PL-16-3133 34-,
Miami Shores Village PrrIt Tlig.-Ott
ti
r 10050 N.E.2nd Avenue NE
Work C/aSSI t tiow Styptic
Miami Shores,FL 33138-0000
g Phone: (305)795-2
204 �� �"at8tus AF�p�o��,
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• 11,1�I2Ei# Expiration: 06/16/2017
a.
Project Address Parcel Number Applicant
61 NE 104 Street 1121360120030
DAVID&MARY GERHARDT
Miami Shores, FL Block: Lot:
Owner Information Address Phone Cell
DAVID&MARY GERHARDT 61 NE 104 ST 305-754-7805
Miami Shores FL 33138
Contractor(s) Phone Cell Phone
Valuation: $ 2,450.00
CHAPMAN SEPTIC SERVICE,INC. (305)815-9901
Total Sq Feet: 300
Type of Work:ABANDON EXISTING TANK,INSTALL 900 Available Inspections:
Type of Piping: Inspection Type:
Additional Info:ABANDON EXISTING TANK,INSTALL 900 HRS Approval
Bond Return: Final
Classification:Residential Scanning:3 Review Plumbing
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
Bond Type-Owners Bond $500.00
CCF Invoice# PL-11-16-62081
$1.80 11/17/2016 Check#:2394 $500.00 $322.80
DBPR Fee $4.50
DCA Fee $4.50 11/16/2016 Check#:19931 $50.00 $272.80
Education Surcharge $0.60 11/17/2016 Check#:2396 $272.80 $0.00
Permit Fee $300.00 Bond#:3250
Scanning Fee $9.00
Technology Fee $2.40
Total: $822.80
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNERS 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. Futhe ore,I out ize the above-named contractor to do the work stated.
i/ November 17,2016
Authorize Signat a Owne / Applicant / Contractor / Agent Date
Building Department Copy
November 17,2016 1
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Miami Shores Village Nov is Zo,s
Building Department BY.".
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 2014 5t
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC E] ROOFING REVISION EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: d `e IC(/HtJ
City: Miami Shores County: Miami Dade Zip: 3,6
Folio/Parcel#: 0 l-(f 13(o -B 1; ' IQ g Q Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: -1,� Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder):( } Cgtk Q `4 f Phone#:
Address:(01 1016f
City: ( State:�� Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACT R:Co pany Name: r Phone#:�"O'p
I S'V'G I
Address: `�} a f 9
City: Stater Zip:3c3.�i�3pg
Qualifier Name: ��`` Phone#i (ice/
State Certification or Registration#:-5M q ��7` ��'� Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ C�'Y�71/ Square/Linear Foota of Work: 304
Type of Work: ❑ Addition Alteration ce❑ New Re air/Re la ❑ Demolition
YP P P Gy
Description of Work: Zi 6
�3r�o 4t
Specify color of color ru tile:
Submittal Fee$JQ Permit Fee$ //.��� CCF$ r �® CO/CC$
Scanning Fee$ Radon Fee$ `-f •s® DBPR$ C4 . Notary$
Technology Fee$ 2 •u® Training/Education Fee$ '(to 10 Double Fee$
Structural Reviews$ Bond$ 600 �Qtl d
TOTAL FEE NOW DUE$ �
(Revised02/24/2014)
o —�
Bonding Company's Name(if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
City State Zip
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. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES,BOILERS,HEATERS,TANKS,AIR CONDITIONERS,ETC.....
