200 Pinefield Dr - BR17-003249 - ROOFCITY OF SANFORD
BUILDING & FIRE PREVENTION
PERMIT APPLICATION
N
Application No: 1 ( - 3
Documented Construction Value: $ 14.000 - -:-
Job Address: 0 P -Cle( U cc/- /1 d Fl 3 Z 7% Historic District: Yes [INo
Parcel ID: Residential Commercial
Type of Work: New Addition Alteration Repair Demo Change of Use Move
Description of Work: 1:E 514fU C' 6,,
Plan Review Contact Person: . lu 60 5A_djc K Z Title: uq
Phone:' '+7 2 Fax: Email:Ld4Acrl ol X,o 1 1
Property Owner Information
Name P-7-(5A • 6-o. 54-d1W.1__ Phone: ( 2 72 - e'606 Street: :
2L-):—, Pi( Cam' T( d 6 y _ ,' l t Resident of property. City,
State Zip: Contractor'
llnfofmation Name
4 ,°Phone: Street: >
Fax: City,
State Zip: State License No.: Architect/
Engineer Information Name:
Phone: Street:
Fax: City,
St, Zip: E-mail: Bonding
Company: Mortgage Lender: Address:
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: 511 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 permits 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 c with all applicable laws regulating construction and zoning.
ignature of Owner/Agent Date Signature of Contractor/Agent Date
09 Al-C 6 o SF tX Li t
Print Owner/Agent's Name Print Contractor/Agent's Name
I li11111I/
Signa u otary-State of Flori Date \\
O`PNA S ry oE.Notary-State of Florida Date
1A0 Tq •• ` ..
e Uy Con
41une 17. Ires:
Owner/Agent is Personally Known to Me:dr11 t No. FF ' ZQttr,tor/gent is Personally Known to Me or
Produced ID _ Type of ID L "
Ia dldCed I' Type of ID
F \
BELOW IS F6*10PF 6 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
Fire Sprinkler Permit: Yes No
APPROVALS: ZONING:
ENGINEERING:
COMMENTS:
of Heads
UTILITIES:
FIRE:
Flood Zone:
of Stories:
Plumbing - # of Fixtures
Fire Alarm Permit: Yes No
WASTE WATER:
BUILDING:
Revised: June 30, 2015 Permit Application
THIS INS MEIt4T _PREPARED B,C;
Name: }/(.(-
Address: 7c e s11c
NOTICE OF COMMENCEMENT
State of Florida
County of Seminole
Permit Number:
l! Ii ll I!#I If l1111 1 II 1111 I 11
tAR'ANT NALAYf 5ENINOLE COUNTY
Ci..i:::RI( OF CIRCUIT COURT CONPTROLLER
BK 901 3 P3 17 ._;4-
CLERK'S s 2017111913
RECORDED 11<'i,;_ /2:+1,.! 1 - ° j iIn1T41
RL C'ORDI1,• ; FE.EC; lii,l:lil
RECORDED BY hdevore
q
r
Parcel ID Number: 5 U " 1 3 J I
The undersigned hereby gives notice that improvement will be made to certain real property, and in accordance with
Chapter 713, Florida Statutes, the following information is provided in this Notice of Commencement.
DESCRIPTION OF PROPERTY: (Legal description of the property and street address if available)
Lo r 3 c la2y lKfS i tlHs Pia 62 P65 7; .- -76
2r,0 (iuEtiild A%vZ - St1v-;-oC-6 , fL 3277/
GENERAL DESCRIPTION OF IMPROVEMENT:
OWNE", FOR AT)_ON:
7Name: + U—t,oC
Address: 2-6o P (J ',
Fee Simple Title Holder (if other than owner) Name:
Address:
Persons within the State of Florida Designated by Owner upon whom notice or other documents may be served
as provided by Section 713.13(1)(b), Florida Statutes.
Name:
In addition to himself, Owner Designates of
To receive a copy of the Lienor's Notice as Provided in
Section 713.13(1)(b), Florida Statutes.
Expiration Date of Notice of Commencement (The expiration date is 1 year from date of recording unless a
different date is specified)
WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF
COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13,
FLORIDA STATUTES, AND CAN 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 COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT.
Under a
my
perjury, I are that I have read the foregoing and that the facts stated in it are true
to a best nowledge and eli
o ccsc, l—c9 Cl C:2
Owners Signature Owner's Printed Name
Florida Statute 713.13(1)(g): "The owner must fth. notice ofcommencement and no one else may be permitted to sign in his or her stead."
State of io County oi'< ' 'j nol c.
