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Home My WebLink About2005-Certificate of Occupancy CITY HALL Inspection Services Div 215 Church Avenue PO Box 1130 ~ Osh""'h WI ~ 54903-1130 OJHKOfH ON THE WAT~R City of Oshkosh Approved: Issued: 7/6/05 7/6/05 Midwest General Contractors 100 N. Westahven Drive Oshkosh, Wisconsin 54904 CERTIFICATE OF OCCUPANCY An Occupancy Permit is hereby granted for the new duplex located at 400 402 Wyldewood Drive, Oshkosh, Wisconsin 54904 as described in Building Permit Application number(s) 109013. This building is to be used only as a duplex and is located in the R-3PD, Multiple Dwelling District with a Planned Development Overlay. LIMITATIONS: Maximum persons and/or living units: Two living units CONDITIONS: 1) Final grading must be done in accordance with the approved subdivision drainage plan. This plan is on file in the public works office, 3rd floor of City Hall. 2) Erosion control measures must be maintained until the lawn is established. Note: Final grade must be a minimum of 6" below all siding. NOTE: 1) Copies of inspection results are available upon request in room 205, City Hall. 2) Future permits may be required for additional work to your property. A new Certificate of Occupancy shall be required prior to occupancy, should additional building(s) be erected, or should any buildings mentioned above be altered or moved. The use of land, or buildings, shall not be changed until a Certificate of Occupancy is issued for that occupancy. All conditions noted above must be complied with in order for this certificate to be valid. Jc~i~ Building Systems Inspector ~ Building Permit Work Card Job Address 400 402 WYLDEWOOD DR Permit Number 0109013 Create Date 6/29/04 Owner WYLDEWOOD CONDOMINIUMS LLC Contractor MIDWEST GENERAL CONTRACTORS INC Category 120 - New Duplex Type . Building o Sign o Canopy o Fence o Raze I Plan F1-021-0304 MP . Zoning R3-PD Class of Const: 8 Size irreg Value $230,000.00 - . Unfinished/Basement 1594 Sq. Finished/Living 1594 Sq.Ft. Garage 572 Sq. Ft. Ft. - Rooms 5 Beprooms 2 Baths 2 D Projection ! - - Stories 1 Height 17 Ft. Canopies 0 Signs 0 - - - Foundation . Poured Concrete o Floating Slab o Pier o Other o Concrete Block o Post o Treated Wood Occupany Permit Required Flood Plain No Height Permit Not Required - Park Dedication Required # Dwelling Units 2 # Structures 1 Use/Nature New Duplex! single story, 2 car attached garaage per unit, 12x12 deck per unit, sun room on one unit. of Work HV AC Contr BREWER HEATING , Plumbing Contr WATTERS PLUMBING Electric Contr CUMINGS ELECTRIC INC Inspections: Date 7/1/05 Type Re Final Inspector Nicole Krahn approved w/cond. lIl' ay w/ Midwest dropped off the signed and dated correction notice noting that the corrections were corrected. No re-inspection was conducted. Ok to issue the occupancy per the office policy. DatelTime requested: 7/1/05 Access: 07:55 AM Notice Type: Phone Number: ] Ready DatelTime: 7/1/05 07:55 AM Requested By: o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid ~ Building Permit Work Card Job Address 400 402 WYLDEWOOD DR Permit Number 0109013 Create Date 6/29/04 Owner WYLDEWOOD CONDOMINIUMS LLC Contractor MIDWEST GENERAL CONTRACTORS INC Category 120 - New