96 Ocean Blvd 2013 Pool CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
Application Number . . . . . 13-00003562 Date 11/05/13
Property Address . . . . . . 96 OCEAN BLVD
Application type description SWIMMING POOL/SPA
Property zoning . . . . . . . RES GEN MF DISTRICT
Application valuation . . . . 25000 --------------
-------------------------------------------------------------
Application desc
new inground pool ---------------- ------
-----------------------------------------------------
Owner Contractor
------------------------
SCOTTS POOL SERVICE INC
BORDERS, RONALD 10549 BURRIS DR
8 SPARWHEEL LN FL 32225
HILTON HEAD ISL SC 29928 JACKSONVILLE
----------------------------------------------------------------------------
Permit . . . . . . SWIMMING POOL
Additional desc . - 87 . SO
Permit Fee . . . . 175 . 00 Plan Check Fee
Issue Date . . . . Valuation . . . . 25000
Expiration Date . . 5/04/14 ---------------
---------------------------------------------------- --------
Special Notes and Comments
POOL - Wellpoint (if used) must discharge into vegetated
area 101 minimum from street or drainage feature (swale,
structure or lagoon) .
2010 FLORIDA BUILDING CODE, 2008 NATIONAl ELECTRIC CODE
REQUIRED INSPECTIONS :
*POOL STEEL
*ELECTRICAL GROUNDING AND BONDING
*FINAL (PUMPS MUST BE RUNNING FOR FINAL)
SWIMMING POOL SAFETY INSPECTION REQUIRED
---------- -----------------------------------------------------------------
Other Fees . . . . . . . . . STATE DCA SURCHARGE 2 . 63
DEV REVIEW-SINGLE & 2-FAM 50 - 00
ENG REV PRE APP > 3 HRS 25 . 00
STATE DBPR SURCHARGE 2 . 63
- --------------------------------------------------------------------------
Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- ----------
Permit Fee Total 175 . 00 175 . 00 . 00 . 00
Plan Check Total 87 . 50 87 . 50 . 00 . 00
Other Fee Total 80 . 26 80 . 26 . 00 . 00
Grand Total 342 . 76 342 . 76 . 00 . 00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
BUILDING PERMIT APPLICATION MEOW&*&,%
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233 FILE COPY
Office (904) 247-5826 Fax (904) 247-5845
JobAddress: &,IFAAJ RLM ?jT1+VL16 96# Permit Number: _L�3-
Legal Description Y-10 ATZAA)TIC &H Parcel 9
Floor Area ot- Sq.Ft. Sq*Ft
Valuation of Work$ ;Z5 6160 Proposed Work heated/cooled non-heated/cooled
Class of Work(circle one): (9 Addition Alteration Repair Move Demolition pool/spa window/door
Use of existing/proposed structure(s) (circle one): Commercial Residential
If an existing structure,is a fire sprinkler system installed? (Circle one): Yes No N/A
Florida Product Approval#
For multiple products use product approval form
Describe in detail the type of work to be performed: JAY 60N_ Aco L
Property Owner Information:
Name: P49-Al Ao"e4--s' Address:
City NIJ-710P nC-44 State5-1- Zip 2W2 6 Phone 2,6 R 0060
E-Mail or Fax# (Optional)
Contractor Information: CONTRACTOR EMAIL ADDRESS:
Company Name:56rrSl Aewt -'VCX C116e-= �416 -Qualifying Agent: (.7-Ap -
P -A&E
Address: /0,571/-9 9t4AZ-!5; kk, city /YX State IEM' _ Zip -3,:U 2-5-
Office P Job Site/Contact Number�j5�4 6,j�&3 0 7-7 Fax#Y04 �YF_ZA 41_
State Certificaiion/Re-gi-stration# r PC <5/-.5-a 3
Architect Name&Phone 4
Engineer's Name &Phone#
Fee Simple Title Holder Name and Address
Bonding Company Name and Address
Mortgage Lender Name and Address
4pplication i's hereby made to obtain a permit to do the work and installations as indicated I certify that no work or installation has commencedprior to the
issuance of a permit and that all work will be pe�formed to meet the standards of all laws regulating construction in thisjurisdiction. Thi's permit becomes null
and void if work is not commenced within six(6)months, or if construction or work is suspended or abandonedfor a period of six�6)months at anytime after
work is commenced I understand that separate permits must be securedfor Electricar Work,Plumbing,Signs, Wells,Pools, Furnaces, Boilers,Heaters,
Tanks andAir Conditioners,etc.
