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88 Nicole Ln 2015 Screen room CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD J ;r ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 RESIDENTIAL ADDITION MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-SB14 JOB INFORMATION: ]Ob ID: 15-SCRN-132 Job Type: SCREENED ENCLOSURE Description: REMOVE EXISTING, ENLARGE PATIO, NEW SCRN ENCLOSURE Estimated Value: $6,000.00 Issue Date: 2/11/2015 Expiration Date: 8/10/2015 PROPERTY ADDRESS: Address: 88 NICOLE LN RE Number: 169519-0715 PROPERTY OWNER: Name: PEARLMUTTER, NEIL S Address: 88 NICOLE LN GENERAL CONTRACTOR INFORMATION: Name: TROPICAL ENCLOSURES BY MASTER Address: 4411 KELNEPA DR QA SCOTT RAY NORTON Phone: - - PERMIT INFORMATION: PUBLIC WORKS: Roll off container company must be on City approved list and container cannot be placed on City Right-of-Way. (Approved: Advanced Disposal, Realco Recycling, Republic Services, Shapell's and Waste Pro.) Full erosion control measures must be installed and approved prior to beginning any earth disturbing activities. Contact Public Works (247-5834) for Erosion and Sediment Control Inspection prior to start of construction. FEES: ENG REV RESIDENTIAL BLD $25.00 PLAN CHECK FEES $40.00 UTIL REV RESIDENTIAL BLDG $25.00 BUILDING PERMIT FEE $80.00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. CITY OF ATLANTIC BEACH S 800 SEMINOLE ROAD J ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 �~ r STATE DCA SURCHARGE $2.00 STATE DBPR SURCHARGE $2.00 Total Payments: $174.00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. 2 , BUILDING PERMIT APPLICATION CITY OF ATLANTIC BEACH JAN 16 800 Seminole Road,Atlantic Beach, FL 32233 Office (904)247-5826 Fax (904) 247-5845 By Job Address: �� /� tT(�UCQ G..� . �C Permit Number: 015-5cl?IV �- Legal Description L4 ( Ti�K losi 4e .Qe� Parcel # For a o q.Ft. t Valuation of Work$� w Proposed Work heated/cooled non-heated/cooled Class of Work(circle one): New <2dditio Alteration Repair Move Demolition pool/spa window/door Use of existing/proposed structure(s) (circle one): Commercial Residential F - If an existing structure,is a fire sprinkler system installed? (Circle one): Yes No N;/ Florida Product Approval# OPY For multiple products use product ap TOrm FILE C Describe in detail the type of work to be performed: maV2 ext' inq OtAd CWS uc� �' new sc.1,ePhc`asc4r1e Propertv Owner Information: Name: ea ( OLnd K44tL1w 4Add ress: City fx fn. StateIR-Zip ' 33 Phone s`4? —9$77 E-Mail or Fax#(Optional) Contractor Information: CONTRACTOR EMAIL ADDRESS: ,V rCr�ComPanY Name � 2nCjoSG� �u al L*fying Agent: .Sc044-xr)o P_ Address.W60 W4,66 C City -jo-y- State l Zip 7224-5 Office PhoneJob Site/Contact Number 571/-S'3// Fax# 9,99 3yp-o 31 State Certification/Registration# 5 cc t.$( (S"D 28I' 13 Architect Name&Phone# Engineer's Name&Phone# Fee Simple Title Holder Name and Address Bonding Company Name and Address Mortgage Lender Name and Address Application 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 period of six_(6)months at any time after work is commenced. I understand that separate permits must be secured for Electrical Work, Plumbing,Signs, Wells,Pools, Furnaces,Boilers,Heaters, Tanks and Air 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 FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type o work will be coma.. lied with whether specified herein or not. The granting of a permit does not presume to gi e authority to violate or cancel the arovisions of anor local law regulating construction or the performance of construction. 3i ature of .. _;e, // Signature of Contract Tint Name l ...... .... .. ..... ../V .............. Print Name �oPL c 3efore me Before me his D'y of 20 this 16 Day of 20 $� Zot y vuytKEVIN WAYNE NEWSOME t KEVI WAYNE NEWS Qi MY COMMISSION#EE108253 °, +'! 'MY Comm1I9 SION# E108253 ` AX61ed 1.26.10 EXPIRES June 30,2015 �'' EXPIRES June 30, =;mora.••• �;le• � (407);, 0153-°- -=klorfdalloteiYSeiilfce.CAr11 v.. _asp c .r • .c .