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PL-03-21-682
`� z`��\� *,\� \ ziS t\t i t t �ttl 1 e��\�\ t \ �` �� �.�S� f�' �O ��� {\�\ }��,��:.5 �i �\�i� �l.�c � Z�t� f��\ �� �i �1��� ��J�: ..���. ��'i� iti\�� 2�\ �\�\ -�c �\�� 1i> >� ���t\� � .�"" �.`�.\ �� �.Z��t�� s.� ���\� t Z 1.�1t�� i����' � i > � 4� �� `� � -�� ���� ����t i��,� `\7��� � \�..t`1��s �� �� .���\�\'.,f.�y����,���� �x� ��,� : t j�� e 2� �3 �° � t � �j �\�,\\` 1 � - � �� 'i l "R :: � .R� 2� �.� t�l� ��� �� 1 �?� �Z1S� 1��� \��� � ?�"i`1ti�� "C�"' ;� I�CT'11 Sf1�?CE�"�VI�IB�� 1�� ;s ` ��� t } . � s\�z;s; ��� ti�� \���� ti s� �� `t��+$� �"'� � �s 1(3450 NE 2 Au2 ��� l � � \ �\ �� l�� \`t�ir �\z\�� s�\� � � T�� t � eaa � � � � � � ��\ Z �.� � ���\` �lt �t�:���1�.��\t; �' ' R�iami Shores FL 3323$ e` ` � \ l � \���� �,�� `� �� ti. $� `t� ��l�� l t�� �`�. � � ,�\ ����\l��\��i�ti\.14� � s z f Z �� � .� 4�. �,'; �,.'... �s 3Q5-795-2204 �\����}t ti�.`�O;\`11".s�\ � ��� z l�� ��t��i�\��`\\�\���`, { �' �` ��t4 ��, �n�,..,'� �t� � �t,}� �����1�� �� � i�\ � l ��ti ��� � ��€� � ��; �.� �;,ttS'�`.:� \��\����`,`�t��Z��\\\ ���\���?�ti 1�z,\� 11��`���� <<.i �.`�.....��,. �:Y��,.it�.a,t.E.�,.,.�:.\i...�.�..11; .���� ��\����\ ����\� � ��\ ��' �i�� �\�1�. � ,�����1Z.�`�����:,;��,,,,��,����������� �����,.: Expir�ti�n: saJ��J�2oz� ��„ t,.,.., ��,����� locati�n R,ddr�ss Parcel Number ? 92C}t}!V�22Tf��11E,IVli�mi Shores,FI�3313� 1132E?SQiSE?�&tD � 0 �e�nt��ts � Robert Cahen ���A��M�rn�.�����P��mmP^MN�tl_�N`���..�wr��r �uARC PlU�V1�ING CONTRACTC7R lLC�,�F.V�n��Ntl4��.�.���Coe�tr�ctor�� 2 E 9200�1�7�TH AVE,Miami Shares,Fl 3313� RAFAEL CftESPf� ; robco75C�a�mail.com 20S WES'C PARK DR,MIAMI,FI�33172 i � �usin�ss:7542353�28 rcplumbin�cantraetor@gmail.e4m z�.�.�....�_._�....�,_�.,_��K�,�__�....m.__.���.m.�.�. �..� �._�..�...4�,w..__�._.-mm. ,�-�.�._.�a.M_m.�..�.m�vv.._�.�w.a_�,____� ���...__._�... _ � � lnS BChan�e�u�s�fs � �escrip�ic�n:REPCAC£A�ATHTU�AND VAtVE,REPLAC�TW(� �� Vaivation; $�,�50,tt� � o �� , 3 � € SHOWER RANS AND VA�VES AND RESURFA�E FIXTUftES . � �����'�t� � � , � ` ` ` `\�� ` � Ta�al S Feet: 2,600.Ogi ���� ���'L� ���� ��� � � � ��`�� � � 1 � � S Q , \�t�;::� �,;\.. O'�� `. � \� Fees Amount Payments Date Paid Amt Paid Application Fee-�ther $50.Q0 Te�tal F��S $326.37 CCF $2.40 ChBCk#6£�7 04fQ9J2021 $326.3? ��PR Fe� $z.ao �ca F�� $a.00 amaunt aue: ��.o� Educatian Surcharge $0.