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Permit Int Remodel 1648 Sea Oats Dr 2012 �. z= CITY OF ATLANTIC BEACH f 800 SEMINOLE ROAD - � � ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 Application Number . . . . . 12-00000812 Property Address . . . Date 7/03/12 1648 SEA OATS DR Application type description RESIDENTIAL ALTERATION Property Zoning . . . . . . . TO BE UPDATED Application valuation . . . . 5000 ----------------------------------------------------- Application desc INTERIOR REMODEL ----------------------------------- Owner Contractor ------------------------ ------------------------ PERRYE JEFFREY H & TINA R. OWNER 1648 SEA OATS DRIVE ATLANTIC BEACH FL 32233 --- Structure Information 000 000 INTERIOR REMODEL Occupancy Type . . . . . . RESIDENTIAL -------------------------------------------- Permit . . . . RESIDENTIAL ALT/OTHER Additional desc . . RELOCATE WALLS, NEW DRYWALL Permit Fee . . . . 75 . 00 Plan Check Fee . 00 Issue Date Valuation . . . . 5000 Expiration Date . . 12/30/12 ----------------------------------------- Special Notes and Comments 2010 FLORIDA BUILDING CODE, 2008 NATIONAL ELECTRIC CODE *REPORT ANY UNFORSEEN STRUCTURAL DAMAGE TO THE BUILDING DEPARTMENT IMMEDIATELY. * A DRYWALL SCREW INSPECTION SHALL BE REQUIRED AND A INSULATION INSPECTIN. * -------------------------------------------------------- Other Fees . . . . . . . . . STATE DCA SURCHARGE 2 . 00 STATE DBPR SURCHARGE 2 . 00 ----------------------------------------------------- Fee summary Charged Paid Credited Due ------- ---------- ---------- ---------- ---------- Permit Fee Total 75 . 00 75 . 00 . 00 . 00 Plan Check Total . 00 . 00 . 00 . 00 Other Fee Total 4 . 00 4 . 00 . 00 . 00 Grand Total 79 . 00 79 . 00 . 00 . 00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITV OF' ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. -s� City of Atlantic Beach Building Department EDate PPLICATION NUMBER 800 Seminole Road ssigned by the Building Department.) Atlantic Beach,Florida 32233-5445 a Phone(904)247-5826 - Fax(goo)247-5845 / E-mail: building-dept@coab.us uted: CSIv� p� City web-site: http!/A ww.coab.us APPLICATION REVIEW AND TRACKING FORMA Property Address: kO *Deartmnt review re uired Yes o Applicant: //��/� Zoning istrator Project: � �/�} /� ady Public Works Public Utilities Public Safety Fire Services rim Other Agency Review or Permit RequiredERev,iew or Receipt Date rmitVerified B Florida Dept.of Environmental Protection Florida Dept.of Transportation St.Johns River Water Management District Army Corps of Engineers Division of Hotels and Restaurants Division of Alcoholic Beverages and Tobacco Other: APPLICATION STATUS Reviewing Department First Review: roved. []Denied. (Circle one.) Comments: BUILDING PLANNING&ZONING Reviewed by: 4 Date: r7 TREE ADMIN. Second Review: QApproved as revised. ❑De ed. PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: [—]Approved as revised. ❑Denied. Comments: Reviewed by: Date: Revised 07/27/10 BUILDING PERMIT APPLICATION CITY OF ATLANTIC BEACH 800 Seminole Road, Atlantic Beach, FL 32233 Office (904)247-5826 Fax (904)247-5845 Job Address: 2- Valuation Permit Number: Legal Description 3/Si-a T..,�s_z g£ S�[,. �,, � L,;7 f� � Valuation of Work$ S, v o v oor ea o q, t. G Parcel# Proposed Work heated/cooled 2-oc� q t non-heated/cooled � co Class of Work(circle one): New Addition Alteration epa Move Demolition pool/spa a window/d Use of existing/pro