: 6802 STEPHENS PATH Permit Type: RE -ROOF ZEPHYRHILLS, FL. Class of Work: ROOF REPLACEMENT Township: Range: Book: Proposed Use: SINGLE FAMILY RESIDENTIAL Lot(s): Block: Section: Square Feet: Subdivision: SILVER OAKS Est. Value: Parcel Number: 03- 26 -21- 0160 - 00000 -0330 Improv. Cost: 9,200.00 k E a Date Issued: 8/05/2010 Name: KLINGER, RIC RD Total Fees: 80.00 Address: 6802 STEPHENS PATH Amount Paid: 80.00 ZEPHYRHILLS, FL. 33542 Date Paid: 8/05/2010 Phone: (813)788 -3219 Work Desc: REROOF SHINGLE - YMAN - • • IN - - F - ID IAL 80.00 e} - ' \.(°-c11 0,5 6 i\ g' 4 D - IN =1• - r N TAPE JOINTS ROOF INSP FINAL REINSPECTION FEES: Reinspection fees will comply with Florida Statute 553.80 (2)(c) when extra inspection trips are necessary due to any one 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 efo - - . riling your notice of commencement." CONT CTOR SIGN E PERMIT OFFI R PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED PROTECT CARD FROM WEATHER Build'. . a lment . (0i i Date Received I I V � 3 , gZ — N C� I L Phone Contact 4 Permittin r 2 Owner's Name I: L( „ ' • `, . 4Q Qv) j 09K- Owner Phone Number • I � ��i ? b 0 J Owner's Address 6•43c) a_ $f.i1 Jl 5 bc/k_ f 1 Owner Phone Number Fee Simple Titleholder Name' Owner Phone Number I Fee Simple Titleholder Address I JOB ADDRESS r r f Q__ LOT # 33 SUBDIVISION I3 UkY () k -S I PARCEL ID# 53 2 - - 24 "O ( 60 -- C_XQcr) — Q Ci (OBTAINED FROM PROPERTY TAX NOTICE) WORK PROPOSED I NEW CONSTR f I ADD /ALT ,.,I 1 SIGN 1 1 MOVE I DEMOLISH INSTALL REPAIR t� PROPOSED USE I)I SFR I I COMM I 1 OTHER I TYPE OF CONSTRUCTION IX BLOCK 1 I FRAME I I STEEL n OTHER I DESCRIPTION OF WORK ! ^r00 W C � 1 r& .Q.S BUILDING SIZE 1 1 SQ FOOTAGE I 3140 1 HEIGHT I kij BUILDING I C ir 00' - VALUATION OF TOTAL CONSTRUCTION I 1 ELECTRICAL $ AMP SERVICE 1 1 PROGRESS ENERGY El W.R.E.C. I 1 PLUMBING $ 4r6qq I 1 MECHANICAL $ VALUATION OF MECHANICAL INSTALLATION • I I GAS 13;4 ROOFING 1 1 SPECIALTY I I OTHER - FINISHED FLOOR ELEVATIONS I I FLOOD ZONE AREA I )YES 1 - IN() • BUILDER COMPANY 1 SIGNATURE REGISTERED I Y/ N . 1 FEE CURRENT I Y/ N I Address I Ucense # I ELECTRICIAN COMPANY I SIGNATURE REGISTERED I Y/ N 1 FEE CURRENT I Y / N I Address I 1 - License # I PLUMBER COMPANY I SIGNATURE REGISTERED I Y/ N I FEE CURRENT I Y/ N I Address I 1 License # I MECHANICAL COMPANY I • SIGNATURE REGISTERED I Y/ N I FEE CURRENT I Y/ N I Address ( • 1 License # I SIG 1i COMPANY ( 1 K a. odrtiz 6 Tn� SIG " 1 4110 REGISTERED Y/ N 111 FEE CURRENT I Y/ N I r Address 13 6L t t SP ! k ( S 3' r L I (.�/ Ucense # I C' -CC ( 2- S" 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) 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 onslte, 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. (A/C upgrades over $5000) ** Agent (for the contractor) or Power of Attorney (for the owner) would be somr nne with notarized letter from owner authorizing same OVER THE COUNTER PERMITTING (Front of Application Only) Reroofs Sewers Service Upgrades NC Fences (PIot/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 "deed" restrictions" which may be more restrictive than County regulations. The undersigned assumes responsibility for dompli ice 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 ", 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 responsibilityto 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: 7 - 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 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 (8) 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, th \job is considered abandoned. WARNING TO OW . ER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE F '' ' IMPROVEMENTS TC OUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR EN a = ' OR AN ATTO : NEY BEFORE RECORDING Y ' U NOTICE OF COMMENCEMENT. FL. ' DA JURA 7.03) OWN' ' AG • T _� - CONT'+ O: _ _ .