253 Royal Palms Dr SIGN19-0004 Planet Fitness sign permit SIGN PERMIT PERMIT NUMBER
CITY OF ATLANTIC BEACH SIGN19-0004
» 800 SEMINOLE ROAD ISSUED:4/23/2019
rl " ATLANTIC BEACH. FL 32233 EXPIRES: 10/20/2019
MUST CALL INSPECTION PHONE LINE (904)
14 BY 4 PM FOR NEXT DAY INSPECTION.
• •ALL • • • • • • • • OF • • • • BUILDINI
CODE, NEC, IPMC, AND CITY OF ATLANTIC BEACH CODE OF ORDINANCI
ALL CONDITIONS OF
NOTICE: In addition to the requirements of this permit,there may be additional restrictions applicable to this property
that may be found in the public records of this county,and there may be additional permits required from other
governmental entities such as water management districts,state agencies,orfederal agencies.
O. ADDRESS: . • OF • •
253 ROYAL PALMS OR I SIGN WALL PLANET FITNESS -SIGN $5800.00
TYPE OF REALESTATE ZONING: BUILDING USE SUBDIVISION:
CONSTRUCTION: NUMBER: GROUP:
177602 0060 SECTION LAND
ADDRESS:
SHARK SIGNS OF NE FL INC 5317 Shen Avenue Jacksonville FL 32205
• ADDRESS: CITY: STATE: ZIP:
O U R PROPERTIES INC PO BOX 330108 ATLANTIC BEACH FL 32233-0108
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY 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 RECORDING YOUR NOTICE OF COMMENCEMENT.
LIST OF CONDITIONS
Roll off container company must be on City approved list. Container cannot be placed on City right-of-way.
7STATE
7
IPTION ACCOUNT QUANTITY PAID AMOUNT
LAN CHECK 455-WOO 322-1001 0 $415.00
IGN NO ELECTRIC 455-0000-322-1000 0 $000
ITHOUT ELECTRIC 4550000-322-1000 111.26 5630.00
SURCHARGE 455-0000-20807W 0 $18.68
SURCHARGE 455-W00T20806M 0 $12.45
ZONING REVIEW COMMERCIAL AND INDUSTRIAL USES Wl-0000-329-LONG 0 $30.00
TOTAL:$1,576.13
Issued Date:4/23/2019 1 of 2
v1 iAr;. City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assigned by the Building Department.)
800 Seminole Road Op/3/(
Atlantic Beach,Florida 32233-5445 1 1
Phone(904)247-5826 Fax(904)247-5845
E-mail: building-dept@coab.us Date routed: I C
City"th-site: htfpfl a .coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 2S3 R�-(Al.- P�l-MS De rtmentreview re uired Yes No
(� c lkh
Applicant: �l-SA-RK S(Cly O-t-r u(K �Lnin
Tree W inlstra or
Project: l N Public works
Public Utilities
Public Safety
Fire Services
gga@v(fq@_$ QeptSignature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified B
Florida Dept of Environmental Protection
Flodda Dept.of Transportation
St.Johns River Water Management District
Amy Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: pproved. ❑Denied. ❑Not applicable
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by:� Date:{- /I- 1 `i
TREE ADMIN. Second Review: ❑Approved as revised. ❑Denied. [_]Not applicable
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied. ❑Not applicable
Comments:
Reviewed by: Date:
Revised 091912017
City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assigned by the Building Department.)
800 Seminole Road
Atlantic Beach, Florida 32233-5445
Phone(904)247-5826 Fax(904)247-5845
E-mail: buildingdept@coali Date routed.
City web-site: hfp'.//w .ccab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 253 R04rtt, Pki De artment review required Ye No
�+ wilding
Applicant: SbU�RK J1GN O� �(� nin
' Tree Aurnmisturator
Project: I.�AS Public Works
Public Utilities
tT Kiii Public Safety
Fire Services
"fee $ Dept Signattgsi aa,.:.
