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335 2ND ST ADDITION -i►1-"-Ly f. `S\ CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD 'J ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 RESIDENTIAL ADDITION MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814 JOB INFORMATION: Job ID: 14-RADD-456 Job Type: RESIDENTIAL ADDITION Description: demo, remodel, addition Estimated Value: $60,000.00 Issue Date: 12/3/2014 Expiration Date: 6/1/2015 PROPERTY ADDRESS: Address: 335 2ND ST RE Number: 169783-0000 PROPERTY OWNER: Name: CHAVOUSTIE, STEPHEN M Address: 335 2ND ST 335 2ND ST GENERAL CONTRACTOR INFORMATION: Name: PRO-BUILDERS OF FLORIDA LLC Address: 1115 SOAKS RIDGE DR LUIS EDUARDO ROSERO Phone: - - PERMIT INFORMATION: PUBLIC WORKS: Full right-of-way restoration, including sod, is required. 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 and Shapell's.) 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: PLAN CHECK FEES $160.00 BUILDING PERMIT FEE $320.00 STATE DCA SURCHARGE $4.80 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. STATE DBPR SURCHARGE $4.80 Total Payments: $489.60 C) b b �°. .fl n n d � ro m a d mi xCt) 7 c oCD� a oCD ,� a o' O ~° ° o o voa o a 0 CD CD m �. d o 0 CD 0 CD CA ¢ CD y CD N b O n a. O b `T cr j CDn UD ao CD txrJ o CD y o � O CD . CD rD n � C Z 5).":s y CD p CD CD CCD 04 ►», CD eD e•f A� CD O' CDCDs �• cs' o � xi O CCD CD 0 C a a t V) C O� t� , W N p lO 00 --4 - .� p \p oo o � CSC/) COO)CD C/) o N CD CD CD CD CD CD o✓ °G CD oCD CDA 10 CD CD CD CD CD CD o y h .'S A G fD b O O. C A d A r• 'O O O A'+ O' O O ft _ CIa CD 0 c A n ,P J ON (.A P., wCD N . Vj •� CD o CD n 0 CDCD n O �. rCh � N p- 0 CD CD N fDCD y Q CD C 0 a� C ' A C 'T A i b O Q. C d y A O C - A� O C O CD M CD w it A r 0 CD a o z z z N CD CD Cr C :D qLD -� _-� O ��3 lV�� �J✓ �• � `n � � Ci V' _ a V� S' � w 0 CD O C Q1 `Cf 6 (D N CD N CDD C CD UQ o cD I N CD CD CrJ 1 1 cc O n A CD CD J n '�- Q. CDD CD CD CD CD CA R 0 O 1 O I O O CD O 1 N q ,O NCDO O MCAD O A LCD n CCD - 0 � O �* C. tom* r l C O N CD rA BUILDING PERMIT APPLICA i )N CITY OF ATLANTIC BEAC. 800 Seminole Road,Atlantic Beach, FL -2233 Office (904) 247-5826 Fax (904) 24'' y845 Job Address: 335 2nd St P;�rmit Number: Legal Description ._ Ca`t ,�— '? S— 01 ( `, lL`,;Ze I/2.L5 I /wFloor Area Sq.Ft. Valuation of Work k lc Proposed Work heated/cooled non-heated/cooled 400 Class of Work(circle one): New Additio <�eration Repair Move(.Dem molitionol/spa window/door Use of existing/pro osed structure(s)(circle one): Commercial �esidentia If an existing structure,is a fire sprinkler system installed?(Circle one): t o N/A Florida Product Approval # For multiple products use product approval form Describe in detail the type of work to be performed: Demolition of detached c Cage & eastern portion eof 15,c, esidence to meet lot set backs, convert 1 car garage to finished office/laundry room. Buil., ttached 2 car garag _�O6 REitacls laut�oof - 0C*A0t-%_T10 N VORTtoN aF Rt=5ip y.lGF -0N.nE[i: G ►ST/�►yG "Co SAGE Property Owner Information• Name: Audrey&Harold Wagner Address: 335 2"d St. City Atlantic Beach State FL. Zip 32233 Phone 678 E-Mail or Fax#(Optional)AUDREY.WAGNER@HOTMAIL.COM Contractor Information: Company Name: Address: 1 i 1 S� Qualifying Agent f��,t,n , �� =tOC +C �Y� ici �Ttii City yti�+r��-xi��y 14 S e _ p Office Phone � — '':�� �►��y Job Site/Contact Number °CO . jrjrL Zi State Certification/Registration '`�- 6 Q0� Fax# Architect Name&Phone# Engineer's Name&Phone# alp4. 6 0 0 V57 50 Fee Simple Title Holder Name and Address—N/A Bonding Company Name and Address Mortgage Lender Name and Address_BB&T Application is hereby made to obtain a permit to do the work and installations as indicated. 