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EL-14-1541Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-217343 Permit Number: EL -7-14-1541 Scheduled Inspection Date: August 19, 2014 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: MARCUS, LINDA Job Address: 361 NE 100 Street Miami Shores, FL Project: <NONE> Contractor: BRITE ELECTRIC comments Work Classification: Service Change ;JMOTMZMIll STM Parcel Number 1132060135380 Phone: (954)214-7908 INSTALL NEW 200 AMP METER CAN RISER AND 200 A I ..... '" r_"`_ PANEL INSPECTOR COMMENTS False Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-217154. CREATED AS 1:2 REINSPECTION FOR INSP-217091. O. K. to connect service. F P L notified. 6 aug. 2014 Failed ❑ F P L not connected. Correction' Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. August 18, 2014 For Inspections please call: (305)762-4949 Page 16 of 27 Miami Shores Village Building Department JUL 162014 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 ,. Tel: (305) 795-2204 Fax: (305) 756-8972 �-� `---- INSPECTION LINE PHONE NUMBER: (30S) 762-4949 � FBC 20 t BUILDING Master Permit No. LZ // — PERMIT APPLICATION Sub Permit No. JOB ADDRESS:' 1361 P- t 1 oO ST' City: Miami Shores County: Miami Dade Zip: 33 /39 Folio/Parcel#: // -:5-20,6 - 0/-3 "5.3SO Is the Building Historically Designated: Yes NO Occupancy Type: Rt` Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder):_ I I tj bA ffi&z<fj.S Phone#:5e-Z9'-- 757 Address: v� ` Al- • G5- Ida 5-1% City: M1,0171 511-aQt3S State: F -e I Zip: 3313 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: O R r m et.ec-r"R f e- Phone#: q S y`a1+7?d0 Address: Yv,'S "'Oy - xt®e< City: T. ,r wA , State: FL Zip: 3 336 �j Qualifier Name: `�jr M9`/ E.: ekRg'I h6Z. L Phone#: W -2d--i r9/9� State Certification or Registration #: e e A® ® ® / 032 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address City: State: Zip: Value of Work for this Permit: $ Q./o®<®® Square/Linear Footage of Work: Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: Q� N CrV L z, 46tE" °�, �JL'+ A�aiP> 5 'i7dr(L. G•a'/+� �/� a2 Specify color of color thru tile: Submittal Fee $ Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ ❑ BUILDING at ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLICWORKS ❑ CHANGE CONTRACTOR ❑ CANCELLATION Ej SHOP DRAWINGS JOB ADDRESS:' 1361 P- t 1 oO ST' City: Miami Shores County: Miami Dade Zip: 33 /39 Folio/Parcel#: // -:5-20,6 - 0/-3 "5.3SO Is the Building Historically Designated: Yes NO Occupancy Type: Rt` Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder):_ I I tj bA ffi&z<fj.S Phone#:5e-Z9'-- 757 Address: v� ` Al- • G5- Ida 5-1% City: M1,0171 511-aQt3S State: F -e I Zip: 3313 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: O R r m et.ec-r"R f e- Phone#: q S y`a1+7?d0 Address: Yv,'S "'Oy - xt®e< City: T. ,r wA , State: FL Zip: 3 336 �j Qualifier Name: `�jr M9`/ E.: ekRg'I h6Z. L Phone#: W -2d--i r9/9� State Certification or Registration #: e e A® ® ® / 032 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address City: State: Zip: Value of Work for this Permit: $ Q./o®<®® Square/Linear Footage of Work: Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: Q� N CrV L z, 46tE" °�, �JL'+ A�aiP> 5 'i7dr(L. G•a'/+� �/� a2 Specify color of color thru tile: Submittal Fee $ Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and o reinspection fee will be charged. Signatur Owner or Agent The foregoing instrument was acknowledged before me this ` day of 2014 -by Ukl gel, 'A00 -K& who is personally known to me or who has produced V-wY�fS uc ° As identification and who did take an oath. NOTARY PUBLIC: CAROLINA MONTEALEGRE ® NOTARY PUBLIC STATE OF FLORIDA Comm# EE152305 Sign: Print: (14r til,a IV(dYlJ&J6Jf4 My Commission Expires: h- /i L / {`f Signature Contractor Q The foregoing instrument was acknowledged before me this! day of4� 20,(, by S 1 d &8Y o�G/J7d��QS who is personally known to me or who has produced �ir�+lef'� i✓'c ° as identi an RE NOTARY PUBLIC NOTARY PUBLIC: STATE OF FLORIDA Comm# EE152305 C r' E Expires 12/11/2015 Sign: Print: r alio�a VACV� Zai 12�r� My Commission Expires: 12,1 it APPROVED BY Plans Examiner Zoning Structural Review (Revised02/24/2014)(Revised 5/2/2012)(Revised 3/12/2012) )(Revised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007) Clerk AC# 6.2 2 8 7 81... STATE: OF. FLORIDA' DBPAR STIK TCZ'IICATsCOARIS RS LICffi+T HQ TON SEW L12072601512 0.7°' 26` 2:OI2 �2700.4D5rS 19000010 ! Th® >ELEC�'RI CtSN�RACTOR, �, A Named bel.bit I$ CLR1tIFILD trader the provisions of -'Chant upiratimi date: AUG .3:L, .2014 ,, ..-S HRISIDNBY F rrw 4 i HR.ITE: C 3325 GRIFFIN RD SIIITts*#267 FORT LAUDERDALE FL 33312„ RICK SCOTT GOVERNOR nrccr'AV AR RFni IIRFn RY LAW KEN LAWSON SECRETARY 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2013 THROUGH SEPTEMBER 3o,2014 DBA: BRITE ELECTRIC Receipt #:��RICAL/mss/CONTA Business Name: Business Type: (ELECTRICAL CONMcTOR) Owner Nam: SIDNEY F SCHREIDELL Business Opened:o9/16/2005 Business Location: 4631 SW 42 AVE State/C0untY/Cert/Reg•EC0000103 FT LAUDERDALE Exemption Code: Business Phone: 954-214-7980 Rooms Seals _ Employees Machines Professionals 5 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non -regulatory in nature. You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: SIDNEY F SCHREIDELL 4631 SW 42 AVE FORT LAUDERDALE, FL 33314 2013 -2014 Receipt #OIA-13-00000186 Paid 10/03/2013 29.70 ror verairig Business Onry Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee penally Prior Years Collection Cast Total Paid 27.00 0.00' 0,00 2.70 0.00 0.00 29.70 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non -regulatory in nature. You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: SIDNEY F SCHREIDELL 4631 SW 42 AVE FORT LAUDERDALE, FL 33314 2013 -2014 Receipt #OIA-13-00000186 Paid 10/03/2013 29.70 7/14/2014 7:00 AM FROM: Lion 727-937-2138 TO: 9549731041 CERTIFICATE OF LIABILM INSURANCE Date 7/14/2014 producer; Lion Insurance Company Ttds cerifficate is issued as a manner of information only Md confer no 2739 U.S. Highway 19 N. Holiday, FL 34691 rights upon the certificate Holder. This Cerdficate dam not amendl, extend or alter the coverage worded by the pokes belOw' Insurers Affording Coverage NAIL (727) 938-5562 Insured: South East Personnel Leasing, Inc. 8t Subsidiaries 2739 U.S. Highway 19 N. Holiday, FL 34691 Insurer A: Uon Insurance Company 11075 Insurer s: Insurer C: Insurer D: Insurer E: Coverages The policies of Insurance listed low have been issued to the insured named ebwm for the policy period indicated. Notwithstandmi; any requirement, term or cmiditin o arty contract or other documerl with respect to which this certificate may be issued or may pertain. the Insurance afforded by the policies described herein is subject to all the tames, exclusions, and omnlifions of such policies. Aggregate limits stem may have been reduced by paid claims. INSR LTR ADDL INSRO Type of Insurance Policy Number Policy Effective Date Policy Expiration Date umits (MM/DD/YY) (MM/DD/YY) GENERAL LIABILrrY Each Occnrnmas $ Commercial General Liability Claims Made 11 Occur Dame to rented promises (EA occurtence) Iced Exp Personal Adv Injury neral aggregate limit applies per. Policy 13Project 13LOC General Aggregate Products - CompfOp Agg UTOMOBILE LIABILITY combined Sime Limit Any Auto (EA Accident) Bodily Irlisy AU Owned Autos Scheduled Autos (Per Person) 9odily troy Hired Autos Non -Owned Autos (Par Accident) Property Damage (Per Awderd) 3 EXCESSIUMBRELLA LIABILITY Each Occurrence Occur ❑ Clabus Made Aggregate Deductible A Workers Compensation and WC 71949 01/01/2014 01101/2015 x I we 8tatu- OTH- Employers' Liability tory Limits ER E.L. Each Accident S1.000.