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 FINANCING9 CONSULT WITH
YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT.
Ihere certify that I have read and exam ined th* plication and know the same to be true and correct. All provisions of laws and ordinqnces governing this
type ) workwillbecomp r I s ed herein or not. The granting of a permit does not presume to give authority to violate or cancel the
V, Vied with whethe elciral-i
provi.si.ons of any otherfederal,state, or localsf,w regulating construction or the pe�formance of construction.
Signature of Owne Signature of Contractor
Print Name Print Name IF................FPLtft,0
.... ....... .................................o............................................
........... . .........0.....................................................
............6.0 A
t10 iv I
Before me Before me
thig 11+1#Dav of Dr-_C0 16 4!5k 120 /Z this tq-!Y Day of 0C,I
" / $007TARMD
SWTT ARNOLD My COMMISSION 0 EE021610
MY COMIMISSION#EE 021610 i EAPHIES:DOW
Notary Public R Notar�Yublic Bonded Thru Notary Public Unden~
EXPIRES:December 27,2014
----Kevise 1:26.10
Bonded Thru Notary N*Urder~
7
NOTICE OF COMMENCEMENT FILE COPY7,.
(PREPARE IN DUPLICATE)
/�3— 3'5' 6.2— L
Permit No. Tax Folio NO.:,...��
State of FZZ— County of
To whom it may concern:
The undersigned hereby Infonns you that improvements will be made to certain real property,and in
accordance with Section 713 of the Florida Statutes,the following information is stated in ffs NOTICE OF
COMMENCEMENT.
Legal description of property being improved: 57� TL-411,17-Z6.
Address of property being improved.
General clescAption of improvements:
Owner 460f—k
Address
Owner's interest in site of the improvement
Fee Simple Titleholder(if other than owner)
Name
JAddress
intractor T- Sep-016E Wz—"
'�-'4 X F, 2_2
Address L
honeNo. ___Fax No. V6 J
t t
y(if any)
Address Amount of bond
Phone 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
documents may be served:
Name—
Address
Phone 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 Statutes.(Fill in at Owner's option).
Name
Address
Phone No. Fax No.
Expiration date of Notice&Commencement(the expiration date Is one(1)year from the date of recording unless a
different da!e Is specified):
THIS SPACE FOR-JR—ECORDEWSUSE ONLY OWNER
Signed: DATE
Before Me...1s day of-"---
Court f Duval,Sta ,af Fknida has personally appeared
YOA/ h rein by
II
Doc#2013270485,OR BK 16569 Page 1347, himself/harselfanoi affirms that all statements and declarations herelin
Number Pages: 1 are ftue and accurate
Recorded 10/22/2013 at 03:34 PM,
SCOTTARNOLD
Ronnie Fussell CLERK CIRCUIT COURT DUVAL OMMISSION#EE 021610
-5 A Myc
COUNTY pj EXPIRES:December 27,2014
County of
RECORDING$10-00 14.t-�ry4 unty of Bonded Thru Notary Public Underwriters
No Public at Large,State of
m, "'mrrrissio
y oomrnission explres:
Personally Knovn —or
Produred Identification
FC
OCT 2 2 2013 FILE COPYro
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FILE- COPY
_7.
