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PRE 2010 DOCS4°; 42643City of Fridley, Minn. 2 0412- 6431 1 University Ave. N. E., Minneapolis, Minn. 55432 _ BUILDING PERMIT Date: February 26, 1973 Qom: -Robert Laugen Homes Inc, Builder Same address JEU6 East Fish Lake Road, Osseo Address Same LOCATION OF BUILDING Na 1481 Street North Innsbruck Drive N.E. part of Lot Lot, 12 Block 2 Addition or Sub -Division Innsbruck North 1st Addition Corner Lot Inside. Lot X Setback Sideyard &64AMevation liic+;M&W Wlaffi/W Wve Top of Footing DESCRIPTION OF BUILDING To be Used as: Dwelling Front 42t Depth 24.3' Height 28' Sq. Ft. 10201 Cu. Ft. 28s.560 Garage Front 22' Depth 24' Height 10' Sq, Ft. 528' Cu. Ft. 5,280 Type of Construction Wold Frame Est. Vogt _A3 ,348 To be Completed June, 1973 Stipulations: Provide a hard surface driveway. Provide a verifying survey before capping. $275.00 SAC charge paid. WATER LOCATION: SEWER LOCATION: In consideration of the issuance to me of a permit to construct the building described above, I agree to do the proposed work in accordance with the description above set forth and in compliance with all provisions of Ordinances of the city of Fridley. _ I n _ /-'A _ In consideration of the payment of a fee of 6 3. 00 , permit is hereby granted to Robert Laugen Houses Inc to construct the building or addition as described above. This permit is granted the express condition that the person to whom it is granted and his agents, employees and workmen, in all work done in, around and upon said building, or any part thereof, shall conform in all respects -to the ordinances of Ivridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildings otbin the rdinances. city limits and this pest may be revoked at any time upon violation of any of the provisions of said e 731" _, wilding Inspector CLARENCE BELISLE NOTICE: This permit does not cover the construction, installation for wiring, plumbing, gas heating, sewer or water. Be sure to we the Building Inspector for separate permits for these items. r GERALD T. COYNE 300 BRUNSWICK AVE. S. GOLDEN VALLEY, MINN. MINN. REG. NO. 4741 INDUSTRIAL — JUDICIAL COMMERCIAL — TOPOGRAPHICAL CITY LOTS — PLATTING LOT SURVEYS COMPANY LAND SURVEYORS REGISTERED UNDER LAWS OF STATE OF MINNESOTA LICENSED BY ORDINANCE OF CITY OF MINNEAPOLIS 5747 W. Broadway . 533-9922 Minneapolis, Minnesota 55428 *umeJriiB l�erfifhate ROBERT LAU -EIN HOOT'S INC. "� -.� e d .�f hm p6 r, RAYMOND A. PRASCH 6917 IDAHO AVE. N. BROOKLYN PARK, MINN. MINN. REG. NO. 6743 INVOICE NO. F. B. NO. SCALE I" c �� 0 — DENOTES IRON v �j At C� LOQ. 12 , Block 2, INNSBRUCK NOItTH We hereby certify that this is a true and correct representation of a survey of the boundaries of the above described land and the location of all buildings and visible encroachments, if any, .from or cn said land. l,a* f . p' �Ir �r .• > Signed ' Surveyed by us this )&qday of. Febro 19,L LOT""SURVEYS COMPANY '�2C-) C g T'rof f7eOrgo(, - e, , z),q r�;.e- /6' C mi Zocr�-ii 0 /Z,; e15 9,5a,2 o-7 APPLICATION FOR RESIDENTIAL, ALTERATION, OR ADDITION BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA OWNER'S NAME : BUILDER: ADDRESS: ADDRESS: NO:. ' y I ,STREET /714.1 & a r lC ,/moi -1 v e - LOT: 1'2- BLOCK: :1- ADDITION: Jhhsif-� AIt/ 111 Ao CORNER LOT: INSIDE LOT: 1/ SETBACK: SIDEYARD: Applicant attach to this form Two Certificates of Survey of Lot and proposed building location drawn on these Certificates. DESCRIPTION OF BUILDING To Be rUsed As: tame l r� S Front : Li l� Depth : a Height: b_ Square Feet: , ; a -� Cubic Feet: -A 4CL, -Front: -L-L, Depth • P4 Height Square Feet; ,'D ;`{ Cubic Feet: Type of Construction: J��I T ery*_ Estimated Cost:_$ S- Q 0° — To Be Completed: %o - / - 7 3 The undersigned hereby makes application for