The foregoing instrument was acknowledged before me this day of t-lbv/ 9
by4--
Who is personally knM16wn`to me Namakf
person making stateTent M
L- ORwhohasproducedidentificationtypeofidentificationproducedCFRTIFIEO
COPY G-71NT M J r- r :a .1 C
L:Rk' )i:. iJ Awls
i%I` Sk`/
ii1NU ` a 3 I..,% 0'. t
t NetwyltignatureBY
i
i
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
j. 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 1 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
R, 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
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
1tmust 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
l 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
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
d j understand that the construction must comply with all applicable laws, ordinances, building codes, and
zoning regulations.
j
j
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: Zr'00 ' 'G G `'y 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 above---------,,, L -
i 0 Signature
stj0jz
i7 Date I
Form of
Identification i V n IV E(2 2_C £v6 Must be
Photo ID) A violation
of this exemption is a misdemeanor of the first degree punishable by a term of imprisonment not exceeding
J 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
ITY QE
NFORD Building & Fire Prevention Division3ARESIDENTIALRE -ROOF POLICY & PROCEDURES FIRE
DEPARTMENT PERMITTING
REQUIREMENTS - NO PLAN REVIEW REQUIRED THIS
DOCUMENT (SIGNED) ALONG WITH AN ACCURATE AND COMPLETED RESIDENTIAL RE -ROOF SCOPE OF WORK ARE REQUIRED
TO BE SUBMITTED AS PART OF YOUR PERMIT APPLICATION. THE
SCOPE OF WORK MUST INCLUDE ALL APPLICABLE FLORIDA PRODUCT APPROVAL NUMBERS FOR ALL ROOF COMPONENTS
THAT WILL BE INSTALLED ON THE PROJECT. A
PERMIT WILL NOT BE ISSUED WITHOUT THESE DOCUMENTS. COPIES WILL BE MADE TO POST ON THE JOB SITE. PROJECTS
LOCATED IN THE SANFORD HISTORIC DISTRICT WILL REQUIRE PLAN REVIEW AND APPROVAL BY THE SANFORD
HISTORIC PRESERVATION BOARD INSPECTION
POLICY & PROCEDURES A
FINAL ROOF INSPECTION IS THE ONLY INSPECTION REQUIRED FOR RESIDENTIAL (SINGLE FAMILY, TOWNHOUSE, MOBILE
HOME, APARTMENT AND/OR CONDOMINIUM) RE -ROOF PERMITS. THE
FOLLOWING IS REQUIRED TO BE PROVIDE ON THE JOB SITE: PERMIT
CARD, POSTED IN A CONSPICUOUS AND WEATHERPROOF LOCATION COMPLETED
RESIDENTIAL RE -ROOF SCOPE OF WORK COMPLETED
AND NOTARIZED INSPECTION AFFIDAVIT ALL
FLORIDA PRODUCT APPROVAL AND CORRESPONDING INSTALLATION INSTRUCTIONS PRODUCT
APPROVAL SHALL MATCH WHAT IS ON THE SCOPE OF WORK) DIGITAL
PHOTOGRAPHS (MUST INCLUDE THE PERMIT NUMBER OR ADDRESS IN EACH PICTURE) o
EACH PLANE OF THE ROOF, SHOWING THE UNDERLAYMENT INSTALLED o
ROOF DECK NAILING PATTERN & SPACING (INCLUDING A MEASURING DEVICE OR RULER) o
ROOF DECK NAILS USED (INCLUDING A MEASURING DEVICE OR RULER SHOWING SIZE OF NAILS) o
UNDERLAYMENT PATTERN & SPACING (INCLUDING A MEASURING DEVICE OR RULER) o
DRIP EDGE & VALLEY ATTACHMENT (INCLUDING A MEASURING DEVICE OR RULER) o
SHINGLES INSTALLED, NAIL PATTERN AND LOCATION OF NAILS SKYLIGHTS (
IF APPLICABLE) o
DIGITAL PHOTOGRAPHS SHOWING ALL INSTALLATION COMPONENTS, PER FL PRODUCT APPROVAL o
DIGITAL PHOTOGRAPHS SHOWING ALL REQUIRED FLASHING, PER FL PRODUCT APPROVAL FAILURE
TO FOLLOW THESE SPECIFIC GUIDELINES WILL RESULT IN AN AFFIDAVIT PROVIDED BY A FLORIDA DESIGN PROFESSIONAL (
ARCHITECT OR ENGINEER), CERTIFYING FBC CODE COMPLIANCE BY PERSONAL INSPECTION. CONTRACTOR (
OR OWNER/BUILDER) SIGNATURE: DATE: -
a CITY OF.
oPERMIT # SANFOI.""