Other Agency Review or Permit Required Review,or Receipt Date
of Permit Verified B
Florida Dept.of Environmental Protection
Florida Dept.of Transportation
St.Johns River Water Management District
Any Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: proved. ❑Denied. ❑Not applicable
(Circle one.) Comments:
BUIL
PLANNING &ZONING Reviewed by: Date: 22 20!
TREE ADMIN. Second Review:
❑Approved as revised. ❑Denied. ❑Not applicable
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied. ❑Not applicable
Comments:
Reviewed by: Date:
Revteetl MI N17
Building Permit Application OFFICE COPY
OPearad 1919118
City of Atlantic Beach Building Department "ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (904) 247-5826 Email: Building-Dept@coalD.us IS REQUIRED.
Job Address: 253 ROYAL PALMS DRIVE ATLANTIC BEACH FL 32233 Permit Number: S
Legal Description 38-2S29E 1.88 GASTRO Y FERRER GRANT PT RECD OIR 10138-1777 RE# 1TI802-0O60
Valuation of Work(Replacement Cost)$5800.00 Heated/Cooled SF Non-Heated/Cooled
• Classof Work: IZNew OAddition DAlteration ORepair OMove ODemo DPool OWindow/Door
• Use of existing/proposed struc[ure(s): OCommercial ❑Residential h
• If an existing structure,is a fire sprinkler system installed?: OYes ONo W
• Will tree( removed inassociation with monposed pro'ect7 Oyes Imust submit separate Tree Removal Per N N
Describe in detail the type of work to be performed: INTERNALLY ILLUMINATED CHANNEL LETTERS ON RACEWAYS REA&Z J Z
"pf planet fMess 3.58'X 31.08'=111.26SF TOTAL,UL LISTING E359831 J (,) < 0
aaoE
Florida Product Approval It for multiple products use product asnArpag
a
Property Oymer Information W l0—„ .4 G p
Name SHOPPES OF LAKESIDE INC Address PO BOX 18 0 M
City ATLANTIC BEACH State FL Zip M233 Phone 904241-1151
E-Mail -- P in F
Owner or Agent(If Agent,Power of Attorney or Agency Letter Required) n V E `W
Contractor Information LL' O w w
Name of Company SHARK SIGN OF NE FL INC Qualifying Agent DONNY CAGLE W } p. _¢ M
Address 5317 SHEN AVE City JACKSONVILLE State FL Zip U2 �W W
Office Phone 9a 766E222 Job Site Contact Number DONNY 9043184728 W W W W
State Certification/Registration# ES1200oa98 E-Mail AMBERCSHARKSIGNSOFNEFL.COM >
Architect Name&Phone# Q w
Engineer's Name&Phone# MARK DISOSWAY,PE 38F]545118
Workers Compensation Insurer BRIDGEFIELD EMPLOYERS INSURANCE OR Exempt D Expiration Date 04/21/2020
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 the laws regulating
construction in this jurisdiction.I understand that a separate permit must be secured for ELECTRICAL WORK,PLUMBING,SIGNS,
WELLS, POOLS,FURNACES,BOILERS, HEATERS,TAN KS,and AIR CONDITIONERS,etc. NOTICE:In addition to the requirements of this
permit,there may be additional restrictions applicable to this property that may be found in the public records of this county,and
there may be additional permits required from other governmental entities such as water management districts,state agencies,or
federal agencies.
OWNER'S AFFIDAVIT:I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
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
-RECORBJNQ Y NOTICE OF COMMENCEMENT�� �
�C\• 'gnature of Owner or Agent) nature of Contractor)
Signed and sworn to(or affirmed)before me this 9TH day of Signed and sworn to(or affirmed)before me this 9TP day of
APRIL 2019 IV OONNY CAGLE.ADEM PER LOA APRIL 2019 Jw DOI P( AGLE
(Signature of tary) SlggeLi[RD
qw A xF U !
