PRE 2010 DOCSVillage of Fridley, Minn.
BUILDING PERM"
NO 7 83
Office of INSPECTOR OF BUILDINGS
it
Owner,
Architect
Builder
Fridley, Minn.,
LOCATION OF BUILDING
No. --!� �Ra street. 2A4 - l LLb —Part Of Lot
Lot, N —i:,Block— Addition or Sub-Division–
DESCRIPTION OF BUILDING
Front Depth Height- Stories f -L Manner of construction
To be used as,
To be completed. l� Estimated Cost
Permit is hereby
the building described In the above statement. This permit is granted
upon the express condition that the person to whom It is granted, and his agents, employees and workmen, in all
the work done in, around and upon said building, or any part thereof, shall conform In an respects to the ordi-
nances of Fridley, Idinn., regarding the construction, alteration, maintenance, repair and moving of buildings
within the city limlts; and this permit may be revoked at any time upon violation of any of the provisions of said
ordinances.
of Buildings.
AGREEMENT AND SWORN STATEMENT
In consideration of the issue and delivery to me by the Inspector of Buildings of Fridley of
the labove permit,l hereby agree to do the proposed work in accordance with the description
above set forth and according to the provisions of the ordinances of Fridley, and, being first duly
sworn, I hereby state and say that the facts stated by me and contained in the above permit are
true as therein stated.
J,
Subscribed and sworn to before me at Fridley, Minnesota, this t7x�"
day of A.D. lwl—�-
City of Fridley, Minn.
,BUILDING PERMIT N? 5650
Date:
Owner: uilder
Address
L 0LBUILDING
4 Part Of Lot
Lot Block . ...... Addition or Sub-pvi Ommn
Corner Lot --- Inside Lot 4Mack Sideyard
Sewer Elevation Jdation Elevation
DESCRIPTION OF BUILDING
Too
Ft 9�.�Ca. Ft.
'ont Depth,A,0Z_ Height Sq.
on Depth eight Sq. Ft._Cu. Ft
Type of Construction Est. Coit t/'4'0 Z2 To be Completed
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.
In consideration of the payment of a fee of permit Is hereby granted to..._.
toconstruct the building or addition as described above. This permit is granted upon
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
Fridley, Minnesota regarding location, construction, alteration, maintenance, repair and ,to
of buildings
within the city limits and this permit may be revoked at any time upon violation of any of the provisions of said
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.
.4j10.4
«_ . 4- _ - -
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDIZY, MINNESOTA
Owner's Name DONALD BRAUSEN Builder Same
Address 4832 - 2d. Street N. E. Address
LOCATION OF BUILDING
No. 4832 Street 2nd Street N, E. Part of Lot
Lot 9 and 10 Block 4 Addition or Subdivision Plymouth Addition
Corner Lot Inside Lot x Setback ` Side -Yard
SEWER ELEVATION FOUNDATION ELEVATION
Applicant attach to this form Certificate of Survey of Lot and proposed building
location.
DESCRIPTION OF BUILDING
To be used as:
DETACHED GARAGE Front____M 16 Depth 22 Height 10
Sq. Ft. 352 Cu. Ft. 3,520
Front Depth Height
Sq. Ft. Cu. Ft.
Type of Construction Frame Estimated Cos
To be Completed
The undersigned hereby makes application for a permit for the work herein specified,
agreeing to do all work in strict accordance with the City Ordinances and ruling of
the Department of Buildings, and hereby declares that all the facts and representations
stated in this application are true and correct.
DATE 10/23/61 SIGNATURE
(A Schedule of Fee Costs can be found on the Reverse Side.)
City ®f Fridley, NUmm. C45�17.s'
PERMIT N? 7210
.19
Date:
Owner: Buildei
Address _ _ _ Address
CA O B ILDING
No. Street P
Lot Block Addition or Sub -
Corner Lot ._ Inside Lot _ _ Setback PSide d /
Sewer Elevation ____ — Fo on Elevation
DESCRIPTION OF BUILDING
To as:
Front Depth Height Sq. Ft. -tlo-vcu. Ft.
Fro . Depth Height Sq. Ft. Cu. Ft.