DEPARTMENT Building & Fire Prevention Division
FIRE RESIDENTIAL RE -ROOF SCOPE OF WORK
JOB ADDRESS: L C N i C tl - i 52 2 /
STRUCTURE TYPE: SINGLE FAMILY RESIDENCE/TOWNHOUSE O MOBILE HOME O APARTMENT/CONDOMINIUM
RE -ROOF TYPE: O REPLACEMENT (TEAR OFF EXISTING ROOF AND REPLACE WITH NEW COMPONENTS)
O RE-COVER (NEW ROOF INSTALLED OVER EXISTING ROOF)
DECK TYPE (PLEASE SPECIFY:
PLEASE NOTE. ONLY 100 SQUARE FEET OF THE EXISTING DECK IS PERMITTED TO BE REPLACED
ROOF VENTILATION: #OFF -RIDGE O RIDGE OSOFFIT OPOWERED VENT
SKYLIGHTS: O YES )ONO IF YES, PLEASE PROVIDE FLORIDA PRODUCT APPROVAL #:
MAIN ROOF AREA
ROOF SLOPE: O LESS THAN 2:12 Q 2:12 - 4:12 CM 4:12 OR GREATER
OTURBINES
TYPE OF ROOF MANUFACTU{REnRr FLORIDA PRODUCT APPROVAL
SHINGLE j N N (y FL#
O METAL FL#
O MODIFIED BITUMEN FL#
O TORCH DOWN FL#
0INSULATED FL#
O TILE FL#
O OTHER: FL#
ROOF EXTENSIONS (PORCHES, PATIOS, ETC.) **IFAPPLICABLE**
ROOF SLOPE: O LESS THAN 2:12 O 2:12 -4:12 O 4:12 OR GREATER
TYPE OF ROOF MANUFACTURER FLORIDA PRODUCT APPROVAL
O SHINGLE FL#
O METAL FL#
O MODIFIED BITUMEN FL#
OTORCH DOWN FL#
0INSULATED FL#
O TILE FL#
O OTHER: FL#
SCPA Parcel View: 32-19-31-515-0000-0380
t
Page 1 of 2
Property Record Card
f
OwIdJohnson,CFA
PVP
Parcel: 32-19-31-515-0000-0380
Owner: SANCHEZ RODRIGO & ROJO KARLA G
SCMWOL1,ccxwyv.r r nod Property Address: 200 PINEFIELD DR SANFORD, FL 32771
Parcel Information
Parcel 32-19-31-515-0000-0380
Owner SANCHEZ RODRIGO & ROJO KARLA G
Property Address 200 PINEFIELD DR SANFORD, FL 32771
Mailing 200 PINEFIELD DR SANFORD, FL 32771
Subdivision Name CELERY LAKES PHASE 1
Tax District S1-SANFORD
DOR Use Code 01-SINGLE FAMILY
Exemptions 00-HOMESTEAD(2016)
0 40 50 50
h, at iy,r
37+ 0,_
W iD
CD W
65 65 50
N
50
inemo e unty
Legal Description
LOT 38
CELERY LAKES PHASE 1
PB 62 PGS 75 & 76
Taxes
Value Summary
2018 Working 2017 Certified
Values Values
Valuation Method s Cost/Market Cost/Market
Number of Buildings 1 € 1 -
Bldg ValueDepreciated
Depreciated EXFT Value
154,147 $145,294
325-_ - $338
Land Value (Market) 30,000 $30,000
Land Value Ag------------
Just/Market Value " 184,472 $175,632
Portability Adj
Save Our Homes Adj
Amendment 1 Adj-
29,315 $23,666
0 -
P&G Adj 0 $0
Assessed Value 155,157 $151,966
Tax Amount without SOH: $2,556.44
2017 Tax Bill Amount $2,105.81
Tax Estimator
Save Our Homes Savings: $450.63
Does NOT INCLUDE Non Ad Valorem Assessments
Taxing Authority Assessment Value Exempt Values Taxable Value
County General Fund 155 157 1 $50,000 105,157
Schools 155 157 25,000 130,157
City Sanford
m
SJWM(Saint Johns Water Management)
155,157
155,157
155,157
I- 50,000
50,000
50,000
105,157
105,157
County Bonds -_- - ------ - - _ 105,157
II Salesa
Description Date Book Page Amount Qualified Jac/Imp
WARRANTY DEED 7/1/2014 08309 0984 I $156,000 Yes I Improved
QUIT CLAIM DEED 7/1/2014 08309 10982 100 No Improved ]
QUIT CLAIM DEED 7/1/2013 08100 1_ 0 I $100 No Improved
1QUITCLAIMDEED4/1/2010
4/1/2010
07447
07447
0966
0967
100 No
100 1 No
Improved
Improved IQUITCLAIMDEED1 _
tt a, W
SPECIAL WARRANTY DEED 10/1/2004 055' 11771 167,700 ( Yes Improved
Find Comparable- Sales
Land
Method Frontage Depth Units Units Price Land Value
LOT 1 I $30,000.00 30,000
Building Information
Is Bed/Bath count incorrect? Click Here.
