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The following attachments arc provided as required: <br /> 1,Qualification statements and/or resumes of the private provider and all duly authorized representatives. <br /> 2. Proof of insurance for professional and comprehensive liability in the amount of$1 million per <br /> occurrence relating to all services performed as a private provider, including tail coverage for a minimum <br /> of 5 years subsequent to the performance of building code inspection services. <br /> Individual Corporation Partnership <br /> Print Corporahoo Name Print Partnership Name <br /> .....a� By: By: <br /> _. (Signature} (signature} (signature) <br /> Fr nt Print Print <br /> Nsmr:,C'�M Q „ l j Name 9 Name <br /> Address•20 114V t l� Its: Its: <br /> Address: Address: <br /> Tcleftine <br /> Telephone Telephone <br /> No. No.: <br /> Please use appropriate notary block. <br /> STATE OFt <br /> COUNTY OF <br /> Individual l/ Corporation Partnership <br /> k3 re this f J day of Before me,this day of Before me,this day <br /> l"V h W,2FSj,personally ,20_, of ,20 <br /> --' <br /> appeared personally appeared personally appeared <br /> who executed the foregoing instrument, of , <br /> and acknowledged before me that same ,a partnerlagent on behalf of <br /> was executed for the purposes therein corporation,on <br /> expressed, behal f of the state corporation,who a partnership,who executed the <br /> executed the foregoing instrument and foregoing instrument and <br /> acknowledged before me that same was acknowledged before me that same <br /> executed for the purposes therein was executed for the purposes therein <br /> expressed. expressed. <br /> Personally known_;or Produced identification a of identification produced . <br /> JSignature of Notary 'A—_ Print Name � �� <br /> Notary Public:NOTARY 5TAAV BELOW <br /> My commission expires; <br /> �+ Notary Putft at to of FW48 <br /> I TV&Eaton <br /> E � t3i3 rta�t5 <br /> Page 2 of 2 <br />