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Home My WebLink About2603 Elm Ave; 17-2624; PLUMBINGJob Address: Z tp o 3 J, n BUILDING & FIRE PREVENTION PERMIT APPLICATION Application No: Documented Construction Value: $ I Historic District: Yes No K Parcel ID: 01-20 -30 —Saco —666D — 4cSo Residential Commercial Type of Work: New Addition Alteration ® Repair Demo Change of Use Move Description of Work: pfQmb Aayse , _,t.e_.e-&4-t...?/1a5L4L4 -'dwla ca Plan Review Contact Person: Phone: Fax: Email: Property Owner Information Name zq t_.0 Sasrrlvr, Phone Title: 32/--(o9& —/r77 Street: ZCo6 3 S . E /h Av-e- Resident of property? : City, State Zip: Sa vJ6,ed rL 327 73 Contractor Information Name Street: City, State Zip: Name: Street: City, St, Zip: Bonding Company: Address: Phone: Fax: State License No.: Architect/Engineer Information Phone: Fax: E-mail: Mortgage Lender: Address: 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. 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 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. FBC 105.3 Shall be inscribed with the date of application and the code in effect as of that date: 5" Edition (2014) Florida Building Code Revised: June 30, 2015 Permit Application 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 pen -nits required from other governmental entities such as water management districts, state agencies, or federal agencies. Acceptance of permit is verification that I will notify the owner of the property of the requirements of Florida Lien Law, FS 713. The City of Sanford requires payment of a plan review fee at the time of permit submittal. A copy of the executed contract is required in order to calculate a plan review charge and will be considered the estimated construction value of the job at the time of submittal. The actual construction value will be figured based on the current ICC Valuation Table in effect at the time the permit is issued, in accordance with local ordinance. Should calculated charges figured off the executed contract exceed the actual construction value, credit will be applied to your permit fees when the permit is issued. OWNER'S AFFIDAVIT: I certify that all of the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Siv re of wi r/A ent Date I C-1L S 6— a lC L Print Owner/Agent's Name Signature of N N SHARON K. HISEY. V = MY COMMISSION # FF 993088 x aJ EXPIRES: July 22, 2020 Bonded Thru Notary Public Underwriters Owner/Agent is 1/ Personally Known to Me or Produced ID Type of ID Signature of Contractor/Agent Date Print Contractor/Agent's Name Signature of Notary -State of Florida Date Contractor/Agent is Personally Known to Me or Produced ID Type of ID BELOW IS FOR OFFICE USE ONLY Permits Required: Building Electrical Mechanical Plumbing[] Gas Roof Construction Type: Total Sq Ft of Bldg: Occupancy Use: Min. Occupancy Load: New Construction: Electric - # of Amps Flood Zone: of Stories: Plumbing - # of Fixtures, Fire Sprinkler Permit: Yes No # of Heads Fire Alarm Permit: Yes No APPROVALS: ZONING: UTILITIES: WASTE WATER: ENGINEERING: COMMENTS: FIRE: BUILDING: Revised: June 30, 2015 Pennit Application SCPA Parcel View: 01-20-30-506-0000-4150 Page I of 2 P3P 9[C7ua :tvry ft,L'ex7n Parcel Information Property Record Card Parcel: 01-20-30-506-0000-4150 Owner: COGBURN ERICA R Property Address: 2603 S ELM AVE SANFORD, FL 32773 Parcel 0 1 -20-30-506-0000-4150 Owner COGBURN ERICA R Property Address 2603 S ELM AVE SANFORD, FL 32773 Mailing 216 FRIESIAN WAY SANFORD, FL 32773-6856 Subdivision Name WOODRUFFS SUBD FRANK L Tax District S1-SANFORD DOR Use Code 01-SINGLE FAMILY Exemptions Seminole County GIS Legal Description LOT 415 FRANK L WOODRUFFS SUBD PB3PG44 Taxes I Value Summary I 2017 Working 2016 Certified Values Values Valuation Method CosUMarket Cost/Market lNumberofBuildings 1 _ 41 1, Depreciated Bldg Value 64,538 157,949 Depreciated EXFT Value Land Value (Market) 8,000 8,000 Land Value Ag Just/Market Value " 72,538 65,949' Portability Adj Save Our Homes Adj 0 0 Amendment 1 Adj 0 0 P&G Adj 0 0 Assessed Value 72,538 65,949 Tax Amount without SOH: $1,322.00 2016 Tax Bill Amount $1,322.00 Tax Estimator Save Our Homes Savings: $0.00 TRIM Notice Help Does NOT INCLUDE Non Ad Valorem Assessments Taxing Authority Assessment Value Exempt Values Taxable Value County General Fund 72,538 $0 72,538 Schools 72,538 $0 72,538 City Sanford 72,538 $0 72,538 SJWM(Saint Johns Water Management) 72,538 $0 72,538 County