1 cert th issuance of a permit and that all work will be performed to meet the standards of all laws regulating constr ,tion in this uta`sd'ction. This permit becromes null and void tf work is not commenced within six(6)months, or if construction or work is suspended or abandoned for apertod of six 16)months at any time after work is commenced. I understand that separate permits must be secured for Electrical Work,PlumbinT;, Signs, Wells,Pools, Furnaces,Boilers,Healers, Tanks and Air Conditioners,etc. WARNING TO OWNER: YOUR FAILURE TO REQ.: i)RD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING T` CE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FIS COMMENCEMENT. LACING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECOR"iiNG YOUR NOTICE OF �hereb certify that I have read and examined this a plication and know the same to be true and correc provisions of laws and ordinances governing this ype work will be complied with whether speci ted herein or not. The granting of a permit does ssume to the authority to violate or cancel the rrovisions of any other federal,state, or local r, re l ing construction or the performance of construc.. .t. � W signature of Owner Signature of Contractor 'rint Name U/J(L��a' W......: .....:... . r......... .-._.................... Print Name l.VIS t!2 C9 S p ........................................................ worn to and subscribed before me ......................................................................'Swo and subs�r' its 11 Da of_ }A , 20 I efor me t i Day of, _ 20l lotary Publi r D.CHRISTOPHER WARD 1 - am ~F Notary Public,State of Florida +? c cion FF o 2 rj — $ Expi a!r;'td/2ot8 p Commission'EE 200098 ised 01.26.10 My comm.expires May 20,2016 t.v I I%) L.0 I 11 LOT 9 BLOCK 4 BLOCK 4 BLOCK 4 FOUND 12- IRON PIPE " N 75`08'09" E 125.19' "MEASURED) NO IDEN7)FlCA710N s FOUN Na 45.00• 25.00• 50L00• (PLAT) r91Y 7p , ?31-0" ' FILE ri 'co fl, LOT 14 LOT 12 LOT BLOCK 4 ,- - - - - BL-OCX---4 - j -BUCK 4 CQIVAIRDIMONER `COVERED s IT J5VD n _ PAD CONCRETE # t cl 22.4' 12.5' • 8. r �fi�4� +1 , TWO STORY JJ r-. N MASONRY d < w x POSTED # 335 ;, .° w J W 10.2CE3 O LED ° am CRETE, Q :t~ La&7 GNU ,•'.. (7lT 0VI) LC) F1X-ft-j2I-A I t • ,.� WOOD L{') I POWER r-- POLEJF 4 a.�• LIGHT UGHT l _ POLE ; POU: �• •- 25.00' 25.00' '•` # j (PLAT) (PLAT} 50.00' (PLAT) 50.00• (PLAT) !- F FOUND 1/2' REBAR FOUND 1 J2' IRON PIPE ® NO IDEN71FlCAlION NO IDEN7iFlCA?ION WOODFOU i ; , EXCEPT POWER N POLE S 75.00'00" W 125.09' 'EASURED) SECOND STREET THE IMAGE SH, (40.0' RIGHT OF WAY) NOT BE f J>C) . r F City of Nflanfic Beach Building Departmer.i-."l ER 800 Seminole Road ` APPLICATION NUME3 6 be assigned by the Building De artment.) Atlantic Beach, Florida 322:33-5445 dd Phone(904)247-5826 - Fax(904)247-5845 City web-site: http://www.,,;i3ab.us )ate routed: APPUCATION REM W AND TRAC .Y'�,HNG FORM Propertry Address: —�,3 d Sr De artmc9nt review re uired Yes No ld�zeApplicant- nine; ;*'..-Zoni I ree A drilinistratol- Project: ^-- W. 2f&-od-c ic 6-_- Public S::. '�y Fire Ser, Review fee $ Dept Signature 'C-ONTRACTOR EMAIL A'DDRESS CONTRACTOR CONTAC # APPLICATIIO�ISTATUS Reviewing DepartrneriTtF_irst Review: �pproved. [IDenier' (Circle one.) Comm Comments: BUILDING PLANNING & ZONING Reviewed by TREE ADMIN. Date: Second Review: []Approved as revised. [IDenied. PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: FIRE SERVICES Third Revle,,VC DApproved as revised. E]Deniec,. Comments: Reviewed by: -.Date: VISED 09252014 City of Adanfic Beach APPLICATION NUMBER it Building Departmeb-ii-1 800 Seminole Road o be assigned by the Building De artment.) Atlantic Beach, Florida 322:33-5445 Phone(904)247-5826 - Fax(904)247-5845 City web-site: http1/www.