'✓' AM BER RAULERSON t h A N 073175
:. Personally Known OR LXI eU21
Personally Known OR _ MY COMMISSION#GG 0731751
t )Produced Iden4ficauon EXPIRES May 15,2021 1 Produced Identlecatlo s' _ _ s U+JaiwMan
Type of ldenthcs' '�' r.BwMaC IOrvN PublicU yoe of ldeMifcadon:
9-
Permll No. �/
�y OFFICE COPY
I^ .8 80 Tes Folla No. � � W O iml Oc i 6 3 ${0 �
OZyZj� ,�kN
C. mKAm
NOTICE OF COMMENCEMENT c
n '
WI:om 11 Moy Concern: fol
The uotlersigvetl hereby IMorme you that Improvdeenk wlll be made to cedahr reel properly,end Iv arordaece with o
Sa ton 713.13 of the Flodda Shonnes,the ropowlng lnformalkn h stated to this NOTICE OF COMMENCEMENT. $ 0. O
1. DrscdpOon of properly: T N A
Legal o Descd" o m
Shoot Address: 253 Rovel Palma pave 710 pBead: FL 32233 A on
2. Genermdmrrlptlonoflmpmvmen, NEWSIGNAGE iAi3
3. Ownerb lnformetlov: Nerve: PFAduntc Bemh.LLC y v
3M1ax Owner of Sign Adtlrm: 6013.Pone De Leon Blvd SmkB SL AURust FL 32084 0
Inhovorin Properly: 100% C
Name and Addrem orfs gmple Mtlaholder(Ir other than owns): y
Shopper of Lakeside Inc S ssor bvM with Our P est' I
, ^ d. Comrxtor f:dormetlon: Namei SHARK SIGNS OF NE FL,INC, rD�,
P add : R17SHEN AVENUE JACKSONVILLE FL 32205
Teleplrane No. 904-766-6222 Fa No.(OpL)
S. Surety lnrormallon: Name:
Address:
Amount M Bondi
Telephone No. Pex Na.(OpL)
6. Lender Ird.a0on: Name:
Compiele ilsgn is Arldrme:
being finned by olbers Telephone No. ,.aN. (Oµ)
7. Identity of person witlrin ll:e Smk M Florida deelghalm by owoa pPou whom Rotlmar o0:a doenmenk may heserved:
Name: loeeph Herlihy
Address: mk LALAugmane, 320
TNephone No. rc767 n Fn No:(OpL)
8. In addition to hlmaelf,omrer deaig:mks tM foflowh,person m bar a ropy of the Lleaor's Sooner as
P Aded in Satlon 713.13(1)(h),Fbdda Smmtm:
Name: loceph Herlihy
Adds®: 601 S.Now a Lm Blvd.,Suite B,St Augustine,F 32084
Tekphoue No, 97&767AI17 Fax No.(OpL)
9. Erptretlon date or Notre or Caboo meut(0e expintloti date h I lar from the date of roording unless
DlBerent date Bapalfled)
WA LIVING TOOWNER: ANY PAYMENTS MADEBY TM OWNER AFTER TM MFIRATION 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 TWf FOR IMPROVEMENTS TO YOUR PROPERTY.
ANOTICEOFCOMMENCEMENTMUSTBERECORDED AND TED ON THE JOB SITE BEFORE THE FIRST
INSPECTION. WYOUINTENDTOOBTAINFINANCING,CON T YOUR LENDEROR AN ATTORNEY BEFORE
COMMENCEING WORK OR RECORDING YOUR NOTICE OF 1hIENCF.MRN'F.