Bonds 72,538 $0 72,538 Sales Description Date Book Page Amount Qualified Vac/Imp QUIT CLAIM DEED 1/l/2008 06950 0388 48,000 No Improved WARRANTY DEED 5/1/1994 02773 1508 44,700 Yes Improved WARRANTY DEED 10/1/1984 01591 1188 50,000 Yes Improved QUIT CLAIM DEED 7/1/1984 01565 1260 100 ( No Vacant WARRANTY DEED10/1/1980 01315 0943 i $SO,000Noi Vacant Fund Comparable Sates Land Method Frontage Depth Units Units Price Land Value LOT 0.00 0.00) 1 $8,000.00 8,000 Building Information I Description Year Built ive Fixtures i Bed I Bath I Base Area I Total SF I Living SF Ext Wall I Adj Value I Repl Value ( Appendages http://parceldetail.scpafl.org/ParcelDetailInfo.aspx?PID=01203050600004150 8/29/2017 G C IN 11 V C 0.2 OWNER BUILDER STATEMENT/AFFIDAVIT Altamonte Springs, Casselberry, Lake Mary, Longwood, Oviedo, Sanford,, Seminole County, Winter Springs Florida Statutes are quoted here in part for your information to indicate the authority for exemptions for homeowners from qualifying as contractors and to express any applicable restrictions and responsibilities. OWNERS MUST PERSONALLY APPEAR AT THE BUILDING DIVISION TO SIGN THIS DOCUMENT BY SIGNING THIS STATEMENT, I ATTEST THAT: (Initial to the left of each statement) I understand that state law requires construction to be done by a licensed contractor and have applied for an owner -builder permit under an exemption from the law. The exemption specifies that I, as the owner of the property listed, may act as my own contractor with certain restrictions even though I do not have a license. I understand that building permits are not required to be signed by a property owner unless he or she is responsible for the construction and is not hiring a licensed contractor to assume responsibility. I understand that, as an owner -builder, I am the responsible party of record on a permit. I understand that I may protect myself from potential financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my own name. I also understand that a contractor is required by law to be licensed in Florida and to list his or her license numbers on all permit and contracts. I understand that I may build or improve a one -family or two-family residence or a farm outbuilding. I may also build or improve a commercial building if the costs do not exceed $75,000. The building or residence must be for my own use or occupancy. It may not be built or substantially improved for sale or lease. If a building or residence that I have built or substantially improved myself is sold or leased within in I year after the construction is complete, the law will presume that I built or substantially improved it for sale or lease, which violates this exemption. I understand that, as the owner -builder, I must provide direct, onsite supervision of the construction. I understand that I may not hire an unlicensed individual person to act as my contractor or to supervise persons working on my building or residence. It is my responsibility to ensure that the persons whom I employ have the licenses required by law and by city ordinance. I understand that it is a frequent practice of unlicensed persons to have the property owner obtain an owner -builder permit that erroneously implies that the property owner is providing his or her own labor p and materials. I, as an owner -builder, may be held liable and subjected to serious financial risk for any injuries sustained by an unlicensed person or his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an owner - builder and am aware of the limits of my insurance coverage for injuries to workers on my property. I understand that I may not delegate the responsibility for supervising work to a licensed contractor who is not licensed to perform the work being done. Any person working on my building who Is not licensed must work under my direct supervision and must be employed by me, which means that I must comply with laws requiring the withholding of federal income tax and social security contributions under the Federal Insurance Contributions Act (FICA) and must provide workers' compensation for the employee. I understand that my failure to follow these laws may subject me to serious financial risk. Rev. 9.14.2009 G c I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern owner -builders as well as employers. I also understand that the construction must comply with all applicable laws, ordinances, building codes, and zoning regulations. I am of aware of