-Open Area 38.79in'
.1APM0 Listed Flow Rates: 1) 25506-320-010 Sump Body
.For 2.5"'plumbing using two outer ports 2) 25520-050-020 2"NPT Plug
308GPM(Floor)&212GPM(Wall) 3) 25506-320-030 Debris Guard
-For 2.5" plumbing using center port only= 4) 25506-320-020 32-Cover
200GPM(Floor)& 168GPM(Wall) 5) 61008-042-022 Screw
Tor 2"plumbing using two outer ports=
268GPM(Floor)& 192GPM(Wall)
Tor 2"plumbing using center port only=
184GPM(Floor)& 176GPM(Wall)
Part Numbers.
25506-320-000 32"Channel Drain wlSump, White
25506-321-000 32"Channel Drain wlSump, Gray
25506-324-000 32"Channel Drain wlSump,Black
T-
25506-327-000 32"Channel Drain wlSump,Dark Gray : 11 -_ t
25506-329-000 32"Channel Drain wlSump, Tan
25506-320-100 32"Channel Drain w/Frame, White
25506-321-100 32"Channel Drain wlFrame, Gray
25506-324-100 32"Channel Drain wlFrame, Black
25506-327-100 32"Channel Drain wlFrame,Dark Gray
25506-329-100 32"Channel Drain wlFrame, Tan
1) 25506-320-110 Frame
2) 25506-320-120 Frame Support
3) 25506-320-020 32"Cover
4) 61008-042-022 Screw
LA 0 Custom Molded Products, Inc.
Foil Free:800.733.9060 or visit us online at www.c-m-p.com
Contact us for details about our complete jine of pool,spa&.vhirlDooi both componentsH
02/11zV
SuperFIO' High Performance Pump
When outfitting your new pool or
looking for a superior replacement for a
Hayward'Super Pump�SuperFlo drops
right into place with ease to minimize
installation time and expens
Heavy-duty motor for long set-vice life
Superior hydr,11.1lic design and
thick-walled body parts deliver
super-qUiet operation.
The strong, silent type
The SuperFloO high performance pump meets all the criteria Performance Curves
for a superior pool,spa or water feature pump. It's super 110- 3450 RPM
energy-efficient super quiet and super easy to maintain. Plus, 35 2'A HP High Speed
2 HP High Speed
it's designed with innovative materials that will stand up to the I'A HP High Speed
30- 100- 1 HP High Speed
S2 I
d
most demanding installations and conditions. Whether you're 25 1/1 1jE1 R&Ob 2e
choosing your first pump or replacing older technology, 80-
Super-Flo is definitely a super choice. M-0 20
r 060-
S 14
• Self-priming for quick,easy start-up.
40
10- Low Speed
• 115-volt or 230-voit models available. 1750 RPM
20
• Performance and pressure tested to ensure superior quality. 5
• UUCUUNSF certified. 20 40 60 80 100 120 140 160
U.S.Gallons per minute
• One-year limited warranty See warranty for details. 'I 1 5 1
5 10 20 25 30
CuNc MLters per hour
Available from:
Pentair
7
Pool Products'
Because reliability matters most
www.pentairpool.com
-831-7133
Phone:800
pumps filters heaters heat pumps automation lighting cleaners sanitizers/water features maintenance products
8/09 Part#P 1-232 (�� �& S @2009 Pentair Water Pool and Spa,Inc.All rights reserved.
Clean Clear
Cartridge Filter
Clamp ring for safe and quick
access to cartridges
Single-piece fiberglass reinforced
polypropylene tank for strength
and corrosion resistance
Easy access 1'/2"drain
2"plumbing for maximum flow
Model Filter Vertical Filter Flow Rate GPM Turnover Capacity-Res.(Gallons)
Number Area Sq.Ft. Clearance* Diameter Res." Com. 8 hirs. 10 hirs. 12 hirs.
cc so so 30" 15.51, 50 19 24,000 30,000 36,000
CC 75 75 39" 15.51, 75 28 36,000 45,000 54,000
cc 100 100 61" 15.51, 100 38 48,000 60,000 72,000
rc—cl so ISO 76" 15.5, 1 ISO 1 56 72,000 t 90,000 108,000
CC 200 200 76" 15.51, 1 150 75 72,000 90,000 �l 008,000
Required clearance to remove flIter elements.
