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Permit No. Parcel ID No. 11-26-21-0010-05700-0250 NOTICEOFCOMMENCEMENT IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII State of Florida County of Pasco 2011086876 THE UNDERSIGNED hereby gives notice that improvement 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 Description of Property Parcel Identification No. 11-26-21-Q010-05700-0250 Street Address: 5528 Gall Boulevard. Zeahvrhills. FL 33542 2. General Description of Improvement 2,000 SF Medical office build out consisting of waiting area, check in, check out, vitals, four (4) euam _ Rooms, three (31 offices. storaae room. IT closet. medical records storaae. staff toilet. oatient toilet. and break room. Rcpt:1371429 Rec: 10.00 DS: 0.00 IT: 0.00 3. Owner Information: JSA Healthcare Corooration (Robert Miiler— Facilities Manaaer) 06/06/ 11 K. Kraenge 1, Dpty C lerk Name 10051 5'" Street North. Suite 200 St. Petersburg FL Address City State Interestin Property• Tenant PRULq S 0'NEIL,Ph D PqSCO CLERK & CQMPTROLLER 06/06/11 02:59 m 1 of 1 Name of Fee Simple Titleholder� OR BK �� PG ��5� (If other than owner) Address City State 4 Contractor: Bollenback Builders. Inc. Name 160 Scariet Boulevard Oidsmar FL 3 C f� 7'7 Address City State Contractor's Telephone No.. 813-855-2656 5 Surety: Not Aaolicable Name Address City State Amount of Bond: $ Telephone No.: 6. Lender• Name Address City State Lender'sTelephone No. 7 Persons within the State of Florida designated by the owner upon whom notices or other documents may be served as provided by Section 713.13(1)(a)(7), Florida Statutes: Thad Carter of Bollenback Builders. Inc. Name 160 Scarlet Boulevard Oldsmar FL Address City State Telephone Number of Designated Person: 813-855-2656 8. In addition to himself, the owner designates Thad Carter of Bollenback Builders, Inc. 9. to receive a copy of the Lienor's Notice as provided in Section 713 13(1)(b), Florida Statutes. Telephone Number of Person or Entity Designated by Owner• 813-555-2656 10. Expiration date of Notice of Commencement is one year from the date of recording unless a different date is specified: WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART 1, 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 WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RDI YOUR NOTICE OF COMMENCEMENT STAT ° ��- COUN O Shnrtvr�,�; � �r�AFER Notary Fuc�l�c - State oi f1oAd� Si ure of Owner or Own r's Aut rized Officer/Director/Partner/Manager . f►IyCornm�ssionEr.piresAug28,2(Ni Comm�ssinn # DD 709355 �h 8onded ' �"'' �' Nota►YA�r►. Signatory's itlelOffice /J � — .�`�a� ShQ-�Q � The foregoing instrument was acknowledged before me this ��day of J�l'Q , 20 �, by �� as � (t�pe of authority, e.g , er trustee, attorney in fact) for �S�- (name of p��}„be,half of whom i� umen was xecuted). Personally Known OR P duced Identification Notary Signature �� r � �� `�- Type of Identification Produced Name (print) S vlh � h 6 P 1� 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 � �.�^- ignature of Natural erson Sig ing Ab e wpdata/bcs/noticecomm encement_pc053048wce