a permit for the work herein specified, agreeing to do all work in sttict accordance with the City of Fridley Ordinances and rulings of the Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and correct. ,.rte DATE: e 3j SIGNATURE: (See Reverse Side For Additional Information.) t ®✓ pficatfon for Pourer Ptants and Hooks Coof age Ye�e'fatione ltalrfgeeptfi'on and Air Conditioning S"nas and (Devices . PARTIAL RATE SCHEDULE GRAVITY WARM AIR: RATE TOTAL Furnace Shell & Duct Work ........................... $10.00 $ Replacement of Furnace ............................. 6.00 $ Repairs & Alterations—up to $500.00 ................. 6.00 $ Repairs & Alterations each add. $500.00 ............... 3.00 $ CH. WARM AM Furnace Shell & Duct Work to 120,000 BTU ............$10.00 $ -Lu. A each add. 60,000 BTU ....................... 3.00 $ Replacement of Furnace ............................. 6.00 $ Repairs & Alterations --up to $500.00 ................. 6.00 $ Repairs & Alterations each add. $500.00 .............. 3.00 $ STEAM or HOT WATER SYSTEM Furnace Shell & tines—to 400 sq. ft. EDR Steam .... .$10.00 $ Furnace Shell & Line—to 640 sq. ft. IDR Hot Water . - 10.00 $ .- :._.Each add. 200 sq ft. EDR Steam ...................... 3.00 ' $L r Each add. 320 sq. ft. EDR Hot Water 3.00 $ OIL BURNER --to 3 gal. per hour ... .:... ...... ..... 6.00 $ over 3 gal. per hour—See Fee Schedule GAS BURNER (up to 199,000 BTU) .............1........ 8.00 $ K _ 00 — aver 199,000 RM see. Fee Schedule ; GAS FITTING FEES: NO RATE TOTAL 1st 3 Fixtures ...................... 1 x$ 200 $ 2.00 Additional Fixtures ................. x .78 $ Gas Range to 199,000 :$ 600 $ AIR C-31-MONING NESTS SLO-36 '0 tori) 18.00 FAN HEATING SYSTEM Bee Fee Schmale VENTILATING SYSTEM dO SURCHGE ALTERATIONS & REPAIIM TOTAL "M $ 35..- ROUGH FINAL - a d - ' 5� Dept. of BIdgm. Phone 880 -MM City of Fridley: The undersigned hereby makes application for a permit for the work herein specified, agreeing to do all work in strict accordance with the City Ordinance: and ruling of the Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and correct. Fridley, Minn. Mare 28, 1973 Owner Robert Langan Homes . . Kind of Building frame Used as residential To be completed about 4/30/73 Estimated Cost, $ 19 600.00 Old—New. Building Permit No. Permit No.�C J. DESCRIPTION OF WORK HEATING or POWER PLANTS—+Steam, Not Water, Warm Air—No-1— Trade ir—No 1Trade Name LENNOX Size No G_ I 132— Capacity, 110- Qf10 Sq. Ft. E.D.R- BTU H.P. Total Connected Load 66, 096 Hind of FuPI Gas BURNER — Trade Name SAME AS ABOVE Size No Capacity Sq. FL ILDR BTU HF. SALESNANs Don Bell COPY OF HEAT LOSS ATTACHED. IiI (RONARKS-0116!) HEATING & AIR CONDITIONING 3260 Gorham Ave. - 929-6767 5k Louis Park, Minnesota 55 126 Ciiy ®f (Fridley Applicre®n for Numbing cad Gear FiWang Flerin, i� Dept. of Bldgs. Phone 560-3450 DESCRIPTION OF WORK// Number, Kind and Location of Fixtures Location Future Connection Openings f wnnecxea wises Sewer New Fixture, Old Openings Cesspool F] PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL Number Fixtures ...................... � x j�jQ $ �(% $23.00 Future Fixture Opening ................ x• 38&x $ $1.50 New Fixture Old Opening .............. x 62& $ $1-50 Catch Basin ... .................... x 3.25 $ Water Heater (Up to gTU) ...... x $ 6D --$3-00 New Ground Run Old Bldg. ............ x 3.25 $ City of Fridley: The undersigned hereby makes application for a permit for the work herei specified, agreeing to do all work in strict accordance with the City Ordinance and ruling of the Department of Buildings, and hereby declares that all the fact and representations stated in this application are true and correct Fridley, Minn Owner Kind of Building Used as To be completed about Estimated Cost, $ Old—N . Building Permit No Permit No. � ROUGH Electric Water Heater $y2.00 GAS FITTING FEES: NO. RATE TOTAL 1st 3 Fixtures .......................... x $1. $ 4 $2.00 Additional Fixtures .................... x Xi $ • 75 Gas Range to TU .............. x $ $5-00 v REPAIRS & ALTERATIONS—Refer to Code Description ................................................