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 RECORDING
YOUR NOTICE OF COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued in the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
SigSignature
natur
WNER or A ENT /ONTRACTOR
The foregoing instru/mgnt was acknowledged before me this The foregoing instrument was acknowledged before me this
/qday of '/ ' -0 020 _,by day of o 20 /(0 by
/l�'A/Q, '/q. (7'x`C1Ylw/.//,who is personally known to who is personally known to
me or who has produced as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: lu Sign:
11
Print: ¢,S Print: IS`�
Seal: Seal: \,seo ►►►►IIID//'''°
ESA CANT "
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APPROVED BY ;P• a � Plans Examiner #FF087
.• 888 ��aQ Zoning
.� sr/Az/c. STASE .ea�
#FF 087888 o Structural Review Clerk
r 9,A • o� d lh O a
(Revised02/24/2014) s�����r�eB�jl��iiii►����\\�`
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PERMIT #: 13-SC-1 718320
APPLICATION #:AP 1262158
STATE OF FLORIDA
DEPARTMENT OF HEALTH DATE PAID:
r ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID:
CONSTRUCTION PERMIT RECEIPT #:
•��"'� DocUMENT #:PR1037925
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: David Gerhardt
PROPERTY ADDRESS: 61 NE 104 St Miami, FL 33138
LOT: 5 BLOCK: na SUBDIVISION:
PROPERTY ID #: 11-2136-012-0030 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION
381.0065, F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE
SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS,
WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE
PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL,
STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 1,050 ] GALLONS / GPD Septic CAPACITY
A [ 0 ] GALLONS / GPD CAPACITY d t0 Pec a
N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1255 1r � �ayatlon at T�oN
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ IDC 9 DAP, iletd e the the
The adlao Prior to Fina� and cc
]
oontra eTt to
D [ 300 ] SQUARE FEET BED CONFIGURATION D SYSTEM seil boil C1,1 (\ sC ataci fitted•A.
R [ 0 ] SQUARE FEET SYSTEM �lme°clot gna ne SSS to e1ua�l theb®t�Ctor is n�+l
A TYPE SYSTEM: [X] STANDARD [' 1 FILLED [ ] MOUND [ Mul to the arigrna e assessed
oS�11tS toe;ill b gad tlrne,
I CONFIGURATION: [ ] TRENCH [X] BED [ ] reinsII�e atthe' '
N at i
F LOCATION OF BENCHMARK: 13.9'NGVD,TOP OF BOTTOM FLOOR
I ELEVATION OF PROPOSED SYSTEM SITE [ 30.00 ] [ INCHES FT I ABOVE BELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 76.00 ] [ INCHES FT ] [ABOVE BELOW BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ 58.00 ] INCHES
1.-Install a 1050 gal.septic tank with an approved filter 4 s
0 2.-The licensed contractor installing the system is responsible for installing the minimum category tb
T with s.64E-6.013(3)(f)FAC.
H 3.-Install 300 sf.of drainfield in BED configuration.
4.-Install 12 of slightly limited soil at the bottom of the drainfield.
E 5.-Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorptioor trench.
R (Comments Continued on Page 2.)
SPECIFICATIONS BY: Yve Cle ont TITLE: ENGINEERING SPECIALIST I
APPROVED BY: 111, TITLE: Engineer Supervisor III Dade CHD
Astrid V Edwards
DATE ISSUED: 11/07/2016 EXPIRATION DATE: 02/05/2017
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC Page 1 of 3
V 1.1.4 AP1262158 SE1012821
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A`QRo` CERTIFICATE OF LIABILITY INSURANCE UNME WOOMM
111 12016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONE-ERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER.
IMPORTANT: If the cartiftcata holder Is an ADDITIONAL INSURER,the poiicy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subjeetto the terms anti conditions of the policy.certain policlos may require an andors=04 A statement on
this certlficats does not confor rights to the certificate holder In lieu of such endorsement(s).
ppmmcm Rpm Sasha Ar Isti
Horizon Insurance.Inc. PNO"E 947 7558600 Fax 941-7$3-"72
7347 62nd Place E InfoftortzonIns.not
Bradenton,FL 34203 g AFFQMNOOGYERAGE NAIca
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INSUrMRA: Apigglachlan Underwrite Inc.
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Chapman Septic Service,Ina wsur�xo:
PO Box 431911
Miami,FL 33243-1911 INsvRoze:
INSUPM P:
COVERAGE'S CERTIFICATE NUMBER: 00000000-968Q77 REVISION NUMSM, 105
THIS IS TO CERTIFY THAT THE POUCMS OF INSURANCE LISTED BELOW RAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTE+NTMSTANDING ANY REQUIREMENT,REMEVT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUII&JT WITH}SPECT TO WKGM THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES OESCRISSD HWWJN IS SUMIE-CT TO ALL THE TERMS.