construction practices and I have access to the Florida Building Codes. I understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service, the United States Small Business Administration, the Florida Department of Financial Services, and the Florida Department of Revenue. I also understand that I may contact the Florida Construction Industry Licensing Board at 1-850-487-1395 or at www.myflorida.com/dbpr/pro/cilb/ for more information about licensed contractors. I am aware of, and consent to, an owner -builder building permit applied for in my name and understand that I am the party legally and financially responsible for the proposed construction activity at the address listed below. I agree to notify the building department immediately of any additions, deletions, or changes to any of the information that I have provided on this disclosure or in the permit application package. Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who does not have a license, the Construction Industry Licensing Board, the Department of Business and Professional Regulation and the building department may be unable to assist you with any financial loss that you sustain as a result of a complaint. Your only remedy against an unlicensed contractor may be in civil court. It is also important for you to understand that, if an unlicensed contractor or employee of an individual or firm is injured while working on your property, you may be held liable for damages. If you obtain an owner -builder permit and wish to hire a licensed contractor, you will be responsible for verifying whether the contractor is property licensed and the status of the contractor's workers' compensation coverage. Property Address 2 (P 6 3 S. Elm Avi-- rL 3Z773 I, e E' k Sa. , do hereby state that I am qualified and capable of performing the requested construction involved with the permit application filed and agree to the conditions specified/abovk. 1 19 A9 /7 Signature of wn r-Builder Date Form of IdentificationP,P 64 Must be Photo ID) A violation of this exemption is a misdemeanor of the first degree punishable by a term of imprisonment not exceeding 1 year and a $1,000.00 fine in addition to any civil penalties. In addition, the local permitting jurisdiction shall withhold final approval, revoke the permit, or pursue any action or remedy for unlicensed activity against the owner and any person performing work that requires licensure under the permit issued. Rev. 9.14.2009 FLORIDA GENERAL DURABLE POWER OF ATTORNEY THE POWERS YOU GRANT BELOW ARE EFFECTIVE EVEN IF YOU BECOME DISABLED OR INCOMPETENT NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING. THEY ARE EXPLAINED IN THE UNIFORM STATUTORY FORM POWER OF ATTORNEY ACT. IF YOU HAVE ANY QUESTIONS ABOUT THESE POWERS, OBTAIN COMPETENT LEGAL ADVICE. THIS DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL AND OTHER HEALTH-CARE DECISIONS FOR YOU. YOU MAY REVOKE THIS POWER OF ATTORNEY IF YOU LATER WISH TO DO SO. THIS POWER OF ATTORNEY IS EFFECTIVE' IMMEDIATELY AND WILL CONTINUE TO BE EFFECTIVE EVEN IF YOU BECOME DISABLED, INCAPACITATED, OR INCOMPETENT. iCO. Cxin lt S;1vvw (Cc o,l'n rar n+S lash lu %V1P_S1(LVA wu.1 , SQAiy R1, (IC' [insert your name and address] appoint 1AfS1an W!& 4 &VIA"Vd lA [insert the name and address of the person appointed] as my Agent (attorney -in -fact) to act for me in any lawful way with respect to the following initialed subjects: TO GRANT ALL OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF (N) AND IGNORE THE LINES IN FRONT OF THE OTHER POWERS. TO GRANT ONE OR MORE, BUT FEWER THAN ALL, OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF EACH POWER YOU ARE GRANTING. TO WITHHOLD A POWER, DO NOT INITIAL THE LINE IN FRONT OF IT. YOU MAY, BUT NEED NOT, CROSS OUT EACH POWER WITHHELD. Note: If you initial Item A or Item B, which follow, a notarized signature will be required on behalf of the Principal. INITIAL A) Real property transactions. To lease, sell, mortgage, purchase, exchange, and acquire, and to agree, bargain, and contract for the lease, sale, purchase, exchange, and acquisition of, and to accept, take, receive, and possess any interest in real property whatsoever, on such terms and conditions, and under such covenants, as my Agent shall deem proper; and to maintain, repair, tear down, alter, rebuild, improve manage, insure, move, rent, lease, sell, convey, subject to liens, mortgages, and security deeds, and in any way or manner deal with all