-,.,1:)ab.us Date routed: APPUCATIONI REVIEW AND TRAC" ING FORM Proper-ty Address: S3bd2-,1 Sr - !TC—rev i ekii�re U i�re d ,_ Applicant: ?-r-4 nnirl, Zoni I ree Ad I'll inistratol- Project: is Wor ZZ '71 7 0 IC Utilities Public Safety Fire Serres: . . Review fee $ Dept Signature CONTRACTOR EMAIL ADDRESS CONTRACTOR CONTACT APPUCATlON STATUS Reviewing DepartraerA f=irst Review: rk(p—proved. Denier! (Circle one.) Comments: BUILDIN PLANNING & ZONING Reviewed by: Date- TREE ADMIN. Second Review: DApproved as revised D e n 4ie d PUBLIC WORKS 00,mments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by:___ FIRE SERVICES Third Revien.-T. DApproved as revised. Cornments: Reviewed by: Date:--. VISED 09252014 City of Atlantic Beach APPLICATION NUMBER Building Departmeh'.i -6 be assigned by the Building Department.) 'L 800 Seminole Road Ik Atlantic Beach, Florida 322:33-5445 Phone(904)247-5826 - Fax(904)247-5845 City web-site: http://www.,,'t:)ab.us Date routed: APPLICATION REVIEW AND TRACKONG FORM Proper�y Address: =?- ,3b- 2,1 d De artr. �nt review required Yes No Applicani: nine.: Zonia-Zb _-)ate routed- GG Tree Ad.: __j r tor Project: is V Public 13 y Fire Ser. S' Review fee $ Dept Signature V CONTRACTOR EMAIL A -)DRESS '-'ONTRACTOR CONTACT # APPLICAT90NESTATOS Reviewing DepartrneroTtFirst Review:--- Approved. s (Circle one.) Comments: BUILDING PLANNING & ZONING Reviewed by: Date: Ita( 4 TREE ADMIN. Second Review: []Approved as revised, FIDenipd. Comments: BLIC UTIL f5E Reviewed by: PUBLIC SAF T FIRE SERVICES Third RevieVIC, F]Approved as revised. E]Denier:- Cornments: Reviewed by: Date: VISED 09252014 City of Atiantic Beach APPLICATION NUMBER E Building Departuren'' :–'b be assigned by the Building De artrnent.) 800 Seminole Road Atlantic Beach, Florida 32233-5445 Phone(904)247-5826 • Fax(904)247-5845 ;., City web-site: http://www.r�oab.us I � =Date routed: LL- APPLIC TION REVIEW AND TRACKNG FORM Property Address: �.�� 2'. G� Sr D �r�rr�aca (� auk uc�e�ae'N aeqaauar�d Yes I�® Applicant: �/�� ��( �,l(.��5 nine ,Zoni Tree Ad rninistrator Project: SC 4" 2f-- odF-6 is VUoI s lc Utilities Public Safety Fire Ser✓ifc es- Review flee $ Dept Signature x-C CONTRACTOR EMAIL. ADDRESS CONTRACTOR CONTACT APPILICA11'M STATUS Reviewing Department First Review: []Approved. [ ]Denier; (Circle one.) Comments: BUILDING PLANNING &ZONING -Al ,/ Reviewed by: _ Date: y /y TREE ADMIN. Second Review: Approved as revised. []Denied. PUBLIC WORKS Comments: PUBLIC UTILITIES ✓� PUBLIC SAFETY Reviewed by: A-4 Date.. FIRE SERVICES Third Review„ []Approved as revised. []Denied. Comments: Reviewed by: _ Date: REVISED 09252014 110 CITY OF ATLANTIC BEACH Building Department FIL E COP y s j 800 Seminole Road J Atlantic Beach,Florida 32233 _ (904)247-5800 , < PLAN REVIEW COMMENTS Permit Application # lel - ;/�QQ - yS6 Property Address: 335- 2r,al Applicant: .60 /y y 1V11d S Project: &mo This permit application has been: 0 Approved Reviewed and the following items need attention: 1, A., PJeo 1 Q rG[ � vra c)o 4 av, lal,'n b�pej r e ss Le)r i­dW vc f al f T +'0 � ms. Cv Please re-submit your application when these items have been completed. Reviewed By: Date: BUILDING PERMIT APPLICATION ' CITY OF ATLANTIC BEACH E z FILE 800 Seminole Road,Atlantic Beach, FL 32233 `' Office (904)247-5826 Fax (904) 247-5845 t Job Address: 335 2nd St Permit Number: Legal Description" �`� �-' S �'� C ; K`,f� `j E 1/7.La I Y&p cel# �(OE ir3 /. Floor Area of `Sq.1"t. qt Valuation of Work$, l�0 Proposed Work heated/cooled 400 non-heated/cooled 400 Class of Work(circle one): New Additio teration Repair Move.De� ol/spa window/door Use of existing/proosed structure(s)(circle one): Commercial dentia If an existing structure,is a fire sprinkler system installed?