$ s � TOTAL FEE $ / 114 C-&4.42 Signed _ Business Phone No- c.- –`� 7b �n s Z Z F I V� K�- w a7< w �� `1 w �<Z t9 aC a ? Z a 0 O I • • N WATER HTR. GAS ELEC. Base 1st ( + I 2nd 3rd Future Connection Openings f wnnecxea wises Sewer New Fixture, Old Openings Cesspool F] PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL Number Fixtures ...................... � x j�jQ $ �(% $23.00 Future Fixture Opening ................ x• 38&x $ $1.50 New Fixture Old Opening .............. x 62& $ $1-50 Catch Basin ... .................... x 3.25 $ Water Heater (Up to gTU) ...... x $ 6D --$3-00 New Ground Run Old Bldg. ............ x 3.25 $ City of Fridley: The undersigned hereby makes application for a permit for the work herei specified, agreeing to do all work in strict accordance with the City Ordinance and ruling of the Department of Buildings, and hereby declares that all the fact and representations stated in this application are true and correct Fridley, Minn Owner Kind of Building Used as To be completed about Estimated Cost, $ Old—N . Building Permit No Permit No. � ROUGH Electric Water Heater $y2.00 GAS FITTING FEES: NO. RATE TOTAL 1st 3 Fixtures .......................... x $1. $ 4 $2.00 Additional Fixtures .................... x Xi $ • 75 Gas Range to TU .............. x $ $5-00 v REPAIRS & ALTERATIONS—Refer to Code Description ................................................$ s � TOTAL FEE $ / 114 C-&4.42 Signed _ Business Phone No- c.- –`� 7b F SUBJECT -0-ERMIT NO. City of Fridley 30086 AT THE TOP OF THE TWINS BUILDING PERMIT RECEIPT NO. `y ------COMMUNITY DEVELOPMENT DIV.�;?,63 SEC. r PROTECTIVE INSPECTION 1 . F ` ,o "n CITY HALL FRIDLEY 55432 NUMBER REV DATE PAGE OF APPROVED BY L J` 612-571-3450 910-F15 8/19/99 10B ADDRESS 1481 North Innsbruck Drive NE I LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 12 2 Innsbruck North Ist AdditionSHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Vern Brewers 3 CONTRACTOR MAIL ADDRESS ZI755337 PHONE LICENSE NO urnsville Four Seasons Roofin 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO 6 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION ❑ ALTERATION XIM REPAIR ❑ MOVE ❑ REMOVE B DESCRIBE WORK Reroof house and garage 36 S Tear -off 9 CHANGEOFUSEFROM TO STIPULATIONS Underlayment must comply with the State Building Code. SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD VENTILATING OR AIR CONDITIONING THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SO. FT CU FT. AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT ANY TIME AFTER WORK IS COMMENCED. NO DWLG. UNITS OFFSTREET PARKING I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION STALLS GARAGES AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED WITH WHETHER SPECIFIED HEREIN OR NOT, THE GRANTING OF A PERMIT $3146 $1.57 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SAC CHARGE PROVISIONS OF ANY OTHER STATE O LOCAL LAW REGULATING CON- STRUCTION OR THE PERFORM NCE ONSTRUCTION $97,25 Fire SC $3.15 LAN CHECK FEE TOTAL FEE Licen $S.0 106.97 SIGNATURE Of fN' TOR ORA OR12EDAGENT IDATEI HE PR P VALID T D THISI OU ER IT S,GNATURE OF OWNER)IF OWNER BUILDER) IDATEI BOG INSP f1AtE F NEW[ ] Effective 5/10/99 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMELY AND DUPLEXES R-1 AND R-269. ((�o BU, I/LDIN.