or any part of any interest in real property whatsoever, including specifically, but without limitation, real property lying and being situated in the State of Florida, under such terms and conditions, and under such covenants, as my Agent shall deem proper and may for all deferred payments accept purchase money notes payable to me and secured by mortgages or deeds to secure debt, and may from time to time collect and cancel any of said notes, mortgages, security interests, or deeds to secure debt. B) Tangible personal property transactions. To lease, sell, mortgage, purchase, Page 1 of 7 exchange, and acquire, and to agree, bargain, and contract for the lease, sale, purchase, exchange, and acquisition of, and to accept, take, receive, and possess any personal property whatsoever, tangible or intangible, or interest thereto, on such terms and conditions, and under such covenants, as my Agent shall deem proper; and to maintain, repair, improve, manage, insure, rent, lease, sell, convey, subject to liens or mortgages, or to take any other security interests in said property which are recognized under the Uniform Commercial Code as adopted at that time under the laws of the State of Florida or any applicable state, or otherwise hypothecate (pledge), and in any way or manner deal with all or any part of any real or personal property whatsoever, tangible or intangible, or any interest therein, that I own at the time of execution or may thereafter acquire, under such terms and conditions, and under such covenants, as my Agent shall deem proper. C) Stock and bond transactions. To purchase, sell, exchange, surrender, assign, redeem, vote at any meeting, or otherwise transfer any and all shares of stock, bonds, or other securities in any business, association, corporation, partnership, or other legal entity, whether private or public, now or hereafter belonging to me. D) Commodity and option transactions. To organize or continue and conduct any business which term includes, without limitation, any farming, manufacturing, service, mining, retailing or other type of business operation in any form, whether as a proprietorship, joint venture, partnership, corporation, trust or other legal entity; operate, buy, sell, expand, contract, terminate or liquidate any business; direct, control, supervise, manage or participate in the operation of any business and engage, compensate and discharge business managers, employees, agents, attorneys, accountants and consultants; and, in general, exercise all powers with respect to business interests and operations which the principal could if present and under no disability. E) Banking and other financial institution transactions. To make, receive, sign, endorse, execute, acknowledge, deliver and possess checks, drafts, bills of exchange, letters of credit, notes, stock certificates, withdrawal receipts and deposit instruments relating to accounts or deposits in, or certificates of deposit of banks, savings and loans, credit unions, or other institutions or associations. To pay all sums of money, at any time or times, that may hereafter be owing by me upon any account, bill of exchange, check, draft, purchase, contract, note, or trade acceptance made, executed, endorsed, accepted, and delivered by me or for me in my name, by my Agent. To borrow from time to time such sums of money as my Agent may deem proper and execute promissory notes, security deeds or agreements, financing statements, or other security instruments in such form as the lender may request and renew said notes and security instruments from time to time in whole or in part. To have free access at any time or times to any safe deposit box or vault to which I might have access. F) Business operating transactions. To conduct, engage in, and otherwise transact the affairs of any and all lawful business ventures of whatever nature or kind that I may now or hereafter be involved in. G) Insurance and annuity transactions. To exercise or perform any act, power, duty, right, or obligation, in regard to any contract of life, accident, health, disability, liability, or other type of insurance or any combination of insurance; and to procure new or additional contracts of insurance for me and to designate the beneficiary of same; provided, however, that my Agent cannot designate himself or herself as beneficiary of any such insurance contracts. Page 2 of 7 H) Estate, trust, and other beneficiary transactions. To