Maximum flow rate.
Carefree. . .by design
Like all PentairWater Pool and Spe cartridge filters,the * 2" plumbing for maximum flow.
Clean&Clear�filter features an easily-cleaned cartridge * Single piece base and body designed for maximum
for the ultimate in carefree pool filtration.The fiberglass- durability.
reinforced tank halves are secured with an innovative * One-year limited warranty. See warranty for details.
clamp ring—just loosen the ring and remove the top half
for easy carthdge access and rinsing. Filter maintenance Available from:
doesn't get any easier
• IY2"drain and washout for quick and convenient
maintenance and winterization.
• Innovative lock-ring requires only half of a revolution
T.�
n.:
for a safe,leak-proof seal.
> Pentair
Pool Products'
Because reliability matters most
www.pentairpool.com
Phone:800-831-7133
pumps filters heaters heat pumps Y automation lighting cleaners /sanitizers/water features/maintenance products
3/11 Part#Pl-121 (�� @2011 Pentair Water Pool and Spa,Inc.All rights reserved.
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WOTT'S POOL SEA VWA
10549 SURFUS DR.
JAX FLA. 32225
CP0015231
W44415M
city of Atlantic Beach APPLICA71ON NUMBER
Building Deparbrient (ro be assigned by the Building DeparbmnLy'
8W Seminole Road
/3
Atlantic Beach,Florida 32233-5445
7. Phone(904)247-W26 - Fax(904)247-5845
E-mail. buikring-ftt@coab.us Date routed:
City vmb-site: http:/AA&vw.coab.US
APPLICATION REVIEW AND TRACKING FORM
Property Address: 0 review req 1 No
&Zoning
Applicant: �5(2 ,o 7/-5 WratDr
-Z./? Qr�l Pubk W2jr
Project: =b0c
Pub rsaw—
Fire Services
Dept Signshire
Review fee
Review or Receipt
Other Agency Review or Pernift Required of Pernilt Vwffied By Date
Florida Dept of Environmental Protection
--�Iorfda 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
APPLJCATION STATUS
Reviewing Department Fimit Review: B�proved. [:]Denied.
(Circle one.) Commenits:
�U I L�Dl�NG
PLANNING &ZONING RevW*-ed by.
TREE ADMIN. Second Review: 04proved as revised. []Denfe'7d.
PU13LIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by- Date:
FIRE SERVICES Third Review: OApproved as revised. E]Denied.
CoMments:
Reviewed by: Date:
Revised 05114109
city Of Atlantic Beach APPLICATION NUMIJIzK
Cro be ankined by the Bwlft DqwbnenL)
Building Departrnent
43 8W Seminole Road 2-
Atlantic Beach,Florida 32233-640
Phone(904)247-W26 - Fax(904)247-5M Date muted:
E-mait buV1ng4qA@coab.uS
CiV"b-s": ":/Mvw.coab.uS
APPLICATION REVIEW AND TRACVJNG FORM
Property Address: QqWM!wnt review reguired Yes No
bul
Applicant ��o 0715 'P6615 &Zoning
Project 2) —1)o er L Public Works
FBW_UbW"
Fire Services
'Review fee $ Dept SignaJm rie
Review or Receipt Date
Other Agency Review or Permit Required Of Permit Ve~By
Florida Dept of Environmental Protection
Florida Dept of Transportation
FSt.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and ResWurants
Division of Alcoholic Beverages and Tobacco
0ther—
APPLICAPON STATUS
Reviewing Department First Review: 0A�proved. E]Denied.
F,
(Circle one.) ornments:
rc=
BUILDING
PLANNING&ZONING RevW**ed by, Aa,,.cb J2��Date: lblalll
TREE ADMIN. /F�Denled.