SI reor is Ab.."ud MhooNMregoN
Pad..AM9 agars
Sohn C I2rk
Print Name
Smk MFlodda
County SAU'a
eeF, g�Inglm en�wg..admowled'et hNore ma lh�enr i- L'XU�V(.1 mf�,
y _ 5" mmada
_NI PF ac laentneaum,and robe mym`n:.rrrz—T
Cth2Riii.�ah
rmganwnawa AaoN muwPn9 ..xti gg., sl�alna orNamrynle clerk
120C9#NW:SIlDjO3
SLlEL000#NOISSIWW00 AW y"•. �(/
N0Su3lnvNN3SWY ' ,',':..;ef� Pdnlm Nabs
OFFICE COPY
Letter of Authorization
To whom it may concern:
This letter authorizes Shark Signs of NE FL, Inc.to act as agent to sign and notarize permit
applications as agent for owner/owner,secure variances required by the local government body,and
to perform sign installation,removals or maintenance.All work done by said contractors will meet or
exceed local, state and NEC requirements. This authorization is for the following lessee/tenant:
Tenant: glane+ �I+neSS 1
Street#: 253 Suite#: Address: R (1Vt11 �1 G,1 M5 �r N�ILYI�Ir� Fl..
Zip Code32233 Zoning: _Real Estate#: I111DD2 - ccxnO
Owner/Agent Name: (1gc� nG l n ta s:Tk- am 'aucu= mer
lULth O .U.R. PtS�C]oper+14M Shc . F -T
Owner Address&Phone#: Snoops of I n ILD,
t A Trlr
k Ut18 C
Signed: Date: a �a
State of .Mc)p do— County of
The foregoing instrument was acknowledged before me this day of "p YCn .20 L
by �hf 15 �k i-'n l 0 herein by himself/herself and affirms all statements
and declarations herein are true and accurate and who is [}personally known to me or[]produced
identification
1 �, n
u
Signed: ' .au C
tNOtaly a[mnp m Seel requiaM)
9MLCAN
NMary Wblk-SOIeaIFlanCE
CommmienaRm95 1
lf h},'fnmm.FxWea MdY 11.3019
Please note:This letter must be notarized to be accepted by building and zoning deparlmems in most counties.
Revised July 22,2014
ny(��JUN:IL I 4 APIT TION �,r//�fit
Florida Department of State
Division of Corporations
Electronic Piling Cover Sheet
Nott:Pk prh d Ude page sed eb k se a emw skeet.Type the fax audit
number(shown below)on the top and bottom of all pages of the document.
(((13h 0000135054 3)))
NUNIIIIIIVNINWINNIIIIIINIIIIIIIIIIIINIIIIIIIIIVIIIIIIIIIIIIINIIIIIIIIIiVllllll{I
W OMA 1sw61sabcr
NOW.DONOT hit the MMESE/RM.OAD button on your browser from this
pap.Dome so will generate another onver sheet.
To:
Division of CoxporatioW
r. Number (850)617-5380
From:
Account Name YOM CAPITAL CONMMON, Xmc.!-W
Account Number I200000002V a'm„ Z
Panne (850)224-8870
Fax Nmober (850)222-1222 y
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•-xntK the mail address for tete tnt9lneaf entity t0 bs wend foxm�
annual xepOYt mailings. enter only we eesll aaereas pleaee.ri
sbeii Addrees: ?")
MERGER OR SEMRE EXCHANGE
SHOPPES OF LA"MF,INC.
Cerdficate Of States r,�• �
Cerbfial Copy - L
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i
tett JUN ) 4 6/920101:07PM'
I 20p
JA 11. 2010 3:25PM CAPITAL CONNECTION N0. 8856 P. '2
1
June Yl, 2010 MWO
FLORIDA DEPARTMENT'OP STATE
SHOPPER OF LAKESIDE, INC. D'vuioaoCCoipmaCwu
P O HOE 330108
ATLANTIC BEACR, FL 32233-0108 -
SUBJECT: SHOPPES OF LAKESIDE, INC-
REF: P93000086267
we received your electronically transmitted document. However, the
document has not been Piled. Please make the following corrections and
re£as the complete document, including the electronic filing cover sheet.