accept, receipt for, exercise, release, reject, renounce, assign, disclaim, demand, sue for, claim and recover any legacy, bequest, devise, gift or other property interest or payment due or payable to or for the principal; assert any interest in and exercise any power over any trust, estate or property subject to fiduciary control; establish a revocable trust solely for the benefit of the principal that terminates at the death of the principal and is then distributable to the legal representative of the estate of the principal; and, in general, exercise all powers with respect to estates and trusts which the principal could exercise if present and under no disability; provided, however, that the Agent may not make or change a will and may not revoke or amend a trust revocable or amendable by the principal or require the trustee of any trust for the benefit of the principal to pay income or principal to the Agent unless specific authority to that end is given. 1) Claims and litigation. To commence, prosecute, discontinue, or defend all actions or other legal proceedings touching my property, real or personal, or any part thereof, or touching any matter in which I or my property, real or personal, may be in any way concerned. To defend, settle, adjust, make allowances, compound, submit to arbitration, and compromise all accounts, reckonings, claims, and demands whatsoever that now are, or hereafter shall be, pending between me and any person, firm, corporation, or other legal entity, in such manner and in all respects as my Agent shall deem proper. 1 (J) Personal and family maintenance. To hire accountants, attorneys at law, consultants, clerks, physicians, nurses, agents, servants, workmen, and others and to remove them, and to appoint others in their place, and to pay and allow the persons so employed such salaries, wages, or other remunerations, as my Agent shall deem proper. WuT (K) Benefits from Social Security, Medicare, Medicaid, or other governmental programs, or military service. To prepare, sign and file any claim or application for Social Security, unemployment or military service benefits; sue for, settle or abandon any claims to any benefit or assistance under any federal, state, local or foreign statute or regulation; control, deposit to any account, collect, receipt for, and take title to and hold all benefits under any Social Security, unemployment, military service or other state, federal, local or foreign statute or regulation; and, in general, exercise all powers with respect to Social Security, unemployment, military service, and governmental benefits, including but not limited to Medicare and Medicaid, which the principal could exercise if present and under no disability. L) Retirement plan transactions. To contribute to, withdraw from and deposit funds in any type of retirement plan (which term includes, without limitation, any tax qualified or nonqualified pension, profit sharing, stock bonus, employee savings and other retirement plan, individual retirement account, deferred compensation plan and any other type of employee benefit plan); select and change payment options for the principal under any retirement plan; make rollover contributions from any retirement plan to other retirement plans or individual retirement accounts; exercise all investment powers available under any type of self -directed retirement plan; and, in general, exercise all powers with respect to retirement plans and retirement plan account balances which the principal could if present and under no disability. M) Tax matters. To prepare, to make elections, to execute and to file all tax, social security, unemployment insurance, and informational returns required by the laws of the United States, or of any state or subdivision thereof, or of any foreign government; to prepare, to Page 3 of 7 w ; execute, and to file all other papers and instruments which the Agent shall think to be desirable or necessary for safeguarding of me against excess or illegal taxation or against penalties imposed for claimed violation of any law or other governmental regulation; and to pay, to compromise, or to contest or to apply for refunds in connection with any taxes or assessments for which I am or may be liable. N) ALL OF THE POWERS LISTED ABOVE. YOU NEED NOT INITIAL ANY OTHER LINES IF YOU INITIAL LINE (N). SPECIAL INSTRUCTIONS: ON THE FOLLOWING LINES YOU MAY GIVE SPECIAL INSTRUCTIONS LIMITING OR EXTENDING THE POWERS