__^-- FILE COPY ., TIFFANY BY THE SEA HOMEOWNERS ASSOCIATION 920 3rd STREET, SUITE - �E NEPTUNE BEACH, FLORIDA 32266 (904) 242-0666 January 13, 2015 VIA EMAIL: NEILSPERL@YAHOO.COM VIA EMAIL: TROPICALENCLOSURES@GMAIL.COM Neil and Kathryn Perlmutter 88 Nicole Lane Atlantic Beach, FL 32233 Re: Lot # 1 ® Screen Enclosure Enlargement APPROVAL Dear Mr. and Mrs. Perlmutter: This letter will serve as approval of your request to enlarge your existing screen enclosure per your submittal, the attached survey and drawings. It is understood that the enclosure will match the color and contour of the existing house. Per the Covenants and Restrictions, "no structure or other improvement or change in the topography of the land shall be erected or made which interferes in respect with drainage or utility easements shown on the subdivision plat." The homeowner is responsible for obtaining necessary permitting and approvals. Please forward a copy of the permits to this office for your file. Please note this approval is subject to all code and legal compliance with City, County, and State agency approvals, if necessary. This letter will be placed in your file for future reference. TIFFANY BY THE SEA HOMEOWNERS ASSOCIATION Attachments: As stated cc: Board of Directors i MAPO SHOWI NG SU EY OF. LOT 1, TIFFANY BY THE SEA, AS RECORDED IN PLAT BOOK 46, PAGES 94 AND 94A OF THE CURRENT PUBLIC RECORDS OF DUVAL COUNTY, FLOR]&A- 3 I NICOLE LAN E o PARCEL "B" PRIVATE STREET 40' RIGHT-OF-WAY ,0 ,Z���� N 89'46'20"E 34.27' \ J OHO CJ ,yD4j w (N89'47'37"E 34.36' FIELD) U G� << FOUND 1/2" IRON FOUND 1/2" IRON f—'0 PIPE (R 4144) PIPE (L9 3672) t, \ W — — z 7.5' JEA CONCRETE p��4j O OO,OO EASEMENT DRIVE c., Q, 00 �x Q CLEANOUT 21.2' 39 00 ui a :D Nva 0 o Q a I o COVERED (n Z d Lq w Q 3 z ENTRANCE w < o w 19.2 ' O Z O.4.4' G' U 0. 0 _ �� o y J 4.0 .%' r LI LOT 2 o N o Z6 h V; 0 1.s' 1.t' W N V L L liJ r o 1.2' Lr) ,. 14c' F- ,� 5.o I o -t O r �' w F i 4' WOAD FENCEoo 4 cr 0 -, - � z _ o z w 19:3' ? a 0.2p O N CO o x 1E z �� N z W A CONCRETE1Ytgc� WALK i N Z Z' r 1.T 6' WOOD F CE 0.7'\. FOUND 4"X4" CONCRETE MONUMENT (NO ID) S89'46'20"W (S89'34'42"W 59 " OFFICIAL NOTES: 1, THIS IS A BOUNDARY SURVEY 2. NO BUILDING RESTRICTION ' FILE COPY AFFIDAVIT FOR ATTACHING A NEW STRUCTURE TO AN EXISTING STRUCTURE TO: Building Inspection Department, City of Atlantic Beach, 800 Seminole Road Home Owner: W q; l &" KA en(,A -lav, tm to t kA Name 9 g .0 6o li n . Street Add ess City. State and Zip Code Contractor:,---S0'2' Y'1 //=J 0 tz ' -;' ` Permit Number 15;-' --5C 2 Al— l 3 As the Contractor for the proposed new structure located at the above address,I have personally viewed with the above named home owner those portions of the existing structure on which portions of the proposed new structure are to be attached for structural support. I am confident that the drawings and details included with this pen-nit application depict the existing conditions of the host structure, and the members of the existing structure upon which the new structure are to be attached are sound with no rot or deterioration. The home owner has been advised by me that, in my best judgment based on experience and knowledge of structural adequacy, the members of the existing structure upon which the new structure are to be attached are sound with no rot or deterioration and will support all structural loads and forces imposed on them. By signing below, I hereby declare that I will hold the City of Atlantic Beach harmless and release it from any responsibility and liability for any adverse consequences or failures resulting from this work, and further that I will not initiate, execute or enjoin any legal action against the City of Atlantic Beach for such consequences or failures. A copy of this document will be recorded as an official record with the Building Inspection Department permit history so that any and all future buyers/owners of this property may be made aware of the st s of work performed on this