Duplex Type . Building o Sign o Canopy o Fence o Raze I Plan F1-021-0304 MP Zoning R3-PD Class of Const: 8 Size irreg Value $230,000.00 - . Unfinished/Basement 1594 Sq. Finished/Living 1594 Sq.Ft. Garage 572 Sq.Ft. Ft. D Projection I Rooms 5 Be.drooms 2 Baths 2 - - Stories 1 Height 17 Ft. Canopies 0 Signs 0 - - - Foundation . Poured Concrete o Floating Slab o Pier o Other o Concrete Block o Post o Treated Wood Occupany Permit Required Flood Plain No Height Permit Not Required - Park Dedication Required # Dwelling Units 2 # Structures 1 Use/Nature New Duplex! single story, 2 car attached garaage per unit, 12x12 deck per unit, sunroom on one unit. of Work HV AC Contr BREWER HEATING Plumbing Contr WATTERS PLUMBING Electric Contr CUMINGS ELECTRIC INC Inspections: Date 10/18/04 Type Insulation Inspector Nicole Krahn no time IREOUESTLINE DatelTime requested: 10/14/04 Access: !open 7-5 Ready DatelTime: 10/14/04 04:45 PM Requested By: MIDWEST GENERAL CONTRACTORS Ir 04:45 PM Notice Type: Phone Number: JAY 420-5878 ] o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid Date 6/21/05 Type Final Inspector John Zarate not approved Request Line- wants final for occupancy DatelTime requested: 6/20/05 Access: IOpen 7-5 01 :55 PM Notice Type: FC Phone Number: 420-5878 ] Ready DatelTime: 6/20/05 01:55 PM Requested By: MIDWEST GENERAL CONTRACTORS Ir o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid Building Permit Work Card Job Address 400402 WYLDEWOOD DR Permit Number 0109013 Create Date 6/29/04 Owner WYLDEWOOD CONDOMINIUMS LLC Contractor MIDWEST GENERAL CONTRACTORS INC Category 120 - New Duplex Type . Building Zoning R3-PD Unfinished/Basement Rooms 5 o Sign o Canopy o Fence o Raze Plan F1-021-0304 MP $230,000.00 Class of Const: 8 Size irreg Value ~Sq. Ft. Bedrooms Finished/Living 1594 Sq.Ft. Garage ~ Sq. Ft. D Projection I 2 Baths 2 Stories Height 17 Ft. Canopies o Signs o Foundation . pou'red Concrete o Concrete Block o Floating Slab o Post o Pier o Treated Wood o Other Occupany Permit Required Flood Plain No Height Permit Not Required Park Dedication Required # Dwelling Units 2 # Structures Use/Nature New Duplex! single story, 2 car attached garaage per unit, 12x12 deck per unit, sunroom on one unit. of Work HVAC Contr BREWER HEATING Electric Contr CUMINGS ELECTRIC INC Plumbing Contr WATTERS PLUMBING Inspections: Date 9/10/04 Type Drain Tile IFAXED REQUEST DatelTime requested: 9/9/04 01 :54 PM Access: Inspector John Zarate no time Notice Type: Phone Number: PAM 231-1667 ] Ready DatelTime: 9/9/04 01:54 PM Requested By: JOHN SKOTZKE CONCRETE CONST o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid Date 10/11/04 Type Rough In Inspector Nicole Krahn no time r"~t hoe DatelTime requested: 10/7/04 Access: !open 7-5 08:55 AM Notice Type: Phone Number: jay 420-5878 ] Ready DatelTime: 10/7/04 08:55 AM Requested By: MIDWEST GENERAL CONTRACTORS It o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid '" Building Permit Work Card Job Address 400 402 WYLDEWOOD DR Permit Number 0109013 Create Date 6/29/04 Owner WYLDEWOOD CONDOMINIUMS LLC Contractor MIDWEST GENERAL CONTRACTORS INC Category 120 - New Duplex Type . Building o Sign o Canopy o Fence o Raze I Plan F1-021-0304 MP . Zoning R3-PD Class of Const: 