I Description I I Fixtures I Bed I Bath I Base Area Total SF Living SF Ext Wall Adj Value Repl Value [Appendages
http://parceldetail.scpafl.org/ParcelDetailInfo.aspx?PID=32193151500000380 11/6/2017
CITY OF
SORD Building & Fire Prevention Division
RESIDENTIAL RE-R 0OF A FFIDA VI T
FIRE DEPARTMENT
RESIDENTIAL RE —ROOF INSPECTION AFFIDAVIT
NAILING, SHEATHING, DRY —IN, FLASHING, AND ALL FINAL ROOF COVERINGS
PERMIT #: T ADDRESS:
t
AS A(N) GENERAL, BUILDING, RESIDENTIAL, OR
ROOFING CONTRACTOR, ENGINEER, ARCHITECT, OF F.S. CHAPTER 468 BUILDING INSPECTOR, I HEREBY AFFIRM, THAT ALL OF THE
FOREGOING INFORMATION IS TRUE AND ACCURATE AND THAT ALL ROOFING COMPONENTS LISTED ON THE SCOPE OF WORK AT THE
ABOVE REFERENCED ADDRESS HAVE BEEN INSTALLED IN ACCORDANCE WITH THEIR PRODUCT APPROVALS AND ALL APPLICABLE CODE
REQUIREMENTS - SPECIFICALLY FLORIDA BUILDING CODE, EXISTING BUILDING. IN ADDITION I CERTIFY THE INSTALLATION MEETS ALL
REQUIREMENTS FOR SECONDARY WATER BARRIER AND NAILING OF THE ROOF DECK, IN ACCORDANCE WITH THE HURRICANE RETROFIT
MANUAL REQUIREMENTS (BASED ON F.S. CHAPTER 553.844).
G0MPAN 7tC-ONTRACTOR:
CONTRACTOR SIGNA
r
DATE: a t
MUST BE SIGNED BY LICENSE HOLDER OR OWNER/BUILDER)
A FINAL ROOF INSPECTION IS REQUIRED:
THIS SIGNED AND NOTARIZED AFFIDAVIT MUST BE PROVIDED AT THE JOB SITE AT THE TIME OF THE FINAL ROOF INSPECTION,
ALONG WITH DIGITAL PHOTOGRAPHS OF EACH PLANE OF THE ROOF SHOWING IN DETAIL ALL COMPONENTS (DECKING,
UNDERLAYMENT, FLASHING, DRIP EDGE ATTACHMENT) WITH THE PERMIT NUMBER OR ADDRESS CLEARLY MARKED ON THE DECK
FOR EACH INSPECTION. THE PHOTOGRAPHS MUST INCLUDE A RULER OR MEASURING DEVICE TO CONFIRM ALL NAIL SPACING AND
OVERLAPS, INCLUDING DRIP EDGE AND VALLEY FLASHING. PLEASE REFER TO THE RE -ROOF POLICY AND INSPECTION PROCEDURE
PAPERWORK FOR FURTHER EXPLANATION OF ALL REQUIREMENTS.
FAILURE TO FOLLOW ALL REQUIREMENTS WILL RESULT IN A FAILED INSPECTION, A RE -INSPECTION FEE AS
WELL AS REQUIRING A DESIGN PROFESSIONAL (ARCHITECT OR ENGINEER) TO CERTIFY, BASED ON PERSONAL
INSPECTION, THE INSTALLATION OF ALL ROOFING COMPONENTS.
STATE OF FLORIDA COUNTY OF-0,/, 'i1d r, Sworn
to and Subscribed before me this 61 day of ZD 1r! ( 20 IV' by: R),`
r' no t c He-Z . Who is Personally Known to me or has Produced (type of identification) -
VD/ (=5?%l z./2 as identification. iff
F Expires 1211@I2020 ior
CwAdISIM NIL C-6550Print/
Type/Stamp Name of
Notary Public