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523 SELVA LAKES CIR - PAVER PATIO 41 .. • , CITY OF ATLANTIC BEACH y 800 SEMINOLE ROAD N � t¢ ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 RESIDENTIAL ALT/OTHER MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814 JOB INFORMATION: Job ID: 16-DECK-1845 Job Type: DECK/PATIO Description: Paver Patios Estimated Value: $2,000.00 Issue Date: 8/30/2016 Expiration Date: 2/26/2017 PROPERTY ADDRESS: Address: 523 SELVA LAKES CIR RE Number: 172027-5504 PROPERTY OWNER: Name: Dewalt, Marcy Address: 523 Selva Lakes CIR PERMIT INFORMATION: UTILITY DEPT.: PUBLIC WORKS: Ensure all meter boxes, sewer cleanouts and valve covers are set to grade and visible. A sewer cleanout must be installed at the property line.Cleanout must be covered with an RT1 concrete box with metal lid. Cleanout to be set to grade and visible. 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. All runoff must remain on-site during construction. 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, Sunshine Recycling and Waste Pro). Full right-of-way restoration, including sod, is required. Any plan change must be submitted as a Revision to the Building Department. 14 PERMIT IS APPROVED ONLY IN ACCORDANCE WI III AL1, (.I I Y OF A I LAN I It. ULA(.II ORDINANCES AND THE FLORIDA BUILDING CODES. J\J riil . CITY OF ATLANTIC BEACH .f 800 SEMINOLE ROAD - r ATLANTIC BEACH,FL 32233 u INSPECTION PHONE LINE 247-5814 FEES: PLAN CHECK FEES $30.00 BUILDING PERMIT FEE $60.00 STATE DCA SURCHARGE $2.00 STATE DBPR SURCHARGE $2.00 Total Payments: $94.00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. ri Jy;, City of Atlantic Beach APPLICATION NUMBER e' ; :�5� Building Department (To be assigned by the Building Department.) 1 800 Seminole Road. E C E I i C` D e [[JJ �r . _, Atlantic Beach, Florda 32233-5445 -�"�: (� ` l e Phone(904)247-5826 • Fax(904) 5 5 �1G 15 2016 ______ � E-mail: building-dept@coab.us Date routed: City web-site: http://www.coab.us Li BY: APPLICATION REVIEW-AND TRACKING FORM Property Address: 523 SEC_VA LP K aa, Department review required Yes No Building Applicant: �1-)/��g.._ Ianninq &Zoni Tree Administrator Project: AVE 2c ( csublic Wor Public Utilitie ) • Public Safety Fire Services Review fee $ Dept Signature Other Agency Review or Permit Required Review or Receipt Date of Permit Verified By_ Florida Dept. of Environmental Protection Florida Dept.of Transportation St.Johns River Water Management District f Army Corps of Engineers Division of Hotels and Restaurants Division of Alcoholic Beverages and Tobacco Other: APPLICATION STATUS Reviewing Department I First Review: 'Approved.�J ❑Denied. �. ��-�6 (Circle one.) Comments: Joe '4 c4 & ,,d BUILDING PLANNING &ZONING Reviewed by: �/ Date: ��Ar r TREE ADMIN. Second Review: ❑Approved as revised. ❑De,.