Bar each corporation, the document must contain the date of adoption of
the plan of manger or share exchange by the sbareholders or by the board
of directors when no vote of the shareholdeze In required.
IN SECTIONS FIFTH ANO SIXTH TWO OPTIONS ARE AVAILARLR, PLEASE CHOOSE ONLY
ONE. TF CHOOSING SHAREHOLDER APPROVAL, TERM THE ADOPTION BY THE HOARD OF
DIRECTORS WITHOUT SHAREHOLDER APPROVAL WOULD NOT HE SELECTED.
THE NAME OF THE MERGER CORPORATION 119 Forsyth, Inc. HAS BERN LISTED
INCORRECTLY IN THE PLAN OF MERGER. IT IS SHOWING THE CORPORATE HAMS BEING
119 Forsyth street, Inc. PLEASE CORRECT YOUR DOCUMENT ACCORDINGLY.
Plea" rQ%urn .your document, along with a copy of this letter, within 60
days,-or yenr�H%,Iing will be considered abandoned.
_' 6ii�caa
ISquestioconcerning the filing o£ your document, please
ca11A(s5�u bWe any n e
T>�4L9t-6906.
I#ar a e�omw,,.0 PAZ And. 4: 810000135054
ReguYat •BQGeimlist II Letter Number: 710100014521
�w
M
�i� 0•: C J
P.0 B0X6327-TSHahmmcc Fund 32314
i
JUN. 11. 2010 3:25PM CAPITAL CONNECTION 10. 8856 P. 3
o
r
ARTICLES OF 71•ffiRGER _=•-s
The following articles ofnWW arc submitted In areordetwe with tM Florida Business Cmporatrop Ae4'y C
porsusm to Send"607.1103.Florida Stems -
Phet: Thotlaon endpoidinlioA oftlu sarraa�l�Wt>abp;
1*nr0 8
- OtsasvwlgpraWe)
,SMPPuc as rA"gTnr,- Tf_ 11,-4a. p930000e62S7
I Sceopelt The name and porisdiedon ofeach mcmdm oogmoadon:
Name e'- -n<. o.ton DOOMMADA
.w: - Orwwr+ 1
119 F rsvthInc. Flort", POIODOP73943
Rom Ptmtrrti.ee, Inc. F1or1A0 P04000028433
Protokor0, Inc. Flortap " 6000063418
0=-Him r•+Hf Pavauwrtew.' Tpo_ ylwrida P040DOU49831
nu, esi.. Aj,Snwt Pxnvwrha www Inc. plwrLda pGAnnnnA17QA
Cont3nond pp ne� eeq�p.
Tbird: The Flan oPntorSa+ s u1mcH
Few*: The merger Nail becottm etkahm on the dm the Articles ofMargrc m filed with the Fk"
Depatmumt of Sesta
OA / (5noc-a Hie wtc Non; Melt U.�hm wnmttm P^urot4 dmdR4oe Q..o•.
ton 90 dela atw ams.ah".)
tW*: AdoM*q of as adopted
d by dw el eholdelon f the XffVMn ea r OrasunasNl7
The Plan otMetger was adopted by Die ehuehoWaa of the sotvMing wrperYim or
Jww s, 201}—'
The Pian pfhfum was adapeed by the boerd ofilkocmn ofthe surviving oorpasation m
end dmehokler eppr l was rat required.
Six*: AdopOoe ofMergc byII�gcaprenion(s)(Convli'i'[oIO.FOe�BrwtplORNt) �`Ys0
The Pian ofMerger was adopted by the ahetdoWws of tlta merging sotpmetiari(s)on
The Plan of Merger wee adopted by the board of disrwn of the margins corpoetion(s)on
_end dtreMlde:appmvel sraf vot nxpured-
(Anah eddrtwut rReets tyxasr yJ
J94.41. 2010 3:25PM CAPITAL CONNECTION 40. 8856 P. 4
UnCLES OF MERGER
(Preat CMrporadoea)
The fhlbwing amulet ofmvga are yawned In aacmdance with the Florida B"imeon Corpowion Aa%
pmeurd to m cdon W7.1 105,Piorida Sumter.