structure. Signed Date / l /1 / IS'--' Before me this _day of In the County of Duval, State of Florida,has rersonally appeared "SC-0 �J— Jv'5 to� ` herein by himself/herself and Affirms all state ents a declarations herein are true and accurate. ;.... KEVIN WAYNE NEWSOfNE MY COMMISSION#EE108253 EXPIRES June 30,2015 (4G43n 1'3 Floridallotaryservice.com Not ublic at Ldrge, State of FL , County of Ltv ®` Personally Known ✓Produced Identification ID Type F:building/affidavit for attaching a new structure to an existing structure.docx 7/21/09 J, FILEC HOMEOWNER SUNROOM ENCLOSURE AFFIDAVIT The purpose of tNs document is to make you aware of any limitations in the enclosure that is being permitted at your residence. The table below, Sunroom and Screen Enclosure Requirements provides a brief description of the various sunroom category requirements. There may restrictions on the use of your present home depending on the category. Of Sunroom you are installing. The property owner is hereby notified that should they make changes to the sunroom which could include, but not be limited to, addition of any form of temperature control system or removal of the doors/windows separating the sunroom from the host structure,'the room may become non-.compliant with the requirements as mandated by the Florida Building.Code, the Florida Model Ehergy:Code and State Statutes. _ OWNER 6have read Ihis compl�le�form ane ,land i ani receiv+inpcategory: I Sunroorn.((I-VV) ` /� (�� �, Printed Name v` -- � u`Y"" Address,08 lV f�.,p l`— �..h' • A' l . f 3cA, igncd: VW-- — ate: I I licforc me Ihis-_/_4_____day of �0 _in Cout al tate of Florida,has personally appeared _' 4rcih "4 rein by himselr/herself and afrirms all statements and declarations herein are true and accurate. Q�� uu; Notary public❑I Large,Stale of_i' _.County of tfKEVIN WAYNE NEWSOME Personally Knownor Produced Idenlifrcat'iun❑ 3,• Y COMMISSION#EE108253 u> ryp -. ... . ....- -- ---- - - --- - --- -------- ----- --- - ---- =•„r,�---E”- 3ES June 30.2015 (407)39M153 FloddallotaryService.com St)nroom and Screen Enclosure Requirements Category II Ill. IV V _ Habitable Space No No No Yes Yes Foundation Walls <200plf Walls-<200plf Walls<200plf can Walls e,200plf Walls <200plf can can have can have` have 8"Wx12"D ftg can have have 8"Wx12"D ftg 8"Wx12"D ftg or 8"Wxl2"D ftg or or 3-1/2"slab if no 8"Wx12"D ftg 3-1/2" slab if no 3-1/2"slab if no concentrated load concentrated concentrated >750lb load>7501b load>750lb" Existing exterior Relocate to Relocate to Relocate to Relocate to Relocate to GFI Breaker exterior if exterior if exterior if enclosed exterior if exterior if enclosed enclosed enclosed enclosed Exit Lighting Not Required Required .Required Required Required Interior Electric Not Required Not Required Not Required Required Required Outlets_ Emergency Egress from Egress and Exit Egress and Exit Egress and Egress and Exit Escape exist. structure must meet code must meet code. Exit must meet must meet code. Openings allowed if open to code. atmosphere and has screen door leading away from residence. Misc. Window Host structure Windows must Windows may be. Host structure Host structure and Door windows/doors be removable fixed or windows & windows& doors Requirements shall not 15 . Host structure. removable. Host " doors shall not may be removed. removed. windows/doors structure windows be removed. Forced entry,air shall not be and doors shall not Forced entry, leakage and water removed. be removed. air leakage penetration Forced entry, air and water requirements leakage and water penetration apply. penetration requirements requirements apply. apply.. Wind BorneNotif Required, Required, can be .Required Debris Opening unless built on host structure, Not Required Not Required host structure is Protection under an if built under protected existing roof existing roof Energy Sheets Not Required Not Required Not Required Required Required TIFFANY BY THE SEA HOMEOWNERS ASSOCIATION 920 3rd STREET, SUITE B NEPTUNE