-d. PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied. Comments: Reviewed by: Date: Revised 05/14/09 ,,,:o—��! ,. City of Atlantic Beach APPLICATION NUMBER ' ! \) Building Department (To be assigned by the Building Department.) -. `i 800 Seminole Road I C` D G � CC T� '"� Atlantic Beach, Florida 32233-5445 Cts �`'t� ~ Phone(904)247-5826 • Fax(904) 247-5845 j;31�� E-mail: building-dept@coab.us Date routed: 7/t 3/ City web-site: http://www.coab.us APPLICATION REVIEW AND TRACKING FORM Property Address: 523 SELVA LAKE(7/ Department review required .Yes No Building Applicant: Ca0i\Dje_,... tannin &Zoning Tree Administrator Project: AVE "Public Wor s (-Public Utili ie Public Safety Fire Services Review fee $ Dept Signature Other Agency Review or Permit Required Review or Receipt Date 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: �pproved. I Denied. (Circle one.) Comments: BUILDING PLANNING & ZONING Reviewed by: 4/7/...--___- Date: S ir-O6 TREE ADMIN. Second Review: A roved as revised. ❑ pp ❑Denied. PUBLIC WORKS ' Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: nApproved as revised. ❑Denied. Comments: Reviewed by: Date: Revised 05/14/09 ;;rfa,�F�, City of Atlantic Beach APPLICATION NUMBER �s r Building Department (To be assigned by the Building Department.) • 800SeminoleRoad.5.,;0,. ._,,y„,,,. Atlantic Beach, Florida 32233-544 Phone(904)247-5826 • Fax(9fiECIVE 47- 1 5 c+ JR gr E-mail: building-dept@coab.us 2016 Date routed: a)/t S/I cc::, City web-site: http://www.coab.us BY:____ ___— APPLICATION REVIEW AND TRACKING FORM Property Address: 5 3 SCLVA LJ\K&CR_ Department review required Yes No p Building Applicant: � »� .._ Plannin1c &Zoni g j Tree Administrator Project: AVE2ublic Worcs C.ILiblic UtilitieS - Public a e y Fire Services Review fee $ igr Dept SigrinallallpillIM Other Agency Review or Permit Required Review or Receipt Date 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: APPLI ATION STATUS Reviewing Department First Review: pproved. ❑Denied. (Circle one.) Comments: BUILDING /u7//6 PLANNING &ZONING Reviewed by: h! �� Date: TREE ADMIN. Second Review: ❑Approved as revised. ['Denied.Co ments: i2 PUsRL UTILITIES / % PU LIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: ❑Approved as revised. DDenied. Comments: Reviewed by: Date: Revised 05/14/09 ,;1‘....A.,,./.,-,;.;\ BUILDING PERMIT APPLICATION :J• -S 1 - ' CITY OF ATLANTIC BEACH 800 Seminole Road,Atlantic Beach FL 32233 <I-` i'! " Office: (904)247-5826 • Fax: (904)247-5845 ' 6_0 Eco -1 845 Job Address: SZS S 'oL CO' j414,,E};`i t,t ci_ 322 3 Permit Number: Legal Description L{3-I` 11 -2S-29E Silva Lam\ O,A 2 RE# 1710 V7 5 D y Valuation of Work(Replacement Cost)$ ZO000-- �+ Sy ( p Heated/Cooled SF Non-heated/Cooled • Class of Work(Circle one): New Additio Alteration Repair Move P- 1,p• Pool Window/Door • Use of existing/proposed structure(s) (Circle one): Commercial 'esidentia • If an existing structure, is a fire sprinkler system installed?(Circle one): Yes 6. N/A • Submit a Tree Removal Permit Application if any trees are to be removed or Affidavit of No Tree Removal Describe in detail the type of work to be performed: A-00 iL C RA,o 1,— V co,r ✓k.r c) Florida Product Approval # for multiple products use product approval form Property Owner Information Name: ��r ./ �,Uo.1 ��Xsoi Address: Q-3 Se4e- LLes ar City �4(o.w k�er.,z_.1 State t-Zip 3Zz33 Phone q6q-2-uu-C.7?S E-Mail (- S7 57 e. (Aoo_ ems,.-. Owner or Agent (If Agent,Power of Attorney or Agency Letter Required) 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. Contractor Information: Name of Company: Quali '•: ' gent: Address: . , State Zip Office Phone Job Site/ • tact Number State Certification/Registration # E-Mail Architect Name& Phone# Engineer's Name &Phone# Worker's Compensation Exempt / Insurer / Lease Employees / Expiration Date Application is hereby made to obtain a permit to do the work and installations as indicated. 