�0 Any proprietor/partner/executive off car/member E.L. Disease -Ea Employee $1.0001000 excluded? No If Yes, describe under special provisions below. E.L. Disease - Policy Limits 1b1.000.000 Ether Lion Imurance Company is A.M. Best Company rated A- (Excelietrt . AMB # 12616 Descriptions of Operadone/Locations/Vehicies/Exclusions added by EndorsemenUSpeciai Provisions: client ID: 30-03-288 Coverage only applies to active employee(s) of South East Personnel Leasing, Inc. & Subsidiaries that are leased to the following `Client CanpW: Brite Electric Coverage only applies to injuries Incurred by South East Personnel Leung, Inc & Subsidiaries active empbyee(s), while working In: FL. Coverage does not apply to statutory employee(s) or Independent contraclor(s) of the Client Company or any other entity. A list of the active employee(s) leased to the Client Company can be obtained by faxing a request to (727) 937-2138 or by calling (727) 938-5562. Project Name: FAX 964973-1041 & 964-791-9416 & 305-756.8972! ISSUE 47-14-14 (17D) Benin Date $1111202 CERT9FICATE HOLDER CANCELLATION VILLAGE OF MIAMI SHORES Stroud any of the above descAbed policies be cancelled before the expiration date thereof, One issuing insurer will endeavor to mail 30 days written notice to the certificate holder nam to the left, but tailors to do so shall impose no obligation or liability of arty kind upon the Insurer, its agents or representatives. 10050 NE 2ND AVENUE MIAMI SHORES, FL 33138 A/'®� R� CERTIFICATE OF LIABILITY INSURANCE TE °ply Q�4 'r' PRODUCER Annette Willis Insurance 18401 N.W. 27 Ave THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Miami, FL 33056 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # Phone (305) 625-2403 Fax (305) 625-6472 INSURED Ju -My -Da Corp DBA Brite Electric SIDNEY SCHREIDELL # CGCO11086CGCO11086 INSURER ATLANTIC CASUALTY INSURER B: GRANADA INSURANCE COMPANY INSURER C: INSURER D: 4631 SW 42 AVE INSURER E: Ft Lauderdale, 171 33314 COVERAGES INSURER F: THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR L ADD'L RD TYPE OF INSURANCE POLICY NUMBER p NFF D� ppuI NNEXPPIIRATION LIMITS GENERAL LIABILITY Q COMMERCIAL GENERAL LIABILITY L039003468 12/11/13 12/11/14 EACH OCCURRENCE 1,000,000 PREMISES E-RENTED o curence 50,000 MED EXP (Any one person) 5,000 A ❑ ❑ ❑ CLAIMS MADE 0 OCCUR ❑ PERSONAL BADV INJURY 1,000,000 ❑ GENERAL AGGREGATE 2,000,000 PRODUCTS - COMP/OP AGG 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: W POLICY ❑ PROJECT ❑ LOC AUTOMOBILE LIABILITY ❑ ANY AUTO 0110FL00010163 01/14/14 01/14/15 COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY 10,000 ❑ ALL OWNED AUTOS B ❑ ❑d SCHEDULED AUTOS (Per person) BODILY INJURY 20,000 (Per accident) ❑ HIREDAUTOS ❑ NON OWNED AUTOS PROPERTY DAMAGE 10,000 (Per accident) ❑ GARAGE LIABILITY AUTO ONLY- EA ACCIDENT OTHER THAN EA ACC AUTO ONLY: AGG ❑ ❑ ANY AUTO ❑ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE AGGREGATE ❑ OCCUR ❑ CLAIMS MADE ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' UABUM ❑ ICY T,AM,TU7 - ❑ OR - E.L. EACH ACCIDENT ANY PROPRIETOR / PARTNER / EXECUTIVE E.L. DISEASE - EA EMPLOYEE OFFICER / MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below LIMIT E.L. DISEASE -POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS ELECTRICIAN LICENSE #CGC011086 LICENSE# ECG0000103 fnenT 01f%ATo ury nco CANCELLATION ACORD 26 (2001108) 4F " ^vv"'A """' "•`^ """ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL CITY OF MIAMI SHORES BLDG 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY 10500 NE 2 AVE OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. MIAMI SHORES, FL 33138 AUTHORIZED REPRESENTATIVE -' - ^ ----^^ATI^\I A. ACORD 26 (2001108) 4F " ^vv"'A """' "•`^ """ New O gC ITY A COPY N5ry 4eM C4AI R lst'PL + lvev'#AQ h,64D(®v8R fv'� 1 m,&4eNTrO dae/ Wigi-L c4NQ 9"ODS iyP• EL. ei- -rp, l az 91.56k Lca,✓a��raa. �G�D oZ 31) A Le A pot , r—/,2 . ix lit' = 3.0 i A eF2/6elzA-r'vA, = /.S' l W 5Me- & = l .'r I D 2 yElL = 5•® 1 QAN&.9 1 DrSfi k/4S/J&V 3'V. / k. /.l. / Cr / 0 /< W 0 J00.,% � =-x 9,65 VOz-r x 9/. q. L.,AtDA 361 /V.,'. sy FERMI T��ly r��tl�'1 I All?I llapgs 23139 g,114_ _j� P] Miami Shc:res Village , �pP lVAfCOAELO PEREZ Notary Public - State of Florida APPROIVED BY DATE N��; "�; My Comm. Expires Nov 9, 2014 I71°,P. Commission # EE 41078 ZONING DEPT Bonded Thrcu National Notary Assn L aV��%/i STATE ANLj Cr,I-jN , f HUL—S AND t�tJl�'nCrl `lr l S.W. Jl AYE. FT. LAUDERDALE, FL 3331gV(W4) 214-71908 9 Fox (854) 781-9418 REI 7635fc1890 Prepared by and return to: MORTON R. GOUDISS, ESQUIRE 1111 Lincoln Road, Suite 325 Miami Beach, FL 33139 Folio # 1 j - ®4a bl b -6 396 Grantee's Social Security No.: Vol - U - 9@-7 9 (Mary Patricia) QUIT -CLAIM DEED 7Pq.20IP 12 1 1997 MAY 127 12.3 DOtSTPOEE 0.40 SURTX 0. 00 HARVEY RUVINF CLERK DADE COUNTYP F THIS QUIT -CLAIM DEED made this,02y day of , 1997, by and between RUTH S. WOLFE, a single woman and the unremarried widow of Richard E. Wolfe, Deceased and MARY PATRICIA FLEEMAN, a single woman, GRANTORS whose address is 361 N.E. 100th Street, Miami, FL, 33138 and MARY PATICIA FLEEMAN, a single woman, GRANTEE whose address is 361 N.E. 100th Street, Miami, FL, 33138. W I T N E S S E T H: That the GRANTORS, for and in consideration of the sum of Ten and no/100 ($10.00) Dollars, and other good and valuable consideration, to them in hand paid by the GRANTEE, the receipt of which is hereby acknowledged, does hereby remise, release and quit -claim unto the said GRANTEE forever, all the right, title, interest, claim and demand which said GRANTORS have in and to the following described real property and improvements, lying and being in Dade County, Florida, to -wit: Lot 20 and the West 1/2 of Lot 21, Block 39, MIAMI SHORES, SECTION 1, according to the amended plat thereof, as recorded in Plat Book 10 at page 70 of the public records of Dade County, Florida. all the estate, right, title, interest, lien, equity and claim whatsoever of the said GRANTORS, either in law or equity, to the only proper use, benefit and behoof of the said GRANTEE forever. IN WITNESS WHEREOF, the GRANTORS have caused this Quit -Claim Deed to be executed on the day and year first above written. W nesses: Signature �1. AMESk Pri ted Na ignature Printed Name -1- GRANT7 '� , "!,-q � V tL RUTS S.?,WOLFE,' a singlev woman and the unremarried widow of RICHARD E. WOLFE, deceased Qg,-. 'at_ Signature Pri ted ami S gnature t wj�a od Printed Nam STATE OF FLORIDA ) COUNTY OF DADE ) ss: RE�FC: 1 7837635N,18') 1 MARY PJMRICIA FLEEMAN, a single woman I HEREBY CERTIFY that on this day, before me, an officer duly authorized to take acknowledgments, and administer oaths, person- ally appeared RUTH S. WOLFE, a single woman and unremarried widow of Richard E. Wolfe, deceased, who personally known to or who produced a �� P►r.