BEACH, FLORIDA 32266 (904) 242-0666 January 13, 2015 VIA EMAIL: NEILSPERL@YAHOO.COM VIA EMAIL:TROPICALENCLOSURESC-GMAIL.COM Neil and Kathryn Perlmutter 88 Nicole Lane Atlantic Beach, FL 32233 Re: Lot # 1 ® Screen Enclosure Enlargement APPROVAL Dear Mr. and Mrs. Perlmutter: This letter will serve as approval of your request to enlarge your existing screen enclosure per your submittal, the attached survey and drawings. It is understood that the enclosure will match the color and contour of the existing house. Per the Covenants and Restrictions, `ono structure or other improvement or change in the topography of the land shall be erected or made which interferes in respect with drainage or utility easements shown on the subdivision plat." The homeowner is responsible for obtaining necessary permitting and approvals. Please forward a copy of the permits to this office for your file. Please note this approval is subject to all code and legal compliance with City, County, and State agency approvals, if necessary. This letter will be placed in your file for future reference. TIFFANY BY THE SEA HOMEOWNERS ASSOCIATION Attachments: As stated cc: Board of Directors Yt Lrr�+ City of Atlantic Beach APPLICATION NUMBER (To be assigned by the Building Department.) Building Department /� I 800 Seminole Road i Atlantic Beach, Florida 32233-5445 1 Phone(904) 247-5826 Fax(904)247-5845 Date routed: E-mail: building-dept@coab.us City web-site: http://www.coab.us APPLICATION REVIEW AND TRACKING FORM N L v ent review required Yes No Property Address: 1� E� Planning&Zoning Applicant: � Tre inistrator S1, p orks �I 1Project:PN ON-C lam'`'^ i Pu is i i ies 1 1 Z P a:H(0 VCA Pub is vel \j �„r� c� S 1 Fire Services �1 5 �.` Review fee $ Dept Signature Review or Receipt Date Other Agency Review or Permit Required of Permit Verified By 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: Approved. Denied. (Circle one.) Comments: /t ,D 6- BUILDING v PLANNING &ZONING Reviewed by: Date: 3 �� TREE ADMIN. Second Review: ❑Approved as revised. ❑Deni PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied. Comments: Reviewed by: Date-.- Revised ate:Revised 07/27/10 -_.4 APPLICATION NUMBER "s,AV ;'Ji City of Atlantic Beach T Building Department I�. (To be assigned by the Building Department.) 800 Seminole Road J r n Atlantic Beach, Florida 32233-5445 2015 Phone(904) 247-5826 Fax(904)247-5845 1 7i3 E-mail: building-dept@coab.us Date routed: City web-site: http://www.coab.us �f APPLICATION REVIEW AND TRACKING FORM gC� l.Yv ent review required Yes No Property Address: �lcaj � lJl� yJ Planning &Zoning Applicant: Tre inistrator Project:Re��� SGr "Po P blic orks P� � S'C4(0 Pubic ies C/czn Fire Services Review fee $ S— Dept Signature I& Other Agency Review or Permit Required Review or Receipt Dateof Permit Verified By 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: Approved. ❑Denied. (Circle one.) Comments: BUILDING PLANNING &ZONING Reviewed by: Date: //Z& //,C::- TREE ADMIN. Second Review: ❑Approved as revised. [—]Denied- 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 X � —,, City of Atlantic Beach v'. --, APPLICATION NUMBER Building Department J � ' (To be assigned by the Building Department.) AN-2 2015 800 Seminole Road Atlantic Beach, Florida 32233-544 J' Phone(904)247-5826 Fax(904j 845 / E-mail: building-dept@coab.us — `�. _ Date routed: City web-site: http://\N"coab.us —_' APPLICATION REVIEW AND TRACKING FORM gC� � ,f� V� l.Yv Den, review required Yes No Property Address: �-p II � W� U,J aPlanning &Zoning Applicant: Tre inistrator P blic orks Project: e � SGY�, , 5'C -� 11 '' Pub is Pu 1c i i ies c/��'� S lJ� Fire Services Review fee $ — Dept Signat e Review or Receipt Date Other Agency Review or Permit Required of Permit Verified By 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 +l Reviewing Department First Review: Approved. ❑Denied. (Circle one.) Comments: BUILDING PLANNING &ZONING Reviewed by: abDate: TREE ADMIN. Second Review: [-]Approved as revised. ❑Denied. S Comments: C� (T/IES PUBLIC SAFET5 Reviewed by: Date: FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied. Comments: Reviewed by: Date: Revised 07/27/10 rt r1,y;. City of Atlantic Beach APPLICATION NUMBER Building Department (To be assigned by the Building Department.) 