Second Review: E]Approved as revised.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed Date:
FIRE SERVICES Third Review: [IlApproved as revised. [:]Denied.
Comments:
ReViewed b Wte:
Revised OSM4109
city of Atlantic Eleach APPLI
Building Department (To be assigned by the Building Depxbwd)
8W Seminole Road 2—
Atlantic Beach,Florlda 3VA3-640
14)247-5M '- FAX(904)247-M5
Phone(9C iVing-dept@coab.us Date muled- /z4,/9?c;2
E-mait bu
Cq vmb-site: ":/Mw.coab-us
APPLICATION REVIEW AND TRACKING FORM
Property Address: C�6 JCM,6� ent I review required Yes No
anning&Zoning
Applicant Pr
T�-- �-' r
PublIeWoft
Project IvAkl z) ef Ffd8IkY1UbIIB69------.
Fire Services
fed Dep�Signatuie
Review or Receipt
Other Agency Review or Permit Required of Permit Vwifted By Date
Florida Dept of Environrnental Protection
Florida Dept of Transportation
St.Johns River Water Management Distrid
Army Corps of Engineers
Division of Hotels and Restaurants
DhAsion of Alcoholic Beverages and Tobacco
F�ie7r
APPLICATION STATUS
Reviewing Department Fimt Review: 4PApproved. FIDenied.
(Circle one.) Comments:
BUILDING
PLANNING&ZONING Reviewed by. DaW.
TREE ADMIN. Second Review: [3Approved as revised. []Denled.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by- Date:-
FIRE SERVICES Third Review: ElApproved as revised. E]Denied.
comments:
Reviewed br. OM:
RrA"dOV14W
city of Atlantic Beach APPUCATION NUMM11
t Cro be assignW by the Buadingl Dqm"enL)
Building Deparbnen
aw Seminole Road
Atlantic:Beach,Florida 322334445
Phone(W4)247-W26 Fox(904)247-89845
Date Muled: L,4
E-mait bufl&1ng4ept@ooab.us
City web-site: http:/ANWW-coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: -R&mwiment.review required Yes No
M
Applicant: &Zoning
ktor
Project Public WockS__:-_>
LOLW—M—M W–'--
Fire Senrices
$ Dept S' natu*_'�_)-
Review fed 19
Review or Rweipt Date
Other Agency Review or Permit Required of Permft Verified 8
_y
Florida Dept of ErMronmental Protection
-�I—oflda Dept of TransportaMon
St.Johns River Wc-der Management District
Army Corps of Engineers
Division of Hotels and Restaurants
DhAsion of Alcoholic Beverages and Tobacco I
—0t h—er - I
APPLICATION STATUS
Reviewing Department First Review: 1��kpproved. [-]Denied.
(Circle one.) Comments:
BUILDING
PLANNING&ZONING RevW*-ed by.
TREE ADMIN. Second Review: 0Approved as revised. E313enfed.
qj ;ORKeS Comments:
B TILITIES
Reviewed Date:
PUBLIC SAFW
FIRE SER\ACES Third Review: []�Approved as revised. E]Denied.
Comments:
ReViewed b . Date:
Fzevised 004M9
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
C 1A
Application Number . . . . . 13-00003562 Date 1/14/14
Property Address . . . . . . 96 OCEAN BLVD
Application type description SWIMMING POOL/SPA
Property Zoning . . . . . . . RES GEN MF DISTRICT
Application valuation . . . . 25000 -----------------------
-----------------------------------------------------
Application desc
new inground pool -----------------------
-----------------------------------------------------
Owner Contractor
------------------------
SCOTTS POOL SERVICE INC
BORDERS, RONALD 10549 BURRIS DR
8 SPARWHEEL LN FL 32225
HILTON HEAD ISL SC 29928 JACKSONVILLE
-- -------------------------------------------------------------------------
Permit . . . . . . ELECTRICAL PERMIT
Additional desc - -
Sub Contractor . . BEACHES ELECTRIC SERVICES INC.