8 Size irreg Value $230,000.00 Unfinished/Basement 1594 Sq. Finished/Living 1594 Sq.Ft. Garage 572 Sq.Ft. -Ft. - Rooms 5 Bedrooms 2 Baths 2 D Projection I - Stories 1 Height 17 Ft. Canopies 0 Signs 0 - - Foundation . Poured Concrete o Floating Slab o Pier o Other o Concrete Block o Post o Treated Wood Occupany Permit Required Flood Plain No Height Permit Not Required - Park Dedication Required # Dwelling Units 2 # Structures 1 Use/Nature New Duplex! single story, 2 car attached garaage per unit, 12x12 deck per unit, sunroom on one unit. of Work HV AC Contr BREWER HEATING Plumbing Contr WATTERS PLUMBING Electric Contr CUMINGS ELECTRIC INC Inspections: Date 6/29/04 Type Footings Inspector Nicole Krahn cancelled Faxed request (prior to permit issuance) - ready 6/29/04 4:00-5:00 --- new request faxed 6/30/04 DatelTime requested: 6/29/04 Access: 10:43 AM Notice Type: Phone Number: 231-1667 ] Ready DatelTime: 6/29/04 10:43 AM Requested By: JOHN SKOTZKE CONCRETE CONST-Mi o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid Date 6/30/04 Type Footings Inspector Nicole Krahn no time r""" Uoe - ceady 2,0Q-3,30 DatelTime requested: 6/30/04 Access: 07:00 AM Notice Type: Phone Number: 231-1667 ] Ready DatelTime: 6/30/04 02:00 PM Requested By: JOHN SKOTZKE CONCRETE CONST-Mi o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid Electric Permit Work Card Job Address 400 402 WYLDEWOOD DR Permit Number 110164 Create Date 06/29/2004 Owner WYLDEWOOD CONDOMINIUMS LLC Contractor CUMINGS ELECTRIC INC Category 621 - Residential-New Duplex Wiring Service p New o ChangeO Temp ON/A I Type o Overhead . Underground ON/A I Volts 120/240 (; Circuits 0 Fixtures 0 Amps 100' . Switches 0 Receptacles 0 Fee $146.00 D Value $7,000.00 Appliances Use/Nature Wiring for New Duplex! single story, 2 car attached garaage per unit, 12x12 deck per unit, sunroom on of Work :meunit. Inspections: Date 07/06/2005 Type Re Final Inspector Kevin Benner approved Request Line DatelTime requested: 06/29/2005 02:43 PM Access: Notice Type: Phone Number: Ready Date/Time: 06/29/2005 02:43 PM Requested by: CUMINGS ELECTRIC INC-Jan o Reinspect Fee 0 Fee Wavied D Reinspect Fee Paid Electric Permit Work Card Job Address 400 402 WYLDEWOOD DR Permit Number 110164 Create Date 06/29/2004 Owner WYLDEWOOD CONDOMINIUMS LLC Contractor CUMINGS ELECTRIC INC Category 621 - Residential-New Duplex Wiring Service p New o ChangeO Temp ON/A I Type o Overhead . Underground ON/A I Volts 120/240 , Circuits 0 Fixtures 0 ,r Amps 1<J0 . Switches 0 Receptacles 0 Fee $146.00 D Value $7,000.00 Appliances Use/Nature ~iring for New Duplex! single story, 2 car attached garaage per unit, 12x12 deck per unit, sunroom on of Work pne unit. Inspections: Date Type Final Inspector Kevin Benner REQUEST LINE DatelTime requested: OS/25/2005 09:08 AM Access: Notice Type: Phone Number: NOT GIVEN Ready DatelTime: OS/25/2005 09:08 AM Requested by: CUMINGS ELECTRIC INC o Reinspect Fee 0 Fee Wavied D Reinspect Fee Paid Date OS/27/2005 Type Re Final Inspector Kevin Benner not approved DatelTime requested: OS/26/2005 00:00 PM Notice Type: ~ Phone Number: Access: Building inspector stated that the OHD id the address plus a 0 or the last did get twice Ready DatelTime: OS/26/2005 00:00 AM