800 Seminole Road 15—C=►�/� a Atlantic Beach, Florida 32233-5445 Phone(904) 247-5826 Fax(904)247-5845 Date routed: : i ; E-mail: building-dept@coab.us City web-site: http://\wwcoab.us �. APPLICATION REVIEW AND TRACKING FORM (�C� 1��� U►�1 ent review required Yes No Property Address: E� �r �,J Planning &Zoning Applicant: Tre d inistrator P blic orks Project: Pu is i i ies (2-�n1 Gk P�-�-�6 S'CA(� Pubic � �,, '/ce/ryl!� Fire Services Review fee $ Dept Signature Review or Receipt Date Other Agency Review or Permit Required of Permit Verified By 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: XApproved. ❑Denied. (Circle one.) Comments: BUILDING PLANNING &ZONING Reviewed by:� C/ /� date: lS TREE ADMIN. Second Review- ''---Approved as revised. ❑Denied. PUBLIC WORKS Comments: PUBLIC UTILITIES Reviewed by: /`_ Date: PUBLIC SAFETY �J FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied. Comments: Reviewed by: Date: Revised 07/27/10 M A SH OWI N G SU EY OF: LOT 1, TIFFANY B PUBLIC RECORDSEOORDUVDIN PLAT AL COUNTY,,OFFLOR DAOK 46, PAGES 94 AND 94A OF THE CUREN NICOLE LAN E PARCEL "B" PRIVATE STREET 40' RIGHT-OF-WAY C CV O1 .° "S N 89'46'20"E 34.27' �� Off• w (N89'47'37"E 34.36' FIELD) UFOUND 1/2" IRON Q GAO ff�/�/ 7d FOUND 1/2 IRON �V i o PIPE (R 4144) � PIPE (L9 3672) — h 7.5' JEA CONCRETE O (6 0 0/ EASEMENT DRIVE 'OD �CQ O 1 O r r r ✓�// CLEANOUT 5 J z,.r 3 O w a U0 co w a O �QQ � vUi COVERED cf) Z < w 5 ENTRANCE Ci U 0 2' L wr O � 0 19.2' �'a� a ' OZ .oa2' n LOT 2 U) h. ? I-- w Li.I uO Z . Ni, G �� F N O LJ 4 v Q QU W a o 1.2' 5.0 _ M OJ yto 4' W0iuD FENCE Ljj r- 00 C14 3: O CJ V U'L Zw 19;3' Air• 10.2' \ 30 0 < U z O X � �z O Nm I �_ PfOPOSP� V�i ri W z CONCRETE �9126- r n 'D WALK V / N 2- CV CV 0' ' tV 0.7' 6' WOOD FENCE 1.T 6' W:.-CD F CE \ FOUND 1/2" IRON FOUND 4"X4" CONCRETE PIPE (LB 3672) MONUMENT (NO ID) S89046'20"W 59.27' (S89.34'42"W 59 21 FIELD) OFFICIAL RECORDS VOLUME 3459, PAGE 1066 NOTES: 1. THIS IS A BOUNDARY SURVEY. THIS SURVEY WAS MADE FOR THE BENEFIT OF orc7oirTln�l I INFS PER PLAT. nl n DPPI IRI It. NATIONAL PERMIT NUMBER _ _ TAX FOLIO N AMER NOTICE OF COMMENCEMENT FLORIDA STATUTE 713.13 J STATE OF FLORIDA ry o F- CC m � O EL �U The undersigned hereby gives notice that improvement will be made to certain real o m:5 property, and in accordance.with Chapter 713, Florida Statutes, the following informationM o is provided in the Notice of Comanencement: EY 16� o (O�ONJ O 1. Description of proper; : (legal description of thd.pi-operty, and "street address if available). CO 5 LO V) z n � o 2. General description of impro ement: L✓ewt �'1G OSIAfe- k Ct�lY1�Q N o af oA?z0 3. Owner Information: o E 00 o o w a. Name and address: c 1t.. ��z�x c)� L 3 Z 3 3 u �?l�o ca�E'_ 1�-+�T-- b. Interest in property: 6u,v�� , c. Name and address of fee simple titleholder(if other than owner): 4. Contractor(Name and address): p /�� a. Phone number: 7 i Z 35-6-:D b. Fax 5. Surety: a. Name and address: b. Phone number: c. Fax number: _ d. Amount of bond: $ 6. Lender: (Name and Address)' _ a. Phone number: T b. Fax number: 7. Persons .within the State of Florida designated by Owner upori whom notices or other documents may be served as provided in Section 713.13(1)(a) 7., Florida Statutes: (name and address)' a. Phone number: b. Fax number: 8, .In addition to himself, Owner designates of _ to receive a copy of the Lienor's Notice as provided in Section 713.13(1)(b), Florida Statutes. 9. Expiration date of notice of commencement (the expirali8n?date is one (1) year from the date of recording unless a different date is specified) S'' ature of Queer' Print Name Sw r tq for of d) and subscribed before me this 2 day of Ve— 20(jl by (Name of per making statement).