► Subscribed - • a sw• to (or affir e•) before me s Sybsc •rn (or a " - • ) to b-for -` zap J ©d by _ ped Va o Is /are er known to me or has/have produced Who Islare p r onalr known to me or has/have identi fOcation. as Thru T• IdenUtication. �� r � 1) Notary Public ell ' .(XJC� # � Notary Public �.�.v� � ' . a��P�:• ° ��• JA��r EL BO G ES : �,� ACQU ;_ f, of ° 9on �= ` ' t, ' ": 'C rn DO 621838 Co sslo N _ *: �° ' *= (; nmmisc i nn Di b O e r 1 2 ' Expires Decemb 1 2010 ,...4., 4 Expi (December 12, 201( n ; `•' 0ac' u, Paw nsuranse R0(7 +�OC•'rN1R Th 0d r F, finted or stamped Name of Notary typed, . printed or stamped tam a ' ■y tYP P ',P itiPP • 11 Mast ,2 visA 47 S‘wt te..- i - WW1 '',"' ' „,-..114. ir A Division of Xyntan Construction, Inc. S V .� "9 _ Proposal Ilr INC. 36413 SR 54 • Zephyrhills, Florida 33541 J Phone: 813 - 782 -6094 • Fax: 813 - 788 -6773 Estimate # I ®� License # CCC 1325505 Job # sely 1 Also, Serving the Central and East Coast of Florida (7663) Customer: RtG\„0,„-- 0 k \ tiaf Q Date: c'l /3 Address: f >ge)a _ j) PeiAt\-, City: zePiq . Lc Zip: 333 Home #: 788 - D1 ci Cell #: Business #: E-mail Address: C pp omplete tear off of existing S h ■ 1' Additional tems: 1.1nc1v (,(P AO (3) S ky.L of ecure all loose roof decking as needed according P11l vtx o , ,cac..clg -, g0 ' , SI, + 0 to Florida Building Codes (� Ri 14 ---VS, �•,��+� ..5 tAr,S M� Ujovki Roof dried in with CL-tIt - , cid(`,t0 -6- j' 3S k 0,� - k, -V.A\ 11t p1 .Si% n‘i ,S, iistall new valley metal with galvanized metal -x q\\ (1) At L.4/ y C' W 'l cv l4 H istall all new C.? " drip edge color: a8 ` O'F' A,LL4— LA- 6" Se •-A...04‘-5 54 0 k 'fnstall all new lead boots a, a (, s-.SPo AS a\A - fro,, r l L4,0-- install all new - 10 year fungus- resistant shingles IX-VOA-5 .Qq 1.¢,0r menu -k- CA",(0 , / xxo Shingle brand/color: r--� AM/Elk LA.) k r I k9 1 e eA Y --. Ge4 ‘ 0 Or Warranty Package. Eti roof related debris removed from job site �y. ',��. All materials, labor and permits furnished Total bid price $ 1 Extra's .:t 41, - Jk, i i'gad plywood replaced at a cost of $ 1. O per sq. ft. in the roof field. All other wood work/additional labor, such as, but not limited to, valley rebuilding, rafter replacement, etc. will be a rate of $.75. C° per man hour plus the cost of materials. THIS BECOMES A BINDING CONTRACT UPON ACCEPTANCE OF PROPOSAL. PURCHASER ACKNOWLEDGES RECEIPT OF A COPY OF THIS CONTRACT. 1. All material is guaranteed to be as specified and completed in a substantial workmanlike manner. 2. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, hurricane and other necessary insurance upon above work. 3. Labor warranty does not cover damage to roofs caused by lightning, hurricane, tornado, hailstorm, impact of foreign objects or other violent storm or casualty damage to roofs due to settlement, distortion failure or cracking of roof deck, walls or foundation of a building. 4. Workman's compensation and public liability insurance on above work to be taken out by RYMAN ROOFING, INC., a Division of Ryman Construction, Inc., or its subcontractors. 