Type of Construction Est. be Completed
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 oY the city of Fridley. V z��
In consideration of the payment of a fee of $c , permit is hereby granted to
to construct the buil or addition as described above. This permit is granted upon
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
Fridley, Minnesota regarding location, conatru on, alteration, maintenance, repair and moving of buildings
within the city limits andldt s permit may be revoked at any time u vid of any of the provisions of said
ordinances.
Building Inspector
NOTICE:
Thb permit does not cover the construction, imtagwon for whhm, phmrhing, gas heathkg, sewer or venter. Be sure to see
the Wfldhis Inspector for soperan permits for these items.
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
OWNER'S NAME BUILDER
ADDRESS
_ ADDRESS
LOCATION OF .BUILDING
No*�
of Lot
Lot. /� Block' Additioa,or Subdivision _
Corner tot Inside Lot Setback Side -Yard,.
SEWER ELEVATION FOUNDATION ELEVATION
Applicaht aitich,to.this form Two Cext,ificates of Survey of Lot and proposed build-
ing locatioa•drawn on these Certificates.._,
DESCRIPTION OF BUILDING
To be used as:
Front Depth Height
S.q,, Ft. Cu.. ,Ft.
Front Depth Height
q. Ft. Cu. Ft..
Type of Construction ' Estimated Cost -
To be Completed
The undersigned hereby`maies application fora permit for the work hereia specified,
agreeing to do all work in strict accordance with the City of Fridley Ordinances and
rulings of the Department of Buildings, and hereby declares that. a11::the facts and
representations stated in this application are true.an4 correct.
DATE_ SIGNATURE '
jSchedule of Fee Costs can be found on the Reverse Side).
01
SUBJECT
Prr�
City of Fridley
AT THE TOP OF THE TWINS
BUILDING
PERMIT
i
R
�
1 • COMMUNITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
�
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
it i
/--'1 CITY HALL FRIDLEY 55432
,
L •---� `�
612-571-3450
910.F15
6/9/86
JOB ADDRESS 4832 - 2nd Street N . E ,
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
91 10
4 1
Plymouth
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP
PHONE
Donald Brausen same
572-•8987
3 CONTRACTOR MAIL ADDRESS
ZIP
PHONE LICENSE NO.
Hackbarth Construction
560-0793
4 ARCHITECT OR DESIGNER MAIL ADDRESS
ZIP
PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS
ZIP
PHONE LICENSE NO.
6 USE OF BUILDING
7 CLASS OF WORK
❑ ADDITION
❑ NEW CX ALTERATION
❑ REPAIR
❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Aluminum Trim
9 CHANGE OF USE FROM
TO
STIPULATIONS
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
SQ. 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
ISTALLS
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
$1,500
$,75
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SACCHARGE
PROVISIONS OF ANY OT ER STATE 05 LOCAL LAW REGULATING CON-
STRUCTION THE PE OR CE O CON TRUCTION.
$25,00
PLAN CHECK FEE
TOTALFEE
$25,75
.'SIGNATURE OF ONTRACTORO UTHORIZED AGENT (DATEI
WHE PtIOP Y. V
DA D THIS IS YOUR PERMIT
'G )NSR
C
GATE
SIGNATURE OF OWNER IIF OWNER BUILDER) (DATEI
01
NEW [
ADDN . [ ,]
ALTER.
Construction Address:
Legal Desa
Owner Name
Contractor
City of Fridley Effective 4/1/86
1R-1 AND R-2
Building Permit Application
Tot. # Z_8145-�t-
Tel. # —
Address • ( iV2— U 01`04 N `� bL) -
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
LIVING AREA: Length Width Height Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECK AREA: Length Width Hgt/Ground Sq. Ft.
OTHER: -Tf y]'� -- (Q(G-4MLULLMj
-
Corner Lot [ ] Inside Lot [ ] Ft. Yd. Set
Type of Construction:
Approx. Completion Date: SO on`e's
Proposed Driveway Width If New Opening Is Desired:
Side Yard Setback
Estimated Cost: $ IS00100
Alt. A Alt B
$ $
See Back Page for Explanation
/ Q
DATE: ��O APPLICANT: Tel..���` ��✓
CITY USE ONLY
Permit Fee
Plan Check
State Surcharge
SAC Charge
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
S.J. (