osed structures) ((circle one): Commercial esidenti p oor If an existing structure,is a fire sprinkler system installed? (Circle one): s N N/A Florida Product Approval # For multiple products use product approval form Describe in detail the type of work to be performed: Pro owner Information: Name:J /,,,_ Ci TL , Address:/t'o 1 -re,, oc%S j r ty ate 1LZi ?zz. E-Mail or Fax#(Optional p— ?Phone S,,V_ y 7 X – 3 J Contractor Information: Company Name: Address: Qualifying Agent: Office Phone Job Site/ City State State Certification/Registration# Architect Name&Phone# Engineer's Name&Phone# CITY OF ATLANTIC BEM11 Fee Simple Title Holder Name and Address SEE P-BRIM Bonding Company Name and Address Mortgage Lender Name and Address REVIEWED .9pplication is hereby made to obtain a permit to do the work and installations as indicated I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. This permit becomes null and void if work is not commenced within six(6)months, or if construction or work is suspended or abandoned for a eriod of six(6)months at anv time after work is commenced. 1 understand that separate permits must be secured for Electrical Work, Plutnbing,Signs, Wells, Pools, Furnaces, Boileis, Heaters, Tanks and Air Conditioners,eta WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTENT) TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. I hereb certify that I have read and examined this a plication and know the same to be true and correct. All provisions of laws and ordinances governing this Ope owork*will be complied with whether speci ted herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any other federal,state, or local law regulating construction or the performance of construction. Signature of Owne Signature of Contractor Print Name .J '` .. .......... Print Name Sworn tAand subscr}bed before me this Sworn to and subscribed before ire t Day of J 4% -e- 20 ( 2.-- this Day of 20 No ary Public ary Public t�G.e+nrrwr _ t � w� Nrgrr►wNe 01 � y�`14 Revised 01.26.10 My CMM-ENO"Nov 1f,2012 c .uon,r no 839650 `7,O0 6 c� 7t 0 1 DO NOT WRITE BELOW OFFICE USE ONLY pp ica e o es: 2 1 DA I E Review Result (circle Approved Disapproved Approved w/ Conditions Review Initials/Date: Development Size Habitable Space Non-Habitable Impervious area Miscellaneous Information Occupancy Group Type of Construction Number of Stories Zoning District Max. Occupancy Load Fire Sprinklers Required Flood Zone Conditions/Comments: iM CITY OF ATLANTIC BEACH OWNER. / BUILDER AFFIDAVIT I. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES, PART 1 "CONSTRUCTION CONTRACTING"REQUIRES OWNER/BUILDER TO ACKNOWLEDGE THE LAW: DISCLOSURE STATEMENT FOR SECTION 489.103(7),FLORIDA STATUTES: STATE LAW REQUIRES CONSTRUCTION TO BE DONE BY LICENSED CONTRACTORS. YOU HAVE APPLIED FOR A PERMIT UNDER AN EXEMPTION TO THAT LAW. THE EXEMPTION ALLOWS YOU,AS THE OWNER OF YOUR PROPERTY,TO ACT AS YOUR OWN CONTRACTOR EVEN THOUGH YOU DO NOT HAVE A LICENSE. YOU MUST SUPERVISE THE CONSTRUCTION YOURSELF. YOU MAY BUILD OR IMPROVE A ONE—OR TWO FAMILY RESIDENCE OR A FARM OUTBUILDING. YOU MAY ALSO BUILD OR IMPROVE A COMMERCIAL BUILDING AT A COST OF$25,000.00 OR LESS. THE BUILDING MUST BE FOR YOUR USE AND OCCUPANCY. IT MAY NOT BE BUILT FOR SALE OR LEASE. IF YOU SELL OR LEASE A BUILDING YOU HAVE BUILT YOURSELF WITHIN ONE YEAR AFTER THE CONSTRUCTION IS COMPLETE, THE LAW WILL PRESUME THAT YOU BUILT IT FOR SALE OR LEASE, WHICH IS IN VIOLATION OF THIS EXEMPTION. YOU MAY NOT HIRE AN UNLICENSED PERSON AS YOUR CONTRACTOR. YOUR CONSTRUCTION MUST BE DONE ACCORDING TO THE BUILDING CODES AND ZONING REGULATIONS. IT IS YOUR RESPONSIBILITY TO MAKE SURE THAT PEOPLE ENVLOYED BY YOU HAVE LICENSES REQUIRED BY STATE LAW AND BY COUNTY OR MUNICIPAL LICENSING ORDINANCES. II. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE, THE BUILDING DEPARTMENT SUGGESTS WORKER'S COMPENSATION INSURANCE BE PURCHASED. III. IRS WITHHOLDING; OWNERS HIRING WORKERS BECOME EMPLOYERS AND SHOULD ALSO OBSERVE IRS WITHHOLDING TAX AND/OR FORM 1099 REQUIREMENTS ON THE WORKERS THEY EMPLOY ON THEIR IMPROVEMENT TRADES. IV. PENALTY; UNLICENSED CONTRACTORS CANNOT BE EMPLOYED UNDER ANY CIRCUMSTANCES. OWNERS BEING SUBJECT TO $5,000 PENALTY-UNDER FLORIDA STATUTE NO. 455-228(1). AN"OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY SEE THE COUNTY "CERTIFICATE OF COMPETENCY' OR THE FLORIDA "CONTRACTORS CERTIFICATE" TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. TELEPHONE THE BUILDING DEPARTMENT(247-5826) IF IN DOUBT. V.ACKNOWLEDGEMENT;I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSUR STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF A , OWNER-BUILDER PERMIT. """"■ ADDRESS PHONE NUMBER 1 -J4 PRINT t SIGNATURE DATE Before me this Z i day of rJ%f 0-L 20t n the county of , //�f Duval,State of Florida,has personally appeared herin by ttt���l'mmmself 1 herself and affirms that `�' ( (J all statements and declarations are true and accurate. Nota Public at Large,State of L ClI d ik County of_ / b Q V Personally Known ❑Produced I C (, - Ap Notary Signature: P117110 6.NVANT F:/BLDG/Owner-Builder AKadavit,REVISED: 4/16/2009 Nogry P*k•No N WW& ',,,C i�00 NOTICE OF COMMENCEMENT State of /—Z. County of Tax Folio No. , .i�.� To Whom It May Concern: The undersigned hereby informs you that improvements will be made to certain real property, the Florida Statutes,the following information is stated in this NOTICE OF COMMENCEMENT.d m accordance with Section 713 of Legal Description of property being improved: Z-i-i o5 —,_ Address of property being improved:1� eneral description of improvements: !7� ✓f� i Owner:���� % '1, � Address: 16 j°C .S e Owner's interest in site of the improvement: U t v I e/— Fee Simple Titleholder(if other than owner): Name: Contractor: Address: Telephone No.: Fax No: Surety(if any) ..yyy�4k Address: Amount of Bond$ � Telephone No: Fax No: Name and address of any person making a loan for the construction of the improvements Name: Address: Phone No: Fax No: ..� Name of person within the State of Florida, other than himself, designated by owner upon whom notices or other e served: Name: Address: Telephone No: Fax No: In addition to himself, owner designates the following person to receive a copy of the Lienor's Notice as provided in Section 713.06(2)(b),Florida Statues. (Fill in at Owner's option) Name: Address: Telephone No: Fax No: Expiration date of Notice of Commencement(the expiration date is one (1)year from the date of recording unless a different date is specified): THIS SPACE FOR RECORDER'S USE ONLY OWNER Signed: —Date: f/ a Before me this day of �_ _in the Cou ty of Duval,State Of Florid as personally appeared Doc#2012135488,OR BK 15984 Page 1788, Notary Public at Large, State of Flo 'da,County of Duval Number Pages: 1 Known: ire.,: ices: Recorded 06/29/2012 at 09:13 AM, Personally JIM FULLER CLERK CIRCUIT COURT DUVAL cii'; cation: ,•ti.