�0 Permit Fee $56.75 Scanning Fee $3.00 Technology Fee $2.67 WQrk Without Permit Fee $106,75 Work Wiihout Permit Fee-Pfus$200 $1QO.Qd Total: $326.37 t11� 1 � �n� � �fi Ir� considee�ti�n �af the issuanc� to me afi this permit, i agree to per�orm the work covered her�under in eompliance with �II ardinances and regula4ion� p�rt�ining thereto and in strict c�nformiEy with the plans, drawings, statements ar specification� submitted to the proper autharitie� of Miarr�i Shores Village. In �ccepting this permit I as�um� resp�nsibiiity for ail work dc�ne by either myself, my ag�nt, servants, ar employ€��. I under�tand that separate permits are requir�d far ELECTRfGA�, PLUMBING,tviEGHANICAL,WIND01Ni, DC}C}RS, RC?C?FlNG�nd iWIN1tt�ING PC3C)�.work. OWN�R a RF�IDAViT: 1 c,�rtify fhat �kI th� fa€ec�oing informat€on 1s a�c�€r�te and thafi ail wQrk will be dane in compliar�ce �i�h ali applicabi� I�w� regulating�„rc.art�tru�tion and zoning, F�t��n�r�, I authori�e the above n�r��d cantractor to d�tt�e wQrk stated_ .��°`.,�`' �,,,.�''�� ,�°� ..��-g ,..�,w.�..�.� C.:.'.._.-�'""" t__--.' Authorized 5ignatur�:Owner 1 Applicant i Contr�etor l Agent Date Aprif 09,2022 Pa��2 caf 2 ' ������; ����������.�µ� �� i i r s i I 1 �� r,_, � :� 4 . t il i r t � ����g .u�u�.�.�N���v�v��4.w ����n 10050 R1.E.Znd Avenue, Miami Shores, Florida 33138 �re0.��o�}��s-22����x,{�os}���-���2 ' ��� ��s��e��c���En���r�c�n���vE+n�eR:{�o�)�s�-���� � F�c 20 �� :�,. '�. � fUtaster Permit N�. ��� �� � � � Sub Perm�t No� ��--���� ����� �� ❑gui���r�� � ���c-r�ic � �oaF�rvG � �Ev�si�� ❑ Ex-r��s���v �����wA� ��r��in�� � nnEc����c��, ��u��.�cwoR�� [� cHa��� o� ❑ c�r�c�L������ ❑ sr�c�R CC?NTRACTC?R [�R,AWINGS JQB AD[?RESS. � �� t;itv: Miami Sn�res Cauntv: Miami Dade Zip� � Folio/Pareel#: Is the Building Hist�ariGally Qesignated:Yes NC� C}ecupancy Type: load: CQnstruc�ion Type: Flood Z�ne: BFE: FFE: QWlVER: Name(Fee Simpl�Titleholder}: Phone#: � � �� P"l��C�rJ�. 63�� � ��^" . � �. � . City: ��1�� � � State: Zip: �� T�nan�JLessee Narr�e: Phone#: Email; f � CQNT �'t'O#t<Comp�ny�a e• � � Phc�ne#: �� "' �� �` Address: �� � �+ �,� GitY��.. .�`�� ,��, ..�.� nState: �ip: f� 4ualifier Nam�: � Fhone#: State CertifiGation�r Registratic�n#: ��� f� � Certificate c�f C�mpetency#: DESIGNfR:Ar�hitect/Engin�er. Fhone#. Addr�ss: �,,;�,��„a City: Stat�: Zip: � � ��w� ��.w� Value of Wcark for this Pe�mit.$ � SquarejLinear Foc�tage of UVork; Type nf Wc�rk: ❑ A,dditi n te.a Alteration ❑ New R�pair�Replace ❑ DemoliCipn �escription of Work: � 1� � f� ��� � ,..` �� �'� �, � c' � � Speci c�ol�r of��1�r tf�r€� ti1�: su�m��ta��ee� ae�m�t�ee$ ccF� cofce$ Scannin�F��$ Radon Fe�$ QBPR§ NotarY$ Technolo�y Fee$ Tr�iningf Edcacation Fee$ Doceble Fee$ Structural Reviews$ �tantl$ TOT�1E.FEE Nf�W DI�E$ � �� '�� _ `� � (aeviseda2/zaJ2Q�4) � �ondin�Company's Name(if appficable� Bondin�Campany's Address City State Zip Mort�age Cender's Name(i�applieable} Mort�age l.ender's Address City State Zip Application is hereby made ta c�bt�in a perre�i�t�do the v�vrk and installatic�ns as indicat�d. 