Requested by: o Reinspect Fee 0 Fee Wavied D Reinspect Fee Paid Electric Permit Work Card Job Address 400 402 WYLDEWOOD DR Permit Number 110164 Create Date 06/29/2004 Owner WYLDEWOOD CONDOMINIUMS LLC Contractor CUMINGS ELECTRIC INC Category 621 - Residential-New Duplex Wiring . Service p New o ChangeO Temp ON/A I Type o Overhead . Underground ON/A I , Volts 120/240 ,~ Circuits 0 Fixtures 0 .. Amps 100 . Switches 0 Receptacles 0 Fee $146.00 D Value $7,000.00 Appliances Use/Nature Wiring for New Duplex! single story, 2 car attached garaage per unit, 12x12 deck per unit, sunroom on of Work one unit. , Inspections: Date 09/30/2004 Type Rough In Inspector Jon Fischer approved REQUEST LINE DatelTime requested: 09/30/2004 08:26 AM Access: Notice Type: Phone Number: not given Ready DatelTime: 09/30/2004 08:26 AM Requested by: CUMINGS ELECTRIC INC o Reinspect Fee 0 Fee Wavied D Reinspect Fee Paid Date 11/23/2004 Type Service Inspector Jon Fischer approved 11/24/04 called in 11/29/04 mailed in DatelTime requested: 11/24/2004 08:27 AM Access: Notice Type: Phone Number: Ready DatelTime: 11/24/2004 08:27 AM Requested by: o Reinspect Fee 0 Fee Wavied D Reinspect Fee Paid HVAC Permit Work Card Job Address 400 402 WYLDEWOOD DR Permit Number 110624 Create Date 06/29/2004 Owner WYLDEWOOD CONDOMINIUMS LLC Contractor BREWER HEATING Category 502 - Residential-Both Plan Fuel ~ Gas I I tOil' I I I Electric I I I Solar I I I Solid I Value $8,600.00 System ~ New' I D Replace I D Other I ~ Forced Air J U Radiant I U Steam I ~ A1C I U Vent I U Electric I U Hot Water I U Suppl. I U Con. Burner I Chimney Type o Chimney A o Chimney B o Direct Vent . Not Applicable I Heat Loss o As Approved o Existing . Not Applicable I Value 0 BTU Rate o As Per Plan o Variable . Other I Value Use/Nature Installation of heating and alc for duplex of Work Inspections: Type Final Inspector Nicole Krahn approved Date 7/1/05 DatelTime requested: 07/01/2005 07:56 AM Notice Type: Phone Number: Access: ] Ready DatelTime: 07/01/2005 07:56 AM Requested By: o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid Plumbing Permit Work Card Job Address 400 402 WYLDEWOOD DR Permit Number 109191 Create Date 06/29/2004 Owner WYLDEWOOD CONDOMINIUMS LLC Contractor WATTERS PLUMBING Category 410 - Residential-Interior Plan Value $11,896.00 Bathtub 2 Showe~ 4 Water Softner 0 Wait. St. 0 Shamp Sink 0 Coffee Maker 0 - Whirlpool Q, ", Floor Drain 2 Local Waste 0 Ice Chest 0 FlrlWst Sink 0 Int Grease Trap 0 - Lavatory 8 Lndry Tray 0 Clothes Wshr 0 Exam Sink 0 Catch Basin 0 Ext Grease Trap 0 - Toilet 6 Disposal 2 Bidet 0 Sculry Sink 0 Wash Ftn 0 RPZ Valve 0 - Res. Sink 2 Dishwasher 2 Beer Tap 0 Hand Sink 0 Urinal 0 Eye Wash Statn 0 Bar Sink 0 .Sump Pump 2 Lab Sink 0 Plaster Sink 0 Standp Rec 0 Wtr Sewer Mtrs 0 Water Heater 2 Classrm Sink 0 Sterilizer 0 Surgeons Sink 0 Ice Maker 2 Deduct Meters 0 - Site Drain 0 Breakrm Sink 0 Dip Well 0 F Prep Sink 0 Gar Drain 0 Wtr Usage Mtrs 0 - Roof Drain 0 Ejector/Grind 0 Drink Ftn 0 Serv Sink 0 Soda Disp 0 Misc. 0 Fixtures Use/Nature of Work ~ r'w D,ploxl ~"gl, ,'my Size Material Type # Conn.Type o o o o o o o o o o Sanitary Sewer Storm Sewer Water Service o o o o o Date 5/31/05 FAXED REQUEST Type Final Inspector Rich Wood