�G/PE APPLICATION V IO Construction Address: Legal Description: Owner Name & Address: V,e/2j 6zea tern Tel. ,# Contractor: T-a&so v s /2¢- MN LICENSE # t) Address: D ? �%� �. %%� I�i�l[� U �e k fLt f/1 ffe- A� Tel. # q9 r / Attach to this application, a Certificate of Survey 'of the lot, with the proposed construction _drawn on, it to scale. DESCRIPTION OF EMPROVEMENT LIVING AREA: Length Width Height Sq. Ft. GARAGE AREA: Length Width Height Sq. Ft. DECK AREA: Length Width Hgt/Ground Sq. Ft. OTHER: ke -- -Fti fill 1.4 Per Construction Type: Estimated Cost: $ 9 3/ Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $ DATE: 5?—d-2? APPLICANT: Tel. # Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee $ Sewer Main Charge TOTAL STIPULATIONS: CITY USE ONLY Fee Schedule on Reverse Side .001 of Permit Valuation (1/10th%) $.50/$1,000 Valuation $1050 per SAC Unit $5.00 (State Licensed Residential Contractors) Alt. "A" or Alt. "B" Above $450.00 Conservation Plan Review Fee Determined by Engineering Agreement Necessary [ ] Not Necessary [ ] L SUBJECT P City of Fridley 3 013 0 AT THE TOP OF THE TWINS BUILDING PERMIT NO. `v DEVELOPMENT DIV. -------COMMUNITY r � � PROTECTIVE INSPECTION SEC. NUMBER REV DATE PAGE OF APPROVED BY CITY HALL FRIOLEV 55432 612-571-3450 910-F15 8/27/99 JOB ADDRESS 1481 North Innsbruck Drive NE 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 12 2 Innsbruck North 1st Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Vern $ Donna Brewers 574-0066 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Ronald Evenson Const. Inc. 2047 Peninsula Rd NE Outing MN 56662 21R-7c)2-SIR7 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO 8 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION 2a ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Colonade Brick veneer - 2 sq. ft., tar paper behind 9 CHANGE OF USE FROM TO STIPULATIONS SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL. PLUMBING, HEATING. TYPE OF CONST. OCCUPANCY GROUP OCCUPANCYLOAD VENTILATING OR AIR CONDITIONING THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SO. FT CU FT AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS. OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT ANY TIME AFTER WORK IS COMMENCED. NO DWLG. UNITS OFFSTREET PARKING I HEREBY CERTIFY THAT 1 HAVE READ AND EXAMINED THIS APPLICATION ISTALLS GARAGES AND KNOW TME SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT 5400 $2.70 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SAC CHARGE PROVISIONS ANY OT R ATE O LOCAL LAW REGULATING CON. STRUCTIO THE PEpfO ANCE CONSTRUCTION $125.25 Fire SC $5.40 PLAN CHECK FEE OTAL FE Lic C 5 00 4 5 SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI ENP OPER BLD ,NSP 00 DATED YAIAS IS PIT QAtL a S,GNATURE OF OWNER SIF OWNER BUILDER, IOATE, L 1 NEW[ ] Effective 5/10/99 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FANDLY AND DUPLEXES R-1 AND R-2 j BUILDING PERMIT APPLICATION Construction Address: l Y�� /S/ �iP�S 11jole 14j - Legal I Legal Description: Owner Name & Address: A&- Tel. # �7 Contractor: MN LICENSE # Address: Iz2JIZ Tel. # W� 7" J'Y97 OWIIJ& tit �j Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DES / 1719N OF IMPRO HENT ( ('0 (- V /J 6e-) LIVING AREA: Length Width Height Sq. Ft. GARAGE AREA: Length Width Height Sq. Ft. DECK AREA: Len Width Hgt/Ground Sq. Ft. OTHER: !COji C� CLQ f�. f �5 r e�C !