�VA,°a,� COUNTY' NY RECORDING$10.00 ,= Naarr Fubik-State of Florida MY CWn.Expires Nov 19,2012 C"wisshm#DO 839ti50 5EDRO©M FAMILY ROOM ------------ 00 BOOM ----------- IVIN�- 19' FELE COPY n cU t 17A � ,- Prepared by: The Law Offices of Rod Schloth,P,A, 2187 South Third Street Jacksonville Beach Florida 32250 File#: RS12-675 Record and return to: Jeffrey H. Perrye and Tina R. Perrye 1648 Sea Oats Drive Atlantic Beach,Florida 32233 General Warranty Deed Made this June 29,2012 A.D.By John H. Chitty,Jr. and Elizabeth P. Chitty,husband and wife,whose address is: 60 Brimley Drive Apartment 418, Fredericksburg, VA 22406, hereinafter called the grantor,to Jeffrey H. Perrye and Tina R. Perrye,husband and wife, whose address is: 1648 Sea Oats Drive,Atlantic Beach,Florida 32233 ,hereinafter called the grantee: (Whenever used herein the term"grantor"and"grantee"include all the parties to this instrument and the heirs,legal representatives and assigns of individuals, and the successors and assigns of corporations) Witnesseth,that the grantor,for and in consideration of the sum of Three Hundred Ten Thousand dollars&no cents, ($310,000.00)and other valuable considerations,receipt whereof is hereby acknowledged,hereby grants,bargains,sells,aliens,remises, releases,conveys and confirms unto the grantee,all that certain land situate in Duval County, Florida,viz: Lot 15, Block 13, SELVA MARINA, UNIT NO 6, a subdivision according to the plat thereof recorded at Plat Book 34 pages 51, 51 A and 51 B in the Public Records of Duval County, Florida. Parcel ID Number: Together with all the tenements,hereditaments and appurtenances thereto belonging or in anywise appertaining. To Have and to Hold, the same in fee simple forever. And the grantor hereby covenants with said grantee that the grantor is lawfully seized of said land in fee simple;that the grantor has good right and lawful authority to sell and convey said land;that the grantor hereby fully warrants the title to said land and will defend the same against the lawful claims of all persons whomsoever; and that said land is free of all encumbrances except taxes accruing subsequent to December 31,2011. Signed, sealed and delivered in our presence: C '—' 4OH4Chitty,Jr. (Seal) Wi ss Printed Name /9Yr�T C. � Address: E izabeth . Chitty Witness Printed Name (Seal)��' Address: State of Florida County of Duval e "L- s- ba/r/ 1 ZZHO The foregoing instrument was acknowledged before me this l2th day ofAve, 2012, by John H. Chitty, Jr. and Elizabeth P. Chitty, husband and wife,who is/are personally known to me or who has produced ,,t identific tion. otary noic Print Name: My Commission Expires: +■..ww» r*oi'�r� �,,•' �� GI.EIVDA M.CARTER JV." I COMrniaaion#DD879202 Expires May 6,2013 "enruGN 8ondadUru Tray Fein Insur4ncQ8M-3W7619 f=� CITY OF ATLANTIC BEACH j � 800 SEMINOLE ROAD ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 Application Number 12-00000812 Date 7 Property Address . . . . . . 1648 SEA OATS DR /05/12 Application type description RESIDENTIAL ALTERATION Property Zoning . . . . . . . TO BE UPDATED Application valuation . . . . 5000 Application desc INTERIOR REMODEL ---------------------------------- Owner Contractor ------------------------ ------------------------ PERRYE JEFFREY H & TINA R. OWNER 1648 SEA OATS DRIVE ATLANTIC BEACH FL 32233 --- Structure Information 000 000 INTERIOR REMODEL Occupancy Type . . . . . . RESIDENTIAL ------------------------------------------------- Permit . . . . . . PLUMBING PERMIT Additional desc KITCHEN SINK Sub Contractor ADVANTAGE PLUMBING Permit Fee . . . . 