approved DatelTime requested: 5/23/05 03:29 PM Notice Type: Telephone Number: JAMIE 733-8125 Access: ~ONT ACT JAY 420-5878 Ready Date/Time: 5/23/05 03:29 AM Requested By: WATTERS PLUMBING o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid Plumbing Permit Work Card Permit Number 109191 Contractor WATTERS PLUMBING Create Date 06/29/2004 Job Address 400 402 WYLDEWOOD DR Owner WYLDEWOOD CONDOMINIUMS LLC Category Bathtub Whirlpool Lavatory Toilet Res. Sink Bar Sink Water Heater Site Drain Roof Drain Misc. Fixtures 410 - Residential-Interior 2 ShoWe~ o ,Floor Drain 8 Lndry Tray 6 Disposal 2 Dishwasher o Sump Pump 2 Classrm Sink o Breakrm Sink o Ejector/Grind o Plan Value $11,896.00 4 Water Softner 0 Wait. St. 0 Shamp Sink 0 Coffee Maker 0 - 2 Local Waste 0 Ice Chest 0 FlrlWst Sink 0 Int Grease Trap 0 0 Clothes Wshr 0 Exam Sink 0 Catch Basin 0 Ext Grease Trap 0 - 2 Bidet 0 Sculry Sink 0 Wash Ftn 0 RPZ Valve 0 - 2 Beer Tap 0 Hand Sink 0 Urinal 0 Eye Wash Statn 0 2 Lab Sink 0 Plaster Sink 0 Standp Rec 0 Wtr Sewer Mtrs 0 0 Sterilizer 0 Surgeons Sink 0 Ice Maker 2 Deduct Meters 0 - 0 Dip Well 0 F Prep Sink 0 Gar Drain 0 Wtr Usage Mtrs 0 0 Drink Ftn 0 Serv Sink 0 Soda Disp 0 UselNature of Work IN'" D'ploxl ""9" 'lo<y Size Sanitary Sewer Storm Sewer Water Service Date Type Rough In ~ Material Type # Conn.Type 0 0 0 0 0 0 0 0 0 0 o o o o o Inspector WJ (Chip) Callies no time FAXED REQUEST / READY AT 9AM DatelTime requested: 9/27/04 08:38 AM Access: Notice Type: Telephone Number: 733-8125 JAMIE Ready DatelTime: 9/27/04 09:00 AM Requested By: WATTERS PLUMBING o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid Job Address 400 402 WYLDEWOOD DR Owner WYLDEWOOD CONDOMINIUMS LLC Plumbing Permit Work Card Permit Number 109191 Contractor WATTERS PLUMBING Category Bathtub Whirlpool Lavatory Toilet Res. Sink Bar Sink Water Heater 410 - Residential-Interior 2 ShoWe'r o , Floor Drain 8 Lndry Tray 6 Disposal 2 Dishwasher o .Sump Pump 2 Classrm Sink o Breakrm Sink o Ejector/Grind o Site Drain Roof Drain Misc. Fixtures Use/Nature of Work IN'W D'p~xI "ng'e ,tor; Size Sanitary Sewer Storm Sewer Water Service Date Type Underground no time Create Date 06/29/2004 Plan Value $11,896.00 4 Water Softner 0 Wait. St. 0 Shamp Sink 0 Coffee Maker 0 2 Local Waste 0 Ice Chest 0 FlrlWst Sink 0 Int Grease Trap 0 0 Clothes Wshr 0 Exam Sink 0 Catch Basin 0 Ext Grease Trap 0 - 2 Bidet 0 Sculry Sink 0 Wash Ftn 0 RPZ Valve 0 - 2 Beer Tap 0 Hand Sink 0 Urinal 0 Eye Wash Statn 0 2 Lab Sink 0 Plaster Sink 0 Standp Rec 0 Wtr Sewer Mtrs 0 0 Sterilizer 0 Surgeons Sink 0 Ice Maker 2 Deduct Meters 0 - 0 Dip Well 0 F Prep Sink 0 Gar Drain 0 Wtr Usage Mtrs 0 0 Drink Ftn 0 Serv Sink 0 Soda Disp 0 # Conn. Type o o o o o o o o o o o o o o o Inspector WJ (Chip) Callies Notice Type: ~ Material Type FAXED REQUEST DatelTime requested: 7/12/04 02:35 PM Access: Telephone Number: JAMIE 733-8125 Ready DatelTime: 7/12/04 02:30 PM Requested By: WATTERS PLUMBING o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid Plurnbing Permit Work Card Permit Number 109191 Job Address 400 402 WYLDEWOOD DR Owner WYLDEWOOD CONDOMINIUMS LLC Category Bathtub Whirlpool Lavatory Toilet Res. Sink Bar Sink Water Heater Site Drain Roof Drain Misc. Fixtures Use/Nature