1 certify that nc��vvork or instailation has commenced priar t� the issuance of a permit and that all w�rk wil( be �erformed tt� m�et th� standards c�f aEl laws regulating ccanstruction in this jurisdictie�n. I understand that a s�parate permit m�st be secured f�r ELECTRIC, PLUNlBING, SI�NS, P�O�S, FURNA�ES, �t�IIERS, HE�TERS,1",41VKS,�IR CO�IDITIQNERS, ETC..... OWNEFt'5 AFFED,AVfT; I certify that all the foregtaing inf�rmation is accurate and that all work will be done in compliance with all applicable laws regulating construction and zonin�. „ A�IVING Tt) OI�INER: YQU� FA►I�URE T� ��C�RD � N�TtCE F CQ �NCE EINT ,�Y RESGf�T lN YCIUR P,AYtNG ICE F�R IMRRQVEIVIENTS Tt} YQUR PR�PER . IF YQU INTEN� T� Q�TAIN FINARI�ING, CARISU�T WfTM YOUR CENQER �R A(V A QRNEY �EFORE RECaR�ING YOUR NCITICE UF �� ENCEMENT." Notfce tt�Ap�alicant: As cr eonditlean to the issuanee of a burlding permit with an estimated vatue exc�eding$2500, the applic�nt must promise in good fatth tfr�t�copy of the notice of carr�rr�encement and cvnstrueti€an lierr tr�w brochure wif�be d�liver�d ta t-he person whose prop�rty is subject to attachment. Alscr,a certifiec�capy of the recorde�'r�otice af commencemerrt must be posiec�at the job site for the first insp�ctfon which occurs seven (7) days after the building permit is issued. 1n the absence af such posted nokiee, the inspectr�an wilt not be ap�aroved and v reinspection fee writl be charged. � .�,,. � � Si�na�ur� Si�n�ture C��tVER or�GENT CC}NTRACTt?R The foreg�ing instrument was acknowledged b�fore me this The f�regoing instrument was acknowledged before me this �`� day of ���� � ���t��.��'o , 2C�«� � . by �� day�af `� �1. ,�0 � r bY � �".�'�� ���'�-� ,+uht�is persor�ally known to � �������t�,____�wrho is perse�nally knc�wn ta me�r who has proc3ueed �?� l�4 as me c�r who has produced as identification and who did take an oath. identification and who did take an aath. NOTI�RY PUB[.IC: NQTARY PUBLI : �� � �; t � , �,.,,._ Sigrt; -�--�` � Sign: Prin�: � � . � � � �_ �� .. Print. �. � �'��,�,.� Sea€: Seal: t� ';a � v �:� � �ab"�;a��nt�a '� 'i.�t�r ��� tdCZ �U � , �_ � _4 � €. .G.2€a' S J ud ^ 'a n �',.:� i.Q('t"7'CS,wC'-°ts`��f -:i�tiU ��^ i��i � _ l, 4 . ***�*��z� �c"�'�. tt�m � ����,*�:���*���� **��*�*��***�����*� �����**�.���wt���!�����QN� ��w�*����*:�*:������ .� *n�`�:.� _xm� � _,,.. �� _ ,� �_ ..,;� �...4r. °�:t�^ __., �� .,�C'�F� `��.._�� ^;�tn�ri�_,: �t:��� �«t�„,,; " ��*�. APPR�VEE�6Y Plans Examiner Zonin� Struetural Revi�w CEerk {RevisedQ2J24J2014} r %9I1���:`"�'�u�:, � � ./ ./i/'��/�'.�f.//�'"" � , , � ;��,�,, ,; s . l/d/�/��F`���✓��`"5��//�� r�`� �, . /%f�� / �/✓ii'F".' � x � ���✓'� � �/%Jf 1��"'��`� =i � ������� � � � � ���� i,:, %i� ��v ��� „,��'- f ��;�,%w f ��� ! � r �. : . �-, �?