�Z (o� a Construction Type: ,��j�. ��1�� Estimated Cost: $ Driveway Curb Cut Width Needed: Ft. + 6 Ft= Ft x $ _ $ DATE: % ��APPLICANT: Tel. # CITY USE ONLY Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: $ /,,$)5 —2� $ /_38..3s Fee Schedule on Reverse Side .001 of Permit Valuation (1/10th%) $.50/$1,000 Valuation $1050 per SAC Unit $5.00 (State Licensed Residential.. Contractors) Alt. "A" or Alt. "B" Above $450.00 Conservation Plan Review Fee Determined by Engineering Agreement Necessary [ ] Not Necessary [ ] CiTY OF FRIDLEY BUILDING INSPECTION 5431 University Ave NE =ridley, MN 55432 763-572-3604 FAX 763-5711287 I- esident al =umace Shell and Duct Work, Sumer & also Replacement Furnace aas Piping (New Furnace, Fireplace, insert) aas Range aas Dryer kAir Conditioning - All Sizes kil Other Repairs or Alterations (List on Back) L% of Value of Appliance or Work Minimum Fee $15.00 for Residential or 5% of cost of mprovement whichever is greater �'--Oo6 � Effective 4/1/2004 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES r. $35.00 $ $10.00 $ $25.00 $ A 5,'® $ mmerelel/Indust lal Ins it utional L25% of Value of Appliance or Work (List on Back) $ Minimum Fee $35.00 for Commercial/industriai/Institutional i t3� State Surcharge $ TOTAL FEE $.�� 3EINSPECTiON FEE $50.00/HOUR kAir Conditioners can not be placed in side yard without written approval °rom adjoining property owner - copy to City FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE JOB ADDRESS 1491 Owner �1-ey h n & I&' -Do yam, F Y-" 'V -i? yes Building Used As ESTIMATED COST (t' QI . PERMIT NO # of Heating Units Circle One (Steam) ) a ~ Trade Name Size No. BTU I M ) HP EDR Fuel LA _Total Connected Load Sumer Trade Name Size No. BTU Hp EDR ek Y is W- 9TCX4 a( )C) I il'u w—, i C The undersigned hereby makes application for a permit for the work herein specified agreeing to do all work in strict accordance with the City Codes and rulings of the Building Division, and hereby declares that all the facts and representations stated in this application are true and correct. HEATING TQ Signed - Tel #' C�744g4-5 FAX # �� Date'(L� )ugh -in Date Final Date FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS COMMON VENT- VENT CONNECTOR AND COMBUSTION AIR VERIFICATION When replacing an existing furnace, the undersigned hereby verifies brat the venting has been examind and is free from rust, deterioration, obstructions, and is securely supported and frestopped where required Yes No The venting system is plastic/PVC and meets all current rent odes and manufacturer specifications including sizing, length, number of elbows and termination. Yes No( The undersigned also verifies that the replacement unit is a fisted assembly and meets the current codes and manufacturer's specifications. This does include AGA-GAMA Category I Central Fumace Venting Tables for fan assisted and natural draft appliances. Yes No( The existing combustion air is sized and installed to meet the current comes and manufactvreu's sp fications. Yes () No W When required to install a new combustion air, if will be sized and installed to meet the current codes and manufacturer's specifications. Yes ( No( When Installing a new venting system, the undersigned hereby verifies that it is a fisted assembly and meets'the current odes and mowfarfiueu's specifications. This does include AGA-GAMA Category I Central Fumace Venting Tables for fan assisted and natural draft appliances. Yes Qo No( ) Is the common vent and vent connectors sized and installed correctly after an appliance has leen removed from the common vent and vented separately as per current odes. Yes No( Appliance Tyre and Size/Common Vent and Vent Connector Information Appliance #1 Type tH- BTU Input Fan Assisted or Nat' �- t Appliance #2 Type BTU Input Fan Assisted or Nat Appliance #3 Type BTU Input Fan Assisted or Nat Total Appliances Total Btu Input Common Vent Type %v-�A- Vent Height 6-436 t Diameter _� inches Appliance #1 Vent Connector Might ft Length ft Diameter in Type Appliance #2 Vent Connector Height ft Length ft Diameter in Type Appliance #3 Vent Connector Height ft Length ft Diameter in Type ALTERATIONS: (Describe) AR—w is 72% , -J-t10-K- Llt4r- '94"' Ups 12 - ,k'p-- -N-, HEATING CO: 1' l- lL Signed By: Date: �- 7-