Laserfiche WebLink
- <br /> . . <br /> Clayton Bristol, PE <br /> 3216 Khst@Ln <br /> Brandon, FL33S11 <br /> Phone:352'212-6306 <br /> Email: Bristol E 'neeringSemices8BgQmaiLcomm <br /> Registered Professional Engineer#84l83 <br /> The following attachments are.provide a,required: <br /> z.ova|Vicetxzngmtemems and/or resumes of the private provider and all duly authorized representatives. <br /> z. Proof of insurance for professional and comprehensive liability in the amount of$1 million per occurrence relating <br /> to all services performed as a private provider,including tail coverage for a minimum of 5 years subsequent to the <br /> performance of building code inspection services. <br /> |a6hvidma< Corporation AT Partnership <br /> Print CorrQotion me Print Partnership Name <br /> By: A By: <br /> (signature) -- ��gnutDrel (signature) <br /> Print Print -�� � �z� Print <br /> Name: Name: �� ~ `�—�~ ~" mame: <br /> QK� <br /> Address: ,^~ . Address: <br /> rL ^~` <br /> Telephone Telephone /l'�� (� Telephone <br /> mv: No: ' No: <br /> Please use appropriate notary block. <br /> STATE OF <br /> COUNTY OF <br /> individual Corporation Partnership <br /> Before me,this______day uf Before me, this day of Before me, this dav <br /> z0___'personally z�___� personally <br /> appeared personally appeared IMS of appeared <br /> who executed the foregoinga partner/agent on behalf of <br /> instrument, and acknowledged corporation, on <br /> before methat same was executed behalf of the state corporation,who executed a partnership, who executed the <br /> for the purposes therein expressed. the foregoing instrument and acknowledged foregoing instrument and acknowledged <br /> before me that same was executed for the before me that same was executed for <br /> purposes therein expressed. the purposes therein expressed. <br /> Personally known or Produced identification lL----Type of identification produced <br /> Al Y-Ck V� <br /> ?imnatu,eofNotary Print Name <br /> Notary Public:NOTARY STAMP BELOW <br /> xxy commission expires: <br /> Alexandra Wilder <br /> E:Explm 09/1212022 <br /> 2of2 <br />