%: ��f: �rr dl'i ��; ,����' r�� ��� %�,�`,�; ��~ r�� w ��F` ��` � �� ,��. �µo- � ������������\\ .. . �z � h�C�,i�����t}� � , t 1��'a. � i t .. �``��C�� �\� ,�., 3���'.��i� ��\l.�`��,.��\�.�'1� � �`'g ��`�����nY���� �3�� ��t�� ���������� i ����`����,�` ����j��t���`� � �tl, bLSi����\��f�`���� = f� ���y� �..���}}���1 � � �7 ���1��,�„1��������y �'.:^�: ��,����, �L �t k��,����1���`. t�t� �������t�����:4t ����������� �Z,,`�` �S �y$��4 � ���� � �� ti g\k\ �� s � �������� .�������� �. � ���`����,o �l,r�����\ �3� ,: ti ji��'�� ,�} ����i������:� � Zt����� � -;� �������1`;. ���\�Zt�t t�����L u�i��tat : ���` ��`�t r �� ���`'': ����: ����� �� � z � � °TI I 1' LI � I�I�fY 1 °A��f��}D°`r,�) �--.., a�tzslza�l TtiOS CERTIFIGAT� I� ISSUED AS A MATTER t}F lNFCC)FiM�A'TIQM ONLY ,0.N� GQiVPERS P{C? �I�HTS UPt?N 1'H� CERTfFICAT� HOLDER. THIS G�R'�IFECAT� G}C?�S t��T AFFIRMA'fi��L`f aR N�GATiV�LY a0.MENL�, �X'f�N� QR ALTEFt TH� GCJVERA�� �FFORD�CT �Y TFIE PC}E.I�E�S a�Low. °r��s c�t�°r���c��r� c�� ��su �ce ���� �a� ca�s�r��ru�� � �ca������ �� EE� r�t� ���u��� ��sur���f�), a�TNo�tz�� �ERR�SENTATtVE C)Ft�R{1DUC�R,ANCt THE GERT�FIG,�T�NOt�DER. IMlPOFtTANT: If th�c�rkifrcate h€�Ider is an ADDITIONAI�tR1�UR�D,tMe poii�y{i�s}must hav�ADDtTtOMAL ENSt1��R provi�tons ar k�e endor��d If SU�Rf�GATit}N IS WAIVEQ,sut�j�ct ta the terms and c�nditions of th� palicy, certain pc�licies may requir�an�ndorsement. A statement�n this c�rtificats dae�ncat confer r6ghks ta the certificate h�Pd�r in iieu af such�ndearsement(�). ��oouc�a cor�vAc�r w�.��: Miscox Inc. �'w��� 888 2Q2-3007 Fa.'e c do.�x�: ( } 4nrc,�o}: 520 Madisan Avenue �•�p�a� — ____ ADDR�SS: GO[1taGE{Ci�htSGOX.Gflt7l 32nd Floar -- - - ---- ----_ --- _i—. _ New York,NY 10022 iwsura��s ,��Fo�zoir�c c�v��aGe _____ r�aic� ENsuRERn: Hiscax Insurance Company€nc 1020Q _ __ _ __ _...___ _ _ ___ IN�uR�D .. .tNSURER�: RC PLU(Ut�ING GONTRaGTQR�E.G __ � _.__� __. 15349 Sw 39 Ian� �a�su��z c: _ � ___ Mi€�mi,F�33185 Er�suRE�o; IFtSUR�Fi E: INSGRER F: �QV�FIA{'sES �ERTIF�CA'TE {�U�fl���: REV��fQR} NU�SER: THIS !S TQ CERTIFY THAT TNE POLEG(ES OF IN6URANCE LISTED BELOW HAVE BEEN ISSUED TO THE IPJSURED NAMED ABOVE FQR THE PC?LICY PERIQD IhlDICATED. NQ7WETHSTF�NDING ANY REQUIREMENT, TERM QR CONDl�It3N C}F ANY CONTRAC7 C?Ft C7THER Df3GUMENT WITH RESPEGT TC?WHICH THES CERTfFIGATE MAY �� lSSUED QR M�Y PER�'A€E�, THE €NSURANCE A�FC?RDEQ �Y THE PQIiCIES DESCRIBFD HEREIN IS SU�JECT TQ ALL THE TERftfiS, EXCLUSfONS AND CPNDITIQNS 4F SUGM PO�IGEES,LIMITS SHOYVN MAY H�VE�EEN REDUCED�Y Pf1lD C�A!