Fret 7lte name and joclullction of the moldo nopo[ation
suit DequanciaNUAlba
Second[ ICONTMl7e)
b.V=, Jaroniwrr D
(Ww "Model
niertaT oogAtinOA.ilYR
Savannah Historlo Properties, luc- Florida P94000055390
9or10011eld AmMisitiolls, Inc. Florida P00000101366
Third Tba Plan of Merger is auched.
Fourth: The purger adopt become of Pcth c on the dao the ArWee of Merger are 61ed+ith the Florida
Depacnmt of 8&w
I ..,_(�+rr•aafkae TlntL: Memx+lve 4nnmetbe pia ronc�aur d6par a mae
tlmi 90 dme dor a@v mag+flm mC1 IHM�if)�/' p' �/�
Fifth_ Adoption of�Aagaby am"Irb,L wrpm9dm-(COMfLe m%LTq sTA L/b/OO,/"'�O
The Pian of MW tw adapted by thr dureh0ldeca ufthe artviving cmp0tatlan on
The Plan vf)AaW use adopted by the board ofdirecrot5 of the awiving 00100MI M an
and aureholda approval.not mgnbvd.
(Iirfh: AeapdanofMUgabye.nd"=paatiM(g)(COP4rLelaadvold6
rArhs®fnQ
Tba Pkn atMrtga was adapaed by the,drm'ehaWer9 ofdte merging cmporetim(a)m L0
i
� The plan o(Mrgerwas adopted by 01e board afdirccrotr of the merging wtporadon(a)on
,��aitd drreholdar apprmel wq not raged.
(Amir addttomd.d✓rr yemsa71
i
JUL 11. 1010 3:251M CAPITAL CONNECTION NO. 8856 P. 5
S~h: SIGNAIUMPOR SAM CORPOR&UON
Name ofCuoomlian Stwiarm of m Offmer m Tynd m P PPP Name of IWiyWal&Title
shooms of Gekaside. Ino. President
'I'19 Fn�a�wh_. Thc_ Prealdant
1
fore PSOPertla9, _Imc, PRSldent
Protokore. l8c. W4L
Prasidant
1
Our Histarie P;apart lPresident
Our Rain street P;ooaPresident
Propertlea, InPresiOant
Savannah Historic PrePresident
" JUN. i1. 2010 3:15PM CAPITAL CONNECTION 10. 8856 P. 6
�N rRf M,RCW.R
N" 6
7be folbaiog ph,ofmagcr is Rtboitkd m complbu wfth lx�R..m�.16�07.1101.Fl�da
$bih,tm .and in meowd VVRh dm 18 of any oftrlppucabl6pmuLrawn ofbicurpondm.
FTM TbC om mdlmisd cdm for ofdle ZgryjM cwpo,a¢on i,
(follows:
L]WYO LfYiIYYYVY
��OF i eYAQLttF rN 1r}gdQg
9E(:,ONDI Then mdjurisdlodon of Omh b 9*0 OOMM lon:
SAML J.,imicti.:
119 Forsyth,Inc. Ew"
xgmh reta1w. F.luddd
W..dnk vw Inc. Fl0ud6
O,v MGd wte n b=adjx res >7!