(Circle one): 7 o N/A Florida Product Approval# For multiple products use product approval form Describe in detail the type of work to be performed: Demolition of detached cottage & eastern portion of esidence to meet lot set backs,convert 1 car garage to finished office/laundry room. Build attached 2 car garage d00 5-f, R1�idcls LtwtyvR� - a�MOL.nnN P0RTt0ti aF G'ZI'S },G .5� �AG� t*l nf T4 Cc Proaerty Owner Information: Name: Audrey&Harold Wagner Address: 335 2nd St. City Atlantic Beach State FL_Zip 32233 Phone 678-491-8994 E-Mail or Fax#(Optional)AUDREY.WAGNER@HOTMAIL.COM Contractor Information: Company Name:V(�_o S%lAF_3 !)!s (S-V f CP612-j Qualifying Agent: Lo/> 0 Address: 1 1 I SS c)A!L I_ 2 �r ►o6v& (.a" . ju;'i}t City C`QAty 11i..l State r_Zip 32? J Office Phone ?U t(- 3 c)(D-(fid of 4 Job Site/Contact Number °10• --9$6 00Q 4 Fax# State Certification/Registration# Architect Name&Phone# Engineer's Name&Phone# A1-ti Rek S F. 4--0'PER ot04- 600 5Z 170 Fee Simple Title Holder Name and Address—N/A Bonding Company Name and Address Mortgage Lender Name and Address_BB&T (�.cU, gctx 0 (tic.6:4rn►v)tl Application is hereby made too a permit to do the work and installations as indicated. I cert 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 tf 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 ElecMca!Work,Plumbing,Signs, Wells,Pools, Furnaces,Boilers,Heaters, Tanks and Ali 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. 1 hereb 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 ofYwlork will be complied with whether sped ted herein or not. The granting of a permit does not presume to the authority to violate or cancel the provisions of any other federal,state, or local law re l ing construction or the performance of construction. � w Signature of Owner Signature of Contractor Print Name U/JR ... ... . r lZ.:�.................. Print Name �V I S F2 C7 St4 - Sworn to and subscribed before me Swo and subscr' eforp me this t1 Da of r 2014— t i Day o 20N. �I�stAw Notary Publi �� D.CHRISTOPHER WARD C 6iOn FF o 2 Notary Public,State of Florida, or Expi a 02/14/2018 commission N EE 200098 ised 01.26.10 My comm.expires May 20,2018 App ica e o es: 2 0 FL DO I NOT WRITE BELOW- OFFICE USE ONLY Review Result circle one): Approved Disapproved Approved w/ Conditions Review Initials/Date• Development Size JILE Habitable Space Non-Habitable Impervious area Miscellaneous Information Occupancy Group ,Q - 3 Type of Construction V Number of Stories 2— Zoning Zoning District -_ Max. Occupancy Load Fire Sprinklers Required Flood Zone _Al A Conditions/Comments: Doc#201420(`045,OR 8K 169-19 Page 389, F11 3 Number Pages:1 Recorded 11/18!2014 at 09:37 AM, P Y NOTICE OF COMMENCEMENT Ronnie Fussell CLERK CIRCUIT COURT DUVAL COUNTY RECORDING$10.00 State of T3bf,C,n County of \ UV l Tax Folio No. _ To Whom It May Concern: The undersigned hereby informs 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 this NOTICE OF COMMENCEMENT. Legal Description of property being improved: —(�g\(o_ 2 G 16 I r — Address of property being improved: 51S 2 iV �[�NT 1( �C � ,FL 3223 General description of improvements:IJerrin l�� jan Of e�r L.o,{ C a Cdu 'rz i I c1ca. r Owner:Ak)WkV'-1-Nf "W Address: n/U J� �T(h NIT(( Owner's interest in site of the improvement: W RC r Fee Simple Titleholder(if other than owner): N 111; Name: Rzof�ul�__M!,> o(= Contractor: S Q S n Address: S Telephone No.:�Q -aOC7 Fax No: Surety(if any) Address: N I A Amount of Bond$ N /� Telephone No: f`i IQs Fax No: t Name and address of any person making a loan for the construction of the improvements Name: I A Address:_!