(V9S. ENSR� � ARt?t;SUBR: . . . .. ,P CY EPF'T Pt}L1CY EXP � - lTR TYPE Qf INSURANG€ i R£}!.t£Y NUA98ER � h1A9lDDlYYYY ! t.9A91[?4IYYYY LIA�FTS � GOMMERCIACCxENERA�LEABIIiTY i j ERCHOC4URR�NGE $ 1,OQQ,O�� -- - 1 aaims•Ma,oE �_j occuR �a�n'a��'�o�teNr�o�- � -- iQQ000 PREMISES(Ea occurrence � ........ _ MEQ EXF(Any one person) $ �J,QQd A �� __ � N � UDC-4465959-CGE�-2Q Q412112020 , (�4121i2021 P������E$aovEr�.�uRv � 1,OQO,QQO '=-GEN`L AGGftEt'aAT�k.IM[T APPLIES PER: � GEN�RAI.RGGftEGR7E i� `�,OQO,OOO i� POLICY�J��cT ❑�Oc � �Rs,oQucrs-cQr��FOP AG� -� 2,OQQ,Q00 � �_ �� I aTr�e�: ; AUTtJR4C}BILE IIABIL�TY � COM6INECl StNGLE LIMIT � . ... Ea accideni -- -- �ANY AUTQ BORlLY INJUftY(Par parson) � �OWNEC� `�.SCHE�ULED ; ��LY iNJIlftY(Per acr.rdefltJ � .... ��UTOS ONIY '��AUTpS ' . = � N1RED f NC.�N-OWNEU ; i PROPERT`f OAPv1A�E � . .� .....�,AUTC15 ON�Y �_ ;AUT4S 4N�Y � ' ' . ..... � � ' P�r accident _____ I I ' � � UM�FEEG.�A�IAB �;I pCCU63 i E�1CH QCGURRENCE $ EXCESS LIAB i � ..^��.���� ........... . �GLAIMB-MADE � AGGREGAT� $ � p�D ' � RETENTEON� i � � WCSRKERS COhAF�NSATtON ; i � PEFt QTN-. .. AN��,NIP6.OYERS'CtABIt�tTY Y/N � I i . STATUTE ER � A,NYPROPRIETOftIPARTN�RIEXECUTIVE i � E k EACH ACGtDENT � OFFIC�RTM�A�BER�XCIURED? � NlA; . .. — _ {t�4assdatory in NH) �.G_D(SEASE-EA EMP�OYEE $ If yes,descnba undar `�" ��� `" ��� DESCRIRT'IQN OF QPE6�ATIpNS t�elow E.�.DISERSE-F'QLlCY LIMIT�$ ( i DESCREPTif>N OF OPERATtQPtS!L4CAT€ONS t 1�EMtC�ES (ACORD 901,Additional R�marks Seks�dute,may be attached#mars�pac�ia requlredj Plumking Gontractor C�RTIFIGrATE HOl�D�R GAMGELLATPAN i�iami Shores Viliage HaIE Building&Zaning 10R50 NE 2nd Ave SNt�tJLp ANY CSF Tti�A�t?YE DESGRI���P4�ICE�S�E CANCELLED�EFC3R� Miam€8hores Fi 39138 TH� EXRiRAT(QN E�ATE THEREQF, NOTICE WI[.k �� ��LfVERED !N AGCOP2DANCE W!T'H TH�POLfCY Rf2C}ViSII?NS. AUTH6Rt2ED REPRESENTRTtYE ` a � ,�, €,a��'��" .�, ._..<.t. r_ CG?19�$-2Q15 AGARD GOR�ORATICIN. AMI rlghts ceserved. �GARR 25(2Q16lU3} The ACQRG�n�m�and I�g��r�r�g��tered mark�a#AG�R� ���QR�� � � � �� i�mi hc�r�� ill�ge � .." �'.. Buildin� �p rfim��� `�`�°,�,;�, #���"� 14Q50 N.E.2nd Avenue '�"��!�'t'�"��`' �� Miami Sh�r�s, Fl�rida 3313� `fel: {305) 795.2204 Fax: (305} 756.�972 Moti�� to �wr�er — orkers' G� �r��atian Insurance Ex�m tion � � � � � �z },�� . � � � �.; ` , t., n.xt � , � �, � � �,{ . , , t, �� � �. � � .t, � ,,,� � 1� � � °� � �u � �r � „ ��� �., , � � � , 1� � ���, � �_' ti �,,, � „�, �.1� � ti a,. t �a: .ti. �,�- r=',.�,>. ��.��„4 ���. � .}. �`��} Sz ,.\�� �r� � ti3.,.. ::,��., \��1� � �-z :4 �`�..�,, l :E.�:�. �`�: -.,� ,S,``,,, ti1�-��v t�:� -7, �t„ 1>'� �� „�,��., :, .�\,�v�. \t .;\��i.,.ti t€;i.`` Z,�, .,���`�,��;�i�i1.<��,'t�.,a�,�ti.`\<�},,z;`�`�Z,%1`>\�'4��1'3��`\C���°,ct,< i�1���'��tt`R�^t{"��`�'a,t;,Z��1k.�,`�� �3fi` '�� ���`c�,l�{a�,�1> ttr, t���<,�<.4�4 '�,�r�`i`til:a „� ��,t,� �'„ ,t .