5. RYMAN ROOFING, INC., a Division of Ryman Construction, Inc. is not responsible to provide any materials or to perform any work other than what is described above. Replacement of deteriorated decking or fascia boards, is not included and will be charged as an extra unless otherwise stated herein. 6. This contract is subject to final approval by RYMAN ROOFING, INC., a Division of Ryman Construction, Inc. and is the entire agreement of the parties and no other written or other forms will recognized, 7. A charge of 1.5% will be made on all unpaid balances after 30 days, plus charges incurred for non - payment procedures, plus attorney's fees. 8. A 4% processing fee will be added to all credit card orders. Ryuran Roofing, Inc., a Division of Ryman Construction, Inc. will not be responsible for any damage to septic tanks, sod, shrubbery, paint, satellite signal Loss, sprinklers, concrete drives or any underground r ping. ; � ` y o ``y 7CyctD. . Payment Schedule: .IL " ' '� _. • _,_, J n / S > I Z. 3 f) 101 y (_\.2_,L\- � • i -� � Payment Method: � .'0,-,- � a / C d _ e - .- W °'w \--. ,..-, 'Vt.) ,,- A L t L . 1 7(' ) (e • — x Acceptance of Proposal STATUTORY 1, I _ . .. I k e \ . 1 \ i. • ACCORDING TO FLORIDA'S CONSTRUCTION LIEN LAW (SECTIONS 713.001 - 713.37, FLORIDA STATUTES), THOSE WHO WORK ON YOUR PROPERTY OR PROVIDE MATERIALS AND SERVICES AND ARE NOT PAID IN FULL HAVE A RIGHT TO ENFORCE THEIR CLAIM FOR PAYMENT AGAINST YOUR PROPERTY. THIS CLAIM IS KNOWN AS A CONSTRUCTION LIEN. IF YOUR CONTRACTOR OR A SUBCONTRACTOR FAILS TO PAY SUBCONTRACTORS, SUB - SUBCONTRACTORS, OR MATERIAL SUPPLIERS, THOSE PEOPLE WHO ARE OWED MONEY MAY LOOK TO YOUR PROPERTY FOR PAYMENT, EVEN IF YOU HAVE ALREADY PAID YOUR CONTRACTOR IN FULL. IF YOU FAIL TO PAY YOUR CONTRACTOR, YOUR CONTRACTOR MAY ALSO HAVE A LIEN ON YOUR PROPERTY. THIS MEANS IF A LIEN IS FILED YOUR PROPERTY COULD BE SOLD AGAINST YOUR WILL TO PAY FOR LABOR, MATERIALS, OR OTHER SERVICES THAT YOUR CONTRACTOR OR A SUBCONTRACTOR MAY HAVE FAILED TO PAY. TO PROTECT YOURSELF, YOU SHOULD STIPULATE IN THIS CONTRACT THAT BEFORE ANY PAYMENT IS MADE, YOUR CONTRACTOR IS REQUIRED TO PROVIDE YOU WITH A WRITTEN RELEASE OF LIEN FROM ANY PERSON OR COMPANY THAT HAS PROVIDED TO YOU A "NOTICE TO OWNER ". FLORIDA'S CONSTRUCTION LIEN LAW IS COMPLEX AND IT IS RECOMMENDED THAT YOU CONSULT AN ATTORNEY. I ACCEPT THIS PROPOSAL AND HEREBY CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE PROVISIONS OF THIS CONTRACT. Purchaser: r__ , 2 - ,) . y r Date: / 0/ i Purchaser: Estimator: -- : .. -- . -__ 1441.-: . ASPHALT SHINGLES 2007 PBC PRODUCT APPROVALS MANUFACTURER PRODUCT TESTS PASSED MIAMI -DADE FL # LESS THAN 110 MPH 110 MPH AND HIGHER ASTM ASTM TAS ASTM ASTM TAS 0'3161 0 7158 107 0 3161 0 7158 107 _ CLASS D CLASS G CLASS .F CLASS G CERTAINTEED CLASSIC HORIZEN X • 5444.1 CARRIAGE HOUSE X 5444.1 CENTENNIAL SLATE X 5444.1 GRAND MANOR X 5444.1 LANDMARK X 5444.1 LANDMARK PLUS X 5444.1 LANDMARK PREMIUM X 5444.1 LANDMARK TL X 5444.1 PRESIDENTIAL SHAKE X 5444.1 ' PRESIDENTIAL SHAKE TL X 5444.1 HATTERAS X 5444.1 PATRIOT X 5444.1 GAF -ELK ROYAL SOVEREIGN X - 10124.1 CAMELOT ' X 10124.1 CAPSTONE X 10124.1 COUNTRY MANSION , X 10124.1 GRAND CANYON X • 10124.1 GRAND SEQUOIA X 10124.1 GRAND SLATE X 10124.1 GRAND TIMBERLINE X 10124.1 TIMBERLINE ARMORSHIELD II • X 10124.1 TIMBERLINE PRESTIQUE GRANDE X 10124.1 TIMBERLINE PRESTIQUE 30 X 10124.1 TIMBERLINE •0 X 10124.1 TIMBERLINE PRESTIQUE 40 X 10124.1 TIMBERLINE 40 X 10124.1 TIMBERLINE PRESTIQUE