� as identification and,who took an oath and executed the foregoing instrument on the 9L&iday of , 1997. Tommi s s iorOpires BAa4a OF rti„� , VAMB.Moftn� "DC. St cwrvft +,on ,+ CC 61..5_15 WATE-OF FLORIDA ) COUNTT OF DADE ) ss: yax��d NOTARY PUBLIC I HEREBY CERTIFY that on this day, before me an officer duly authorized to take acknowledgments, and administer oaths, person- ally appeared MARY PATRICIA FLEEMAN, a single woman who is personally known to me or who produced a t91avZW_. r,., b" ' as identification arkcl who took -an oath and executed the foregoing instrument on the Q ay of 1997. My Commission Expires: BMA► L Ennro NC*n PWft - saat of Florida KV COMOUM EWM Jan 24.20®1 Cion 6 CC 615626 Quit6 -2- RECORUW IN 0ARC jS BOOK 61-,D4CIECOUNrI, aomc, RECORD VERIFIED fiARVE'Y RININ CLEW cIRCurr COURV. executiona-n d -Atte tat ,s t )n I sign my name tothis, my Will, and being duly sworn, declare that Isign voluntarily for the purposes exprbssed -therein- and am of lawful age, of sound raindand',i4dernttpdue , CUPP �W A -i.J (Testator,) The undersigned witnesses being duly sworn, each declares that the Testatorsigned this Will co ps� *s ting of.one-page with,writing on both sides thcreof,,at-the end thereof, and -vU--.'*'h*IA prP and signified, published and declared inlour presence that this., instrument is his bg Last Will and Testament, and -,tha,t-at-tjierequest.of=di Or. uencd-dfl*tgot 0& the p-resenvooftach other and jA the -presence f I I , A�.'" N—t-1- I - - as,v witness to Testator signing this S#bA h hist 0, a- 0 Public each as subscrlbed his _name to this Will vi -day-of =A 66�=Tt Is of lawful; age,:9f s"ad County of City orlown xf Subscribed, sworn to i-nd"acknoWledged before me *the Testator �j cx-f� LI- 4 and A'Q the witnesses, this �4day of 49 Notwy P.bftState of"Plaids S B AftftfWn IJ 3W' 'g MyociMdi�DDU Lao, 4V and Testament Unmarried Individual with One Beneficiary � �� g. N I, .�--Ott.%'H, presently residing at do hert"ake;•publish an# d deelare this tdebe my Last Will and Testament and do hereby revoke any and all other Wills and Codicils heretofore made by me First. I am an unmarried person. I do hereby give all my estate to the following named person: second rn the event ttiat ttse said- cx", A 421 i T*— _ shallpredecese>me, i give all of my estateYto.11 AA -.q,', Third. I order and direct that my just debts and funeral expenses, expenses for,administrntion of my (state a d any'i nheritgnce and successian;taxes, state or federal, upon my estate shall be'paid as so6n after my . detih `�inaybe practical .. Fou' rth. I nominate .� =nr pp ro as xecuto?Y' Z✓iecutrix of this, WilIt i t�fie-event that he/ she sh . pre ecGasemcor aids to survive me or fails o--serve as Executor/ Executrix then I nominate and`,appo' Executor/ Executrix of this my Last Will and Testament. I further direct that no appointee hereunder shall be required to give any bond for the faithful performance of his/her. duties. Fifth. I hereby authorize my Executor/ Executrix to exercise all the powe> , nghts, , ' etions, duties and immunities conferred upon fiduciaries to the extent permitted by law with 1 power to sell, lease, mortgage, invest, reinvest, or otherwise dispose of the assets of my estate. P g W scribe my acme tp thxs will,tliiis Day of , w ,am j . »tee. (Sign here) Signed; sealed;'i*,t lied;.apo Oeclar to be his/her Last Will and Testament by the within named Testator in the presence of us, who in his/heerr``presence and at his/her request,in the presence of each other, have eunto s c ed our names aswitnesses this day of A (1 of lccc,-c (City) uzw (State) (City) (State) (3) (City) 1990 by AFBP. All rights reserved. (State) 5