GRANTED TO YOUR AGENT. THIS POWER OF ATTORNEY IS EFFECTIVE IMMEDIATELY AND WILL CONTINUE UNTIL IT IS REVOKED. THIS POWER OF ATTORNEY SHALL BE CONSTRUED AS A GENERAL DURABLE POWER OF ATTORNEY AND SHALL CONTINUE TO BE EFFECTIVE EVEN IF I BECOME DISABLED, INCAPACITATED, OR INCOMPETENT. YOUR AGENT WILL HAVE AUTHORITY TO EMPLOY OTHER PERSONS AS NECESSARY TO ENABLE THE AGENT TO PROPERLY EXERCISE THE POWERS GRANTED IN THIS FORM, BUT YOUR AGENT WILL HAVE TO MAKE ALL DISCRETIONARY DECISIONS. IF YOU WANT TO GIVE YOUR AGENT THE RIGHT TO DELEGATE DISCRETIONARY DECISION -MAKING POWERS TO OTHERS, YOU SHOULD KEEP THE NEXT SENTENCE, OTHERWISE IT SHOULD BE STRICKEN.) Authority to Delegate. My Agent shall have the right by written instrument to delegate any or all of the foregoing powers involving discretionary decision -making to any person or persons whom my Agent may select, but such delegation may be amended or revoked by any agent including any successor) named by me who is acting under this power of attorney at the time of reference. Page 4 of 7 YOUR AGENT WILL BE ENTITLED TO REIMBURSEMENT FOR ALL REASONABLE EXPENSES INCURRED IN ACTING UNDER THIS POWER OF ATTORNEY. STRIKE OUT THE NEXT SENTENCE IF YOU DO NOT WANT YOUR AGENT TO ALSO BE ENTITLED TO REASONABLE COMPENSATION FOR SERVICES AS AGENT.) Right to Compensation. My Agent shall be entitled to reasonable compensation for services rendered as agent under this power of attorney. IF YOU WISH TO NAME SUCCESSOR AGENTS, INSERT THE NAME(S) AND ADDRESS(ES) OF SUCH SUCCESSOR(S) IN THE FOLLOWING PARAGRAPH.) Successor Agent. If any Agent named by me shall die, become incompetent, resign or refuse to accept the office of Agent, I name the following (each to act alone and successively, in the order named) as successor(s) to such Agent: Choice of Law. THIS POWER OF ATTORNEY WILL BE GOVERNED BY THE LAWS OF THE STATE OF FLORIDA WITHOUT REGARD FOR CONFLICTS OF LAWS PRINCIPLES. IT WAS EXECUTED IN THE STATE OF FLORIDA AND IS INTENDED TO BE VALID IN ALL JURISDICTIONS OF THE UNITED STATES OF AMERICA AND ALL FOREIGN NATIONS. I am fully informed as to all the contents of this form and understand the full import of this grant of powers to my Agent. I agree that any third party who receives a copy of this document may act under it. Revocation of the power of attorney is not effective as to a third party until the third party learns of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of reliance on this power of attorney. Signed this day of 5fi 20 6 Acv\ Your Signature] S 1-1g,3M Your Social Security Number] Page 5 of 7 STATEMENT OF WITNESS On the date written above, the principal declared to me in my presence that this instrument is his general durable power of attorney and that he or she had willingly signed or directed another to sign for him or her, and that he or she executed it as his or her free and voluntary act for the purposes therein expressed. Signature of Witness #1] Printed or typed name of Witness #1] Address of Witness #1, Line 1 ] Address of Witness #1, Line 2] Signature of Witness #2] Printed or typed name of Witness #2] Address of Witness #2, Line 1] Address of Witness #2, Line 2] A Note About Selecting Witnesses: The agent (attorney -in -fact) may not also serve as a witness. Each witness must be present at the time that principal signs the Power of Attorney in front of the notary. Each witness must be a mentally competent adult. Witnesses should ideally reside close by, so that they will be easily accessible in the event they are one day needed to affirm this document's validity. Page 6 of 7 CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC STATE OF FLORID COUNTY OF n This document was acknowledged before me on oo Z ,o 17 [Date] by 2t e q SO-(,to,J [name of principal]. Notary Seal, if any]: SU APOLLA Notary ` Mate of Florida Com; u FF 906302 My'Con. nes Sep 25, 2011 lel .ate S' nature of Notarial Officer) Notary Public for the State of Florida p. Notary Pu01ic State of Florida My CommlSSlon eXplreS: f 5 Commission # FF 906302 9•— Z---) — ZO L7 My Comm. Expires Sep 25, 2019 o Off 1•',, 8andetifto National Notary Assn. 1111 1 ACKNOWLEDGMENT OF AGENT BY ACCEPTING OR ACTING UNDER THE APPOINTMENT, THE AGENT ASSUMES THE FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES OF AN AGENT. Eck SaQ"r"' Typed or Printed Name of Agent] PREPARATION STATEMENT This document was prepared by the following individual: Typed or Printed Name] Signature] Page 7 of 7