LIFETIME X 10124.1 TIMBERLINE ULTRA X 10124.1 SLATELINE X 10124.1 • OWENS CORNING OAKRIDGE PRO 30 X 10874.1 OAKRIDGE PRO 30 AR X 10874.1 OAKRIDGE PRO 40 X 10674.1 OAKRpGE PRO 40 AR . . X 10874.1 OAKRIDE PRO 50 X 10674.1 OAKRIDGE PRO 50 AR X 10674.1 DURATION X 10874.1 DURATION PREMIUM X 10674.1 CLASSIC X 10674.1 CLASSIC AR X 10874.1 SUPREME X 10874.1 SUPREME AR X 10874.1 PROMINENCE • X 10874.1 PROMINENCE AR X 10674.1 BERKSHIRE X 10674.1 WEATHER GUARD HP X 10674.1 TAMKO GLASS SEAL AR X 1958.2 ELITE GLASS SEAL AR X 1958.1 HERITAGE 30 X _ 1956.3 HERITAGE XL X 1956.5 HERITAGE 50 X 1956.4 HERITAGE VINTAGE AR X 7154.1 • 1111111111111111111111 a 111111111111111 a 1111111111111111111 2010112104 Rcpt:1319338 Rec: 10.00 DS: 0.00 IT: 0.00 08/05/10 K. Garcia, Dpty Clerk PAULA S.O'NEIL,Ph.D.PASCO CLERK & COMPTROLLER NOTICE 0 8/05/10 02:01 pm 1 of 1 OTICE OF COMMENCEMENT OR BK 8 3 1 PG 1548 Permit No. Property Identification No. — l — �o — � j j 0 THE UNDERSIGNED hereby give informs you that the improvement will be made to certain real property, and in accordance with Section 713.13 of the Florida Statutes, the following information is provided in this NOTICE OF COMMENCEMENT. 1.Descri . of o property ` ` ) ` 5'1 ` O S P P P rty l egal description: 9 / _ S I 66 J 33 a Street Address: ! r - `� ins .S j' 2.General description of imp vements: re rtd 3.Owner Information a) Name and address: ' \C IVC C 1 ( \ i 1 4 l©L $ b) Name and address of fee simple titleholder (if other than owner) �, c) Interest in property 4.Contractot• Information a) Name and address: ' a , J • a s L - .0 S b) Telephone No.: }p ( • 7B 2_ Fax No. (Opt.) O©r ` �r VYl - �� S 5.Surety Information O t R / a) Name and address: b) Amount of Bond: c) Telephone No.: 6.Lender Fax No. (Opt.) a) Name and address: Phone No. 7. Identity of person within the State of Florida designated by owner upon whom notices or other documents may be served: a) Name and address: Y b) Telephone No.: Fax No. 8.In addition to himself, owner designates the following person to receive a copy of the O Lienor's Notice as provided in Section 713.13(1)(b), Florida Statutes: a) Name and address: b) Telephone No.: Fax No. (Opt.) 9.Expiration date of Notice of Commencement (the expiration date is one year from the date of recording unless a different date is specified): Q . WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENT'S UNDER CHAPTER 713, PART I, SECTION 713.13, FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. STATE OF FLORIDA . - COUNTY OF PASCO 49 r n Notary Public State of Florida „ Ch ristian Ryman Signature o 1 wner or Owner's Authori s flice trectodPartner/Manager • My Commission DD751810 0 , „ov Expires o 1 /24/2012 ~—' R(eti.brrei Print Nance The foregoing instrument was acknowledged before me this 3 day of s� 20 n D• Is� as `� � ID , by TC� in fact) for (type of authority, e.g. officer, trustee, attomey (name of party on behalf of whom ' ent was executed). Personally Known OR Produced Identification Notary Signature Type of Identification Produced D l Name (print) ___CA Verification pursuant to Section 92.525, Florida Statutes. Under penalties of perjury, I declare that I have read the foregoing and that the facts stated in it are true to the best of my knowledge and belief. � � o 9— FORMS /NOC,rvsd2007 Signature o anus! Person Signing Above STATE c FLOC 1GA; COUNTk" , i F C" 1 =. Ek. N A■N•ieir OR RE ON riLG. ' 7 n.. Y TillS CYO . ! I�� 'T '. l " '� _ • 2. C r'1� .J LL E�.