n_.rrp.r=cK:_rte, _ Ekvd6
,pfmfdtlm 1 F1oud0
3.3=W Tb5 tells end muditions of rhe t UWP u follows:
s IOU MN=VRI of wmwxb��
.141 Mixv,mx,Ai AMr IiV-t nfAM
JUN. 41. 2010 3:26PM CAPITAL CONNECTION NO. 8846 P. 7
surviving nese +n D.7m]L. +rr am..n .d,.em.•morrhe
ceneeatian adb+,.i—iM 61---aelil nmen.LA in acfl��aYltle aeon_
'_m9d•nwn,v.�,,,_a of the Sul—hda pp�y�paly�1 lDe ns11,.euin tlK
a.vM1IL,¢[aeomeDOe felkimi.o dv+,�yt}p,gp�yptril rvsota:tive
byc� am
•The --�tviviny,.lgpDneni ee d.•n De taemnwbk mei liable fm n lMg and IMP11—of
tYe MWU mordmi C d:latuil sd1:.+.v.xall n..I De ireoei*a1lrv.vme d-dmelgaay_
' All usmnv ffba�[¢laa racma�on.ahg�Y--naxistaotrm 9le modykeGo o3ww
in ezn .r.n..x.e.nw.n.mm, fDe fe mMinaxh�in IM_mmd3den.ag QUQtm
• neenn3l3hwaeeenain6ffigll ad.m: n.A•.,amP 1,amain the t^e••
Qzosmtlam.
Win tt ...sled ILTla4lnti - btL^aco stot MEOMM Eae n
•P.'D sm mh *. dmwd,mn..s.v M-
•Ffliaytnen+i.ia msv fand Wmn ndmeana M tble plm of x"-ema L sl'd'+•B1R --
Milte.aeti Mild ), ._
•P11Dn+ M ouematY \of&"MLWM
•Tot'.n` 'mm The fo--- >ti „"'""..�.... ^��fft emcvivin_QQ=&mgAajbwj
bS k^-+ +h F/i etx—'-n�narLo S.3>e ad dS4�. •`•1 m eb s e� '�1 e_"tecmrnfS.
d' 'Q�V'm .d M fdl effect a�
IINj .-Mo
I
JUN. 11. 2010 3:26PM CAPITAL CONNECTION 50. 8866 ?. B
'f nthia,r ,••°tea 9z i �j q tl.�lle.rt'u......ta iem�d t anf Wp mr M�.a can.,
risM .mn.Av ..Y:.elien,r tl.bl'YYyedllaf In3W�WQ2f m mom
FUf7Qrx.
A. The ram nas and basis of converting eta immv5t%she oblignious•or ostm aamiaes of
each MOW party Imo the imeleso,shares.obNNeaocu or other mcurill"of the survivor,in
whole or in pan,hac cash or other prnpmy is as fellows:
+7fas • - - d�R. . 5f�7faom t ha Mitt
GOgiprOtldt�e
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"a.s:iinu MUltaNno of the id®deldm tMenn:n..,Jrsadr
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7AhmetmmtaWfshW� .¢I�as and fay ramdilr�tim+?��a�k :,�h•W
�PsSPBbIiFA�u•...r..x a.�.r..r tw'rhe� _
B. Jiro me®et•md basis ofmnverting the dSbj o.ampn 8m ioutesm shares,obligations or
other smehia of each mmgrd My Into the dghMp"m=the intim,ihmys.01111ga0ms
or other securities of the srevl mr,in whole at ie pert,into sash or other proymry is a fol lows:
Not AWee� A e„inn fthe�gp f dahrs eomx¢
fiat mWrq'fm6Ln^.ILML'� —_
JUN. 11. 2010 3:26PM CAPITAL CONNECTION NO. 8856 P 9
ffEMffa pmtnenhfp to thosurvl r,theaurae and butncw ad&rc ofearh genual parUw
Is as follows:
Not A.mGmhfa
$jXM If atimiwd hablUb compwW Is*a sar Af ,the name and basiaass addmw of eaah
Bmormmmgiog membr isufollam:
Not AppU MMI&
Aay ata MMOL yim ale Mquuad by tb-IoM m dm wldah c:h adre<basta—
Cntity u fbmrod,or bod,m imwraramd me m fallo
N oWet th® Mndn _