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CWNER AD!JitE~0 ~? ~ 1ic t LD ADDRESS / . .. - ' DATE TTI'E ...........- ----- -S~ J;J.S ~ -L::L iJATURE OF wORK OwNER &. :&.- Y f JtA!.UJ /h'x_c:1i:Jw1~ ~.J,/n-,>",,~1'~ ----- -- -. CONTRACTOR VALUATION )/{JJAA"d~k-1'1.' -4> ~9ff HJ