62 . 00 Plan Check Fee . 00 Issue Date Valuation 0 Expiration Date . . 1/01/13 ------------------------------------------------ Special Notes and Comments 2010 FLORIDA BUILDING CODE, 2008 NATIONAL ELECTRIC CODE *REPORT ANY UNFORSEEN STRUCTURAL DAMAGE TO THE BUILDING DEPARTMENT IMMEDIATELY. * A DRYWALL SCREW INSPECTION SHALL BE REQUIRED AND A INSULATION INSPECTIN. * STATE P Other Fees LBG DCA SURCHARGE 2 . 00 ----------------------------- ------------------------------------ - STATE PLBG DBPR SURCHARGE 2 . 00 ---------------------------------- Fee summary------ Charged Paid Credited Due ----- ---------- ---------- ---------- Permit Fee Total 62 . 00 62 . 00 . 00 . 00 Plan Check Total . 00 . 00 . 00 . 00 Other Fee Total 4 . 00 4 . 00 . 00 . 00 Grand Total 66 . 00 66 . 00 . 00 . 00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. PLUMBING PERMIT APPLICATION CITY OF ATLANTIC BEACH 800 Seminole Rd Atlantic Beach, FL 32233 Ph (904) 247-5826 Fax(904) 247-5845 g v JOB ADDRESS: © PERMIT# NEW OR REPLACEMENT INSTALLATION: Project Value TYPE OF FIXTURE QTY TYPE OF FIXTURE Bathtub QTY Clothes Washer Septic Tank&Pit Dishwasher Shower Drinking Fountain Shower Pan Floor Drain Slop Sink Floor Sink Three Compartment Sink Hose Bibs Toilet Kitchen SinkUrinal Laundry Tray -- Vacuum Breakers Lavatory Water Connected Appliances Other Fixtures Water Heater Water Treating System RE-PIPE: TYPE OF FIXTURE QTY TYPE OF FIXTURE Bathtub QT' Clothes Washer Septic Tank&Pit Dishwasher Shower Drinking Fountain Shower Pan Floor Drain Slop Sink Floor Sink Three Compartment Sink Hose Bibs Toilet Kitchen Sink Urinal Laundry Tray Vacuum Breakers Lavatory Water Connected Appliances Other Fixtures Water Heater Water Treating System MISCELLANEOUS: ❑ Sewer Replacement ❑ Back Flow Preventer ❑ Grease Interceptor(Trap) ElLawn Sprinkler System-Number of Heads13_ ell g (Requires 3 sets of plans) **SJRWD Well Completion Form. Completed form to be submitted to ect'the g Department for final ins E] Other � �S inspection.** Permit becomes void if work does not commence within a six month period or work is suspended or abandoned for six months.I hereby ce this application and know the same to be true and correct. All provisions of laws and ordinances governing this work will be complied with wfy hether Specified or not. The permit does not give authority to violate the provisions of any other state or local law regulation construction or the peke with fthat I have read Property Owners Name � onstruction. Plumbing Company Phone Number y^3 3 44 Office Phone �J-� j/� Faxy�_9 LA Address: �l;' -_r 11 City —d-) State '/ Zip z2 3 License Holder(Print); State C 1 ication/Registration#�'F(�'/y�e'VS`; Notarized Signature of�ice'ase older l'�nY Ny SHIRL�Y i .: MY COMMtS5�HA S s ribed f e e thi day o sy a EXPIRES:February 14,2014 20 Bonded Thru otary Pub uss CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 4 Application Number . . . . . 12-00000812 Date 9/06/12 Property Address . . . . . . 1648 SEA OATS DR Application type description RESIDENTIAL ALTERATION Property Zoning . . . . . . . TO BE UPDATED Application valuation . . . . 