of Work Sanitary Sewer Storm Sewer Water Service Date 410 - Residential-Interior 2 Showe'r Q, Floor Drain 8 Lndry Tray 6 Disposal 2 Dishwasher o -Sump Pump 2 Classrm Sink o Breakrm Sink o Ejector/Grind o Contractor Plan WATTERS PLUMBING Create Date 06/29/2004 Value $11,896.00 o o o o o o o o row D'pl,," "09" ""y Size Type Underground 4 Water Softner 0 Wait. St. 0 Shamp Sink 0 - 2 Local Waste 0 Ice Chest 0 FlrlWst Sink 0 0 Clothes Wshr 0 Exam Sink 0 Catch Basin 0 - 2 Bidet 0 Sculry Sink 0 Wash Ftn 0 - 2 Beer Tap 0 Hand Sink 0 Urinal 0 2 Lab Sink 0 Plaster Sink 0 Standp Rec 0 - 0 Sterilizer 0 Surgeons Sink 0 Ice Maker 2 - 0 Dip Well 0 F Prep Sink 0 Gar Drain 0 0 Drink Ftn 0 Serv Sink 0 Soda Disp 0 Material Type # Conn.Type 0 0 0 0 0 0 0 0 0 0 o o o o o Inspector WJ (Chip) Callies no time Coffee Maker Int Grease Trap Ext Grease Trap RPZ Valve Eye Wash Statn Wtr Sewer Mtrs Deduct Meters Wtr Usage Mtrs FAXED REQUEST Access: DatelTime requested: 7/8/04 01:18 PM Notice Type: Telephone Number: 733-8125 JAMIE Ready DatelTime: 7/8/04 01 :00 PM Requested By: WATTERS PLUMBING o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid City of Oshkosh Inspection Services Division . 215 Church Avenue, PO Boxl130 ,Oshkosh, WI 54903-1130 Phone: (920) 236-5050 Fax (920) 236-5084 ~r'l.l~QL - _D:"~_.~jj; / FIELD INSPECTIONltEPORY' .~ JOB LOCATION: 400 "'tOZ WYLf)t:w(J().J) CONTRACTOR: M I DkJ~.s7 GW!:.RAt PROJECT TO BE INSPECTED: . ,. Alp ~ 1 .. -Pvpl~}(. JCn~cb TYPE OFINSPECTION:---.:tLhJ Bid) 1-~""JA(, Violations must be corrected and approved within 30 days unless otherwise noted. Call for re-inspections prior to concealment and/or occupancy: Upon completing the corrections, the owner/contractor/agent must sign and date at the bottom of this notice and return it to the spection Services Division by the Compliance Date of . fliff INSPECl10NcQSVLts, el 2 3 400 4fj()() V ~-zS' vA-~~ ~ ~ t\ N~~\D~ \../ Print Name Company ;1'ff J ~ tf.f (; e Il~r"\ f ,&~'3 0 -OJ' Signature: J",y Date ..~ CORRE1CTION NOTICE / FIELD INSPECTION REPORt I JOB LOCATION: L.j Q 0 Y Va.- \.;..;>~ l.>l e ",--"'X:;-;) CONTRACTOR: Co ~~'''~ . . \ € 0::.. PROJECT TO BE INSPECTED:' .. \... -6' ..lJu...C( \e 'f TYPE OF INSPECTION: ~\ ,^-(""i(\ ;re,;,:,,>: ,A,) City of Oshkosh ~~I:lection Services Division ' \ ..c.l5'Church Avenue, PO Box 1130 Oshkosh, VVI54903-1130 "'Phone: (920) 236-5050 Fax (920) 236-5084 Violations must b~ corrected and approved within 30 days unless otherwise noted. Call for re-inspections prior to concealment and/or occupancy. Upon completing the corrections, the owner/contractor/agent must sign and date at the bottom ofthis no#~e and return it to the Inspection Services Division by the Compliance Date of'" .. ... INSPEC1l0NQStlLtS SeLLA ,-- e 6' \, -L-::. 1 VI. s~ II ".. ~ D A U. lA e. '-t 'e ^ Ld<-u..\ V-cd -*::.:c::> ,c"\..f--ev\...lo". ..\:;::ka... ..e. V\.VC::i1:';L-e., Signature: ewc... Company J1 {. J 0 e f.....;.4> :C~-1 e,~lf.1 Co" if c: do r ,r .^,<:?~L" "" ".-",,'.:,",,"'" " Date!;'b"-- J dL o.r- Print Name ~.i: ..' ~ < \ -t\,. V.:> IV'l '5 -~ II .- d (=> "^ U. I.ct <e -.( 'e''. 5 t.A t .A Co. C' :5 L~I._",\ V-cd Or~ "if~ Vl.Ao" ~lL<Z... ~. \i,\-I;;.l4';.-\". ,<, ~ Company (ld/o/ /~6 Date ,6 - ~- C-ZEC::~ d'S