`., .�, 4 1 ��,v \A� .A. �A\. t� „h,�.�, ti� �'Ic�rida Law reyuires Vvorkers' Compensation insuranee coverage ut�der Cha�ter 44t� c�f tl�e Florida Statutes. F1a. St�t. � 440.(}5 allaws corporate afficers in t1�e cor�structian is�dustry to exempt the�nsel��es fi�om t�tis requiretnent for any con�tr��ction projeci prior tc� abtain�n�a bui(ding perTnit. Pursuant to the Florida Di�=�isioi�of t�'arkers' Compef�satic�n �n���tayer Facts Brocl�ure: � r�,n eF��plovet- in t}�e 4onstruetial3 industr�° wl�a enl�loys one ar lnare part-tin�e or futl-time ! e1l�plc�yees, incluclit�g the o��ner,�I�ust obtain i�rt�rkers' c�r1��7e�lsatic�n eQveraQe. Cor�orate affleers � ar t���z��bers af a lir��ited liabilitv cort�pan� (LI.C} i« the ec�nstr�ictian industr� �na�` elect ta be exempt if: 1. The officer�wns at least I O perceflt c�f the stoek af tl�e cor�oration, or in t}�e case of a��L,LC,a stateinent attestin�ta t1�e n�i�li�nuin I t}pereei�t awnersl�ip; ; 2. The c�fficer is listed as ae� afficer of th� cQr��r�tfan in the records af the Florida I�eparhnent of State,Di��ision of Cc�r�pe�rations;a�1d 3. Tl�e carporation is registered and listed as active �vitl� the Florida Departn�ent af � State,Divisia�l of Carporatians. ;�Q �2�ore than tl�ree cQrpor�te officers per corperatio�� ar [imited Eia6iliCy cor��pany nlem[a�rs are ) al}owed t� t�e �xempt. Construction exen�ptio��s are t=��id fc�r a periad af two }�ears or until a � � voiuntary revc�c�tian is filed or the elen�ption is revaked 6y�the DivisioT�. Yc�ur corltractor is requestir��a per�nit�znd�r El�is workers'cc�rnpensatic�n�xen�ption anel has aeknawledge that IZe flr til�e��ill i�c�t use da}� labar,pat-E-ti�z�e emplQ��e�s ar su�cc�ntractors for�=aur prc�ject.TE�e eontr�ctor has pro�ided an affid�vit statif���hat he or sh��i11 Le the oflly pers�n�llow��d to��orh an yaur project. II�these cir�u�nstances,1�1ia��i Sllores Village does nat r�quire w��rification of ��rorkers'con�����sation insurance caverage frc�tl�the c�ntractor's coz�l��z���fc�r dap°la�or,part-tiFT��e�nplQyees or s�it�coi�tractors. � BY SIG\I'tiG BELC��= �'C?t, .1CK'�t�«'LEDGE THA� l'4L H:�VE R�.�I_l TH1S ?vQTICE .�?vI) t;NL7ERST.�'�C� ITS : CQ'VTFNTS. � � x.r Signature. � -- ____ -- C)wner State of Flarida Counry of zvtia�ni-Dad� The faregoin�was acknowled�e befc�re me t}lis ��� day of_������""} ,20��_. ��—���������'�� .'q��.�� wha is personally knv�1 r�to me or has produced �� � . ._ . � ____ __ as�de�lt��rc�tlo��. � p����.�' ,.��,����� Natar}�: �� -___— �g�; ;,�: t�fYGC?AdhtPS�( �AFV�k,� ��' �XP� ���971 t0� ��"l������" RES: SEAL: t.�,�, �a �'heu N ��2�2� � �� ..j.. S rx�l } 4Z�1\ 1 T�?' 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