Permit Fee . . . . 95 . 00 Plan Check Fee . 00
Issue Date . . . . valuation . . . . 0
Expiration Date . . 7/13/14 -----------------------
----------------------------------------------------
Special Notes and Comments
POOL - Wellpoint (if used) must discharge into vegetated
area 10 , minimum from street or drainage feature (swale,
structure or lagoon) .
2010 FLORIDA BUILDING CODE, 2008 NATIONAl ELECTRIC CODE
REQUIRED INSPECTIONS :
*POOL STEEL
*ELECTRICAL GROUNDING AND BONDING
*FINAL (PUMPS MUST BE RUNNING FOR FINAL)
SWIMMING POOL SAFETY INSPECTION REQUIRED -------
2 . 00
Other Fees . . . . . . . . . STATE ELEC DCA SURCHARGE
STATE ELEC DBPR SURCHARGE 2 . 00
------------------ ---------------------------------------------Due
Fee summary Charged Paid Credited
----------------- ---------- ---------- ---------- ----------
Permit Fee Total 95 . 00 9S . 00 . 00 . 00
Plan Check Total . 00 . 00 . 00 . 00
Other Fee Total 4 . 00 4 . 00 . 00 . 00
Grand Total 99 . 00 99 . 00 . 00 . 00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
ELECTRICAL PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Rd, Atlantic Beach, FL 32233
Ph(904)247-5826 Fax (904)247-5845
JOB ADDRESS: ck'ecl'r\ -8 J, , PERMIT
JEA INFORMATION REQUIRED ON ALL PERMITS AMPS VOLTS PHASE
VALUE OF WORK$
NEW SERVICE 0 Overhead [:1 Underground DUnderground up Pole
LiResidential(Main) Service
E10-100 amps 0 101-1 50amps 0 151-200amps O_amps #of Meters
OCommercial(Main) Service OCT Service amps
00-100 amps El 101-150amps 0 151-200amps ._amps
Conductor Type Size
DMulti-Family(Main)Service
E10-100 amps 0 10 1-1 50amps 11 151-200amps amps #of Unit Meters
El Temporary Pole El amps
SERVICE UPGRADE [I_ai-nps El CT Service amps
NEW FEEDER(ADDITIONS,ACCESSORY STRUCTURES,ETC.)
E1100amps L1150amps 0200amps El amps OCT Service amps
ADDITIONS,REMODELS,REPAIRS,BUILD-OUTS,ACCESSORY STRUCTURES,ETC.
Outlets/Switches: 0-30amps 31-100amps 10 1-200amps
Appliances: 0-30amps 31-100amps 101-200amps
A/C Circuits: 0-60amps 6 1-I 00amps
Heat Circuits: # circuits @ kw
Number of Lighting Outlets, Including Fixtures:
OTHER ELECTRICAL PROJECTS
OSwimmingPool [] Sign OSmoke Detectors_Qty []Transformers KVA OMotors hp
FIRE ALARM SYSTEM (Requires 3 sets of plans)
Qty_volts/amps VALUE OF WORK$
REPAIRS[MISCELLANEOUS
0 Replace Burnt/Damaged Meter Can 0 Safety Inspection Ei Panel Change Li OH to UG
N451'her:
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 ordinances 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
Electrical Company 12>4Z0'Q-kr"'e'5 &CCA U C—VTFffice Phone (oZCj —1(?)-fax—
'? -R zip 32 o%/ ?
Co.Address: , city GC state co 7
License Holder(Print): Lj ertification/Registration
I —
Notarized Signature of License Holder Cl-.,,,; -pi-"
i -- efore me this_day 4 20
ENMFER WAVER
MY COMMISSION#FF 011480
Al
-017
EXPIRES:April 24i 2 ignature of Notary Public
Bonded Thru Notary Pubic Undewi