EXCLUSIONS AND CONDMONS OP SUCH POUCIES-LIMITS SHOWN MAY HAVE BEEN REDUCED SY PAID CLAIMS-
TYPE OF WSURANCE POuCIf Nam Porto EFF 4oucv ew
A X ��+� aI7Y EPK-113772 W0412016 01310d1?A17eacm occuftR NcE >u 1,000,000
aAIMs.MAw F-1o=Lm 50 000
M®EXP A oqY angq _ $ 5 000
PMASO ALaADYINJURY i •1000000
UBMAGGREGATELIAMAPPLRSPFA CIMMULAGGREOATE s 200 000
X PDQ 0�cr F-1 Loc PR0DUC7S-CWN0PAro y 2,000.000
OT14M s
AUIUNOftI p LAhishlI tl N Umar $
ANY AUTO 6MELY IN.IIJRY(P-Pu q)
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DESCRIPTION OPOPERA77 DWaur EL DISEASE.POUCYLUT 3
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Septic Tank Contractor
License 0 SM0941167
C9rMFICATl=HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DIISCREBE:D POLICIES BE CANCELLED BEFORE
�Ilage of Miami Shores THE EIp>IIiATION DATE THEREOP,NOTICE WELL BE DELIVERED Liv
ACCORDANCE WITH THE POLICY PROVISIONS.
10050 NE 2nd Ave
Miami,FL 33037 Auh+o�arrATIVF
SSA
01988-2016 ACORD CORPORATION. AA tights reservod.
ACORD 25(2016103) Tho ACORD name and logo are registered Marla of ACORD
Printed by SSA on November 16,2018 at 10MAM
NOV-16-2016 23:21 From: To:13057568972 Paee:4,16
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_ STATE OF FLORIDA
DEPARTMENT OF HEALTH
o� Operating Permit
13-QG-00059 13-BID%1239669
OSTDS Service-SDS*
issued To: ChaPmen Septic Service Inc courdr. Dade
10601 SW 184 Terrace Amount Paid: X290.00
Cruder Ridge.FL 33157 Data Paid: 09106=10
issued Date: 10/012016
Man TW. Chapman Septic Service inc
Expires Oa: 09130/2017
P O Box 43'1911 Issued By:
Miami,FL 33243 Department th in Dade County
11805 SW 26 Street
Miami,FL 33175
(785)31'$-24"
Owner.Chapman Septic Service Inc(,)
SDS 7Yucke: 2 TTS Trucks: 0
The faa'lhy shown above has-been inspected by a duly authorized representative of the Department of Health,and was found in
cmrfanlaanoe with those nates promulgated by the department under the authority elf chapters 391.386 and 489 part Ili,Florida
Statutes.and set forth In Rulefi4E6.Florida Administrative code
This permit grants authority W operate the above referancad balky.service.or system In conformance with depeftent rules
and the 00nd idens of operation shown below.This pgrzrpt is Womble.upon service of notice,when it is determirned by the
depar5tient that the operational conditions and deparhnent standards are not being maintainvA
This permit is for a septage disposal company. Thick(s)shall be presented for inspection upon request from the departmenL
*08=EoMCc PCn*AbWWAe tO W WS-SeDta9e Disposal SWCe M-Temporary Tanta Service LAS-Land Appllcallon Site
ATUM-ATU Maw Envy LSF-nines StabRizoion Facility TM-Tank Mmudaeturer
CftAtW MrAWer.CrlOMM Septic SWAW ino(NCR TRANSITRABLE) DISPLAY CEMT119CATE IN A CONSPICUOUS PLACE
r STATE OF FLORIDA
DEPARTMENT OF HEALTH
HEAM Operating Permit
13-QG-00059 13-sla3z�asss
OSTDS-Service•SDS
issued To: Chapman Septic Service Inc County: Dade
Amount Paid: X290.00
90501 SW 184 TetTace Data Paid 08/06/2016
Cutter Ridge.FL 33157 lssued Date: 10/012016
>=xplres On: 09/30/2017
Mail Ta Chaptaw Septic Service Inc issued By: Ll—�
P O Box 431911 De wftent ealth In Dade County
Miami,FL 33243 11W5 EW26 street
Miami,FL 33175
Owner.Chapman Septic Service Inc(,} (786)315-2444
NOV-16-2016 23:22 From: To:13057568972 Paee'6,'6
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Bd0fi F r4AMjI.00ATION RECEIPT No. EXPIRES23086
OWUM s ries avlCE INCC23086vaL SEPTET 8ER 33(;,r. W
1460'1 S1dl'84R 2 Muse be disprayed at place of business
MAMLT133157Pursuant to County Code
s Chapter EA--ArL 9&10
OWNEIR $EC.TYPE OF RU61NESS t'Aylvlr;Nrat�CEt n
C1aAPM 4N SEPTIC SERVICE INC 196 SPECIALTY PLUMBING CONTRACTOR Ey TAX C0 T CC:roR
Worker($) 10 SM09411657 $75,00 07/19'%20.16
CHECK21-16-091770
Tbls lnr 8�ines.lax Rceeipt odd CaaGrma payment of tho Local Business Ter The Receipt is eot a GOense.