`1 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: 4{IC 'kJ t Gtr(Z– Address:_��:1��1 r4,RNv S IC (?�1�,1J/� 4 y ✓� 'j7 A(jqONV I( t, �1 Telephone No:_/)cJ - gl(� {{ 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. N Telephone No: N Fax No: Expiration date of Notice of Commencement(the expiration date is one (1) year Lorn the date of ec g ess a di f rent date is specified): /V THIS SPACE FOR RECORDER'S USE ONLY OWNER Signed: Date: IM-7h,014- Before me this * day of Ockaby r in the County of Duval,State Of Florida,has personall appeared AttAr V 4 jAp $��y+6 r6 p 0.CHFUSy 1PHER WAF O -- Notary Public,State of Fbrida Personally Known: �Iq or Produced Identification: L Commission#EE 200088 Notary Public: r My comm,expires May 20,2016 My commission expires: ,( a �0 r I CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD J J ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 ELECTRICAL PERMIT MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814 JOB INFORMATION: Job ID: 14-ELEC-615 Job Type: ELECTRIC ONLY Description: 10 outlets Estimated Value: Issue Date: 12/9/2014 Expiration Date: 6/7/2015 PROPERTY ADDRESS: Address: 335 2ND ST RE Number: 169783-0000 PROPERTY OWNER: Name: CHAVOUSTIE, STEPHEN M Address: 335 2ND ST 335 2ND ST COVENANT ELECTRIC INC. FEES: State Elec DBPR Surcharge $2.00 State Elec DCA Surcharge $2.00 Lighting Outlets, Including Fixtures $6.00 Trade Permit Base Fee $55.00 Total Payments: $65.00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. ELECTRICAL PERMIT APPLICATION CITY OF ATLANTIC BEACH 800 Seminole Rd, Atlantic Beach, FL 32233 N Ph(904)247-5826 Fax (904)247-5845 JOB ADDRESS: , ��;0 S j PERMIT# JEA INFORMATION REQUIRED ON ALL PERMITS �-06 AMPS O k(}VOLTS PHASE VALUE OF WORK$. NEW SERVICE ❑ Overhead ❑ Underground ❑T Underground up Pole ❑Residential(Main) Service 110-100 amps ❑101-150amps ❑151-200amps ❑ amps #of Meters ❑Commercial(Main) Service 110-100 amps 11101-1 50amps ❑151-200amps ❑ amps ❑CT Service amps Conductor Type Size ❑Multi-Family(Main)Service ❑0-100 amps [110 1-1 50amps ❑151-200amps []______amps #of Unit Meters ❑Temporary Pole ❑ amps SERVICE UPGRADE ❑ amps ❑ CT Service amps NEW FEEDER(ADDITIONS,ACCESSORY STRUCTURES,ETC.) ❑100 amps ❑150amps 11200amps ❑ amps [I CT Service amps ADDITIONS,REMODELS,REPAIRS,BUILD-OUTS,ACCESSORY STRUCTURES,ETC. Outlets/Switches: JQ�__0-30amps 31-100amps 101-200amps Appliances: 0-30amps 31-100amps 101-200amps A/C Circuits: 0-60amps 61-100amps Heat Circuits: # circuits @ kw Number of Lighting Outlets, Including Fixtures: OTHER ELECTRICAL PROJECTS El Swimming Pool ❑ Sign El Smoke Detectors_Qty [J Transformers KVA Motors hp FIRE ALARM SYSTEM (Requires 3 sets of plans) Qty volts/amps VALUE OF WORK$ REPAIRS/MISCELLANEOUS ❑Replace Burnt/Damaged Meter Can ❑Safety Inspection ❑Panel Change ❑OH to UG ❑Other:&k� Ap-ol-TIOM, /\kl S C. 12LP P_<' 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 SI NU L AM A-11�_ Phone Number L Electrical Company Loy�wmg V_Ltr2lt 1�1C. Office Phone gdm "n4-5KZax Co.Address: )oxh W I )w ft City J AMS MVl�a,C StateYL Zip)�21 q License Holder(Print): 5 RO f%M6 State Certification/Registration# 'R'I o i'gib 7 4 Notarized Signature of LicenJ Holder Before me this day of 20 Signature of Notary Public