1 certib that no work or installation has commenced Thirior 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. s 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 1 understand that separate permits must be secured for Electrical Work,Plumbing, Signs, Wells,Pools,Furnaces,Boilers eaters, Tanks and Air Con, :loners,e . Signature of Prop- er: .dii ii %f /�/ `J ., i" r ,�p�?pp��l ��llll ppE__RGER Before me ._ ¢it.-tu �i Y cmilmibbluN ' this lZ�`Da of KS ga • / y;=>. ` ,„ 5:October 6,2019 - •" F ' "l� P;o!aryPubliicUndeMay• Notary Public: Q- ' - '� Notary Public: I 'hereby cert that I have read and examined this appli on and know the same to be true and correct. All provisions of laws and ordinances governing this type ofwork will be complie with whether specified herein or not. The grantin, of a permit does not lresume to give authority to violate or cancel the provisions of any other federal, state, or local law regulating construction or the 'erformance of construction. Rev.3/14/16 .ems. CITY OF ATLANTIC BEACH • '_' 11 WNER / 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 DIVE 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 EMPLOYED 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 DISCLOSURE STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN OWNER-BUILDER PERMIT. ADDRESZ3 lV4 Ita.IL€S0,f-,CilKt 1G -"Sta4i, IYL Tot/ Z3e- G7 75 ,� W' I �� 32233 PHONE NUMBER G 90.'\ P I T%•ME n Pb(/ g/4/ZOIC61T � DATE Before me this (Z , day of /31"1"-\ 20 D. in the county of Duval,State of Florida,has personally appeared herin by himself/herself and affirms that all statements and declarations are true and accurate. Notary Public at Large,State of FI— ,County of l VG. ❑Personally Known Aitibl '30 7 z D prProduced Identification-=Ir 0�?Y TONI GINOLESPERGER MY COMMISSION#FF 924951 Notary Signature: lairee '•-'� EXPIRES:October 6,20 19 ,,, `,.` Bended Thru Notary Publiic Underwnlers F:/BLDG/Owner-Builder Affadavit;REVISED:4/16/2009 if-Z-Z 3 Jekt Liar cr _ /4. -,lle e4- %K 1 .. I . z 2s _i. k / ;*- : / 90 i :NI %eat #42 X S4 ___. 1-> / di ii 9 fieed 4/444 ,.A _ 1 =-' etre) /fOr , / _ 7- Lin - . )0/ (1-64,, Ib f%2Q te 320 , Poopieilhas-1:0p /90 f 21 4 iv-Igo 1l4y1z ; 1y.2-- - WA 10 lei z .16 cze.2. sri .. babAkfra ie-r --`' hot at//‘ co,t Led ke g '? r i 7r J7 t ,.I I -_)! _ Q.7' 0.82 i 1sLi ! a \' 16 TS jail 4 LOT 0 1 E L ISCREENED - - ,. & CONC. PATIO o CONC., pi 5' 0 3ii0 5.r o eat° v. "aoO 4.5' c'1 8.51 3 (1) 7.5' Q) 1 A/cril PAO 12 I cci 2 STORY 2 STOR COQUINA STUCCOUNo 51 —2 NO 523 IH.9' 7.2• d 4ms• . lirs.• CONC. ky) A cl. sit Cco i /�) COLUMN 1 o V ' CONC. o { WAt�C 1 1.0' 71.2' 17.0' � ' 1.0' • 1. • 1 • - o a• '^'4 r ' ' 20.4, I . •1.2' CONC. { 4 - ; - DRIVE •. : CONC.- i .