paunkoeaccrti6GetloAnfthehaldeeaqualificaticAtodobusloese.Holder m=comply witbanygovernmanmF
ormggovsrmmantal•regulaiory laws and regnirememts which apply to the busieass.
TbeXtE1PT NO.above must badisplayed an all eommercad vehicles-Miami-Dade Code Sec an-M
For mm Information,ylspt i. *s
NOV-16-2016 23:20 From: To:13057568972 Pase:2/6
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�q►CORD�' CERTIFICATE OF LIABILITY INSURANCE DATE(MdVDD1YYYY)
10/25/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE'1WEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE BOLDER.
IMPORTANT: If the cerdficato holdor Is an ADDITIONAL INSURED,the Poli0y(1e6)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED.Subject to the terms and conditions of tho policy,certain policies may require an endorsement. A statement on
this eettittcate does not confer rights to the certificate holder M lieu of such endorsement(s).
Pftow= SUNZ Insurance Solutions LI-C ID:(Essential) NoNTA`T Jennifer Hau r
C/o Essential HR.Inc.dba Hrst Star HR PHOtm 9n.404.0295 c No-
4456 LBJ Freeway,Suite 1080 r
Dallas,TX 75244 ADDRESIEft lennifer.haugertMrstoarhr.com
INS AFFORDINGcOVERAOE .... . . NAIc*
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dba FirstStar HR 110JUR 0
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Dallas TX 75244 - ..
INSURER F
COVERAGES CER'nFICATE NUMBER: 32535117 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF iN^WRANCE I,WED MOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWmiSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY P5RTAIM THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCWSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTFt NSR TYPEOFDISORANCE
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AWMWPRIL�T WAJTNIR JnM r/N OM/2095 10!9/2016
0FFICERffA9A0MqXC=ED7 N/A e.I..EACHACGDENT E 1.000,000
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DE3CRIPr10N OF OPERAnONS befew E L DISEASE-POLICY UMrr a 1.000,00
DESCRIP1101JOFOPFRATIo1�/LOCA7ICNelvEHiCtAB(ACORD1rH.AQdI00�w1rwmarkc8eAatlulo.owyDvattocnaaamerorosesters�uYadl
Coverage provided for all leased employees but not subcontractors of:CHAPMAN SEPTIC SERVICE INC.471 Big Pine Road
Locatlori Coverage effective: 10/1!2013
CERTIFICATE HOLDER CANCELLATION
89500042
VE11a a of Miami Shores SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE
10050 NE 2nd Avenue THE E"WATloN DATE TUMMOF, NOTICE WILL SE DIKJVERM IN
Miami FL 33037 ACCORDANCE WITH THE POLICY PROVISIONS.
AU7HORREED REPRFSENTATlvE
Glen J Distefano %JJUJ
01988-2015 ACORD CORPORATION. AllAghts reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks Of ACORD
32535117 1 1 K star cArtlrlcata I MagmaLAWLpa0min.cpm I t0/25/2036 10:09:09 AM LFvrI I Fags 1 of 1
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