5000 ---------------------- ------------------------------------ Application desc INTERIOR REMODEL Owner Contractor ------------------------ ------------------------ PERRYE JEFFREY H & TINA R. OWNER 1648 SEA OATS DRIVE ATLANTIC BEACH FL 32233 --- Structure Information 000 000 INTERIOR REMODEL Occupancy Type . . . . . . RESIDENTIAL --------------------------------------------------------------------- Permit . . . . . . MECHANICAL GAS PIPE PERMIT Additional desc . . Sub Contractor . . FERRELLGAS L. P . Permit Fee . . . . 65 . 00 Plan Check Fee . 00 Issue Date . . . . Valuation . . . . 0 Expiration Date . . 3/05/13 ------------------------------------------------------------------ Special Notes and Comments 2010 FLORIDA BUILDING CODE, 2008 NATIONAl ELECTRIC CODE *REPORT ANY UNFORSEEN STRUCTURAL DAMAGE TO THE BUILDING DEPARTMENT IMMEDIATELY. * A DRYWALL SCREW INSPECTION SHALL BE REQUIRED AND A INSULATION INSPECTIN. * ------------------------------ ----------------------------------- Other Fees . . . . . . . . . STAT MECH DCA SURCHARGE 2 . 00 STAT MECH DBPR SURCHARGE 2 . 00 ----- ---------------------------- Fee summary Charged P id Credited Due --- ---------- ---------- Permit Fee Total 65 . 00 65 . 00 . 00 . 00 Plan Check Total . 00 . 00 . 00 . 00 Other Fee Total 4 . 00 4 . 00 . 00 . 00 Grand Total 69 . 00 69 . 00 . 00 . 00 E PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF AT ANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. MECHANICAL PERMIT APPLICATION CITY OF ATLANTIC BEACH 800 Seminole Rd Atlantic $each, FL 32233 Ph (904) 247-5826 Fax (004) 247-5845 JOB ADDRESS: V1151-JA ("j_15 g PERMIT# 1Z " 12— v PROJECT VALUE $ AS-0C) AR # s REQUIRED NEW AIR CONDITIONING & HEATING SYSTEM INSTALLATION Air Conditioning: Unit Quantity Tons Per UJ t Heat: Unit Quantity BTU's Per Unit Seer Rating Duct Systems: Total CFM REQUIRED i REPLACEMENT AIR CONDITIONING & HEATING SYSTEM INSTALLATION Air Conditioning: Unit Quantity Tons Per Unit Heat: Unit Quantity BTU's Per nit Seer Rating Duct Systems: Total CFM REQUIRED B FIRE PREVENTION I Fire Sprinkler System Quantity (Requires 3 sets of plans) ----------------------- Fire Standpipe Quantity a (Requires 3 sets of plans) Underground Fire Main Value (Requires 3 sets of plans) Fire Hose Cabinets Quantity (Requires 3 sets of plans) Commercial Hoods Quantity (Requires 3 sets of plans) Fire Suppression Systems Quantity (Requires 3 sets of plans) FIRE PLACES MIS ELLANEOUS: Prefabricated Fireplace Qty Autoi iiobile Lifts Gas Piping Outlets Boiles BTU's Elev ors/Escalators ALL OTHER GAS PIPING Heat xchanger Quantity of Outlets Pumps #Vented Wall Furnaces Refrigerator Condenser BTU's #Water Heaters Solar Collection Systems Tank (gallons) Wells OTHER: Permit becomes void if work does not commence within a six month period or work is Suspended or abandoned for six months.I hereby certify that I have read this application and know the same to be true and correct. All provisions of laws and otYlinances governing this work will be complied with whether specified or not. The permit does not give authority to violate the provisions of any other state or local law regulation construction or the performance of construction. Property Owners Name ,) Phone Number Mechanical Company /-��/�/lc s Office Phone Fax Co. Address: 9 L/`� �3 r � �- J . ; y0 Cit 6 /3c A State�Zip � �)rU _ Y X License Holder(Print): Stat Certification/Registration# DC7 Notarized Signature of License Ho N " SHIRLEY L.GRAHAM r•P1 9,,76w n and subscribed befor this MY COMMISSION 4 QG 5 �ay f T 20 .: EXPIRES!February 14,2014 Bonded Tbeu Notary Public Under ture of Notary llc P 4 c