° _ a I ro • DRIVE : ' e . . - 3va a 1 4' I J P . .Q - ,I/2. +- • a .IRON PIPE EASEMENT l • ec-AGE L`� . .416 71 *a 4 IRON PIPE ca Et' P.R.C. S -0 �� 4 ? SQL VA 523 Selva Lakes Circle Paver Application Sq Ft Lot size 4340 Impervious Calculation House footprint and Patio 1511 Drive 323 Sidewalk 84 AC Pad 9 Impervious Subtotal 1927 75 Impervious Subtotal 1852 New Pavers Replace existing sidewalk w/pavers No impact to Impervious Clac New Rear Patio 12'x16' 120 Walk to new Patio 3'x10' 30 New Front Patio 5'x12' 60 Impervious Total 2062 Impervious as Percentage 47.50% Pervious as Percentage 52.50% Property Appraiser- Property Details Page 1 of 2 DEWALT MARCY Primary Site Address Official Record Book/Page Tile# 523 SELVA LAKES CIR 523 SELVA LAKES CIR 17308-00668 9417 ATLANTIC BEACH, FL 32233 Atlantic Beach FL 32233 523 SELVA LAKES CIR Property Detail Value Summary i RE# 172027-5504 2111.1.Cattitleil2016 In Proaress Tax District USD3 Value Method CAMA CAMA Proaerty Use 0100 Single Family Total Building Value $120,699.00 $134,937.00 #of Buildings 1 Extra Feature Value $2,295.00 $2,060.00 For full legal description see Land Value(Market) $75,000.00 $75,000.00 Legal Dem. Land&Legal section below Land Value(Aaric.) $0.00 $0.00 Subdivision 04274 SELVA LAKES UNIT 02 lust(Market)Value $197,994.00 $211,997.00 Totienme 4340- Assessed Value $197,994.00 $211,997.00 The sale of this property may result in higher property taxes.For more information go Cap DIff/Portabllity Amt $0.00/$0.00 $0.00/$0.00 to Save Our Homes and our Property Tax Estimator.'In Progress'property values, IMMO. #0.00 See below exemptions and other supporting information on this page are part of the working tax roll and are subject to change.Certified values listed in the Value Summary are those Taxable Value $197,994.00 See below certified in October,but may include any official changes made after certification Learn how the Property Appraiser's Office values orooerty. Extra Features 4 ` pt g ;Length al LPI Feature Code Feature Description Bldg. Width �Total Units Value 1 FPPR7 Fireplace Prefab 1 0 0 1 1.00 $832.00 2 1 SCPR2 Screen Porch I 1 118 10 180.00 $1,228.00 Land&Legal Land Legal LN I Qglg I Use Description Zoning Front Depth Category Land clang Land LN Legal Description Units Dike Value 1 43-11 17-2S-29E i 1 10100 iRES LD 3-7 UNITS PER APUD 38.00 115.00 Common 1.00 Lot $75,000.00 2 SELVA LAKES UNIT 2 3 LOT 54 Buildings Building 1 Building 1 Site Address Element Cale Detail [_ " L11 523 SELVA LAKES CIR Unit rAtlantic Beach FL 32233 Exterior Wall 16 16 Frame Stucco Roof Struct 3 3 Gable or Hip rJ --Building Type 0105-TOWNHOUSE Roofing Cover 3 3 Asph/Comp Shng In L Year Bulk 1987 Interior Wall 5 5 Drywall l• 1 Building Value $134,937.00 Int Flooring 12 12 Hardwood L - '-, Int Flooring 14 14 Carpet -J Gross Heated Effective Heating Fuel 4 4 Electric Tt.—...---1 Type Area Area Area ___ Heating Type 4 4 Forced-Ducted Base Area 812 i 812 1 812 Air Cond 13 3 Central Finished Open 89 I 0 27 Porch Element Code Finished 378 0 189 Garage Stories 1.000 Finished upper 774 774 735 Bedrooms 3.000 story 1 Baths 2.500 Total 2053 1586 1763 Rooms/Units 1.000 Property Record Card(PRC) The PRC accessed below reflects property details and values at the time of Tax Roll Certification in October of the year listed. 2015, 2014 http://apps.coj.net/pao_propertySearch/Basic/Detail.aspx?RE=1720275504 8/11/2016 SLVA LAKES HOMfQWNERS ASSOCIATION JLLOUEST FOR ARCHITEC'T'URAL APPROVAL • Ilix eyue$t thrum k to be completed by the Homeowner and submitted to the(ARC)prior to the commencement of work. DATERECEIVED BY ARC: /., , THIS SECTION TO BE COMPLETED BY HOMEOWNER Derr- 71L��f Lo 111:3 Haw _ 0_ ' I ► IN Lot N l Address: _ Z3 Stl.t.WasC;c. .AiltvAlc ,rt V2L33 Horne ,e: o- 64.6- Zo' 7 Other Ph -- Contractor l bat h it. _t7 v ,Mt lL_ W.-- Deatrtbe the Mwk to be door (i.e.ststesn room.addition.fence,prase door,siding,outdoor lights, exterior painting. roof nepeirs'r epl1acement.gutters.�� � etc.) - .i MItL , I 1 r,5c i tb.\ C y Slee---` - xr‘skil Nva <,xx l- ille.,A L `.) t�GJss\s :n 4CO'�� yOSLA Ne tI..pte.A3 , .a, \f'(...e) 411 -. ' ''''PaCN1 iNtte 40 Vet r?tN.c(A,N. c.4 et,s4 ha.n�i y 1 (caste W� �, Cep- a,�.ri.r y t N. SN ,1t. ,coo, ,c.ri.1 k\ri_.c10- Lo con: Attach a copy of ror survey,indicating the location of the work to be done. Describe Location: .Ct r* ink.A(a.4a __- Specifications: Attach a copy of the plans,drawing,picture.specifications(material,color,etc.) All exterior paint must meet SLA specifications.. Pun lase at Duvalnt rid Hardware,3'J St.South.Jacksonville Beach. Reference Selva Lakes stnadard. Egimateai date of c mpletion: q I 1 .'--7_ ♦OlFE: Owners are responsible for the conduct of the contractor. You are required to supervise the work being done. You are personall) responsible and liable kir any damage done to common property or adjacent property. When required by the City of Atlantic Beach you are roqdired to provide the AR 'wf � a copy of the building permit. 1 /' I i ! • Date: � /� A Homeowners Signature -� - Dane Approval IS.'S.'L Date Denied - -- [tet \ _ - ARC SiSAartltl(sl: -- _ 0)-Ay� TREE & VEGETATION AFFIDAVIT ri a* � City of Atlantic Beach "' Department of Community Development -,'iiPlanning&Zoning Division C—..71-01119>': � 800 Seminole Road Atlantic Beach,FL 32233 J'tl>>' (P)904 247-5800 (F)904 247-5845 PERMIT# SECTION I-APPLICANT INFORMATION r Owner(s) r Legal Authorized Agent* NAME OF APPLICANT Marcy DeWalt Nelson NAME OF COMPANY ADDRESS OF COMPANY 523 Selva Lakes Circle,Atlantic Beach,FL 32233 PHONE • 2386775 CELL EMAIL gn5757@yahoo.com CONTRACTOR CERTIFICATION NUMBER ATLBCH BUSINESS TAX RECEIPT NUMBER SECTION II-SITE INFORMATION STREET ADDRESS OF PROPERTY 523 Selva Lakes Circle,Atlantic Beach,FL 32233 If an address has not been assigned to this property,contact the AB Building Department at(904)247-5826 to request an address. LEGAL DESCRIPTION 43-11 17-2S-29E LOT 54 BLOCK SUBDIVISION Selva Lakes REAL ESTATE NUMBER 172027-5504 LOT OR PARCEL SIZE: 4340 SQ FT AC RESIDENTIAL X COMMERCIAL OTHER(SPECIFY) I affirm that I have reviewed the provisions of Chapter 23, "Protection of Trees and Native Vegetation"of the Municipal Code of Ordinances for the City of Atlantic Beach,FL and/or I have participated in a pre-application meeting with the Administrator of those regulations. Subsequently,I affirm that no regulated trees and no regulated vegetation will be damaged,destroyed and/or removed from the a e-descri ed or adjac rop ies in co/junction with this project. fi SIGNA R OF OWNER SIGNATURE OF OWNER Signed and sworn before me on thiiS day of ,2_0((ej,by State of I— ( County of 1::)(.7 ✓a\ Identification verified: I- 4 3a-54 7 z-9(a 0 Oath sworn: r Yes r No - 4 / „„ „�.yie . 70NI GINDLESPERGER 4i k;. MY COMMISSION Y FF 924951 Notary Signature Air w: EXPIRES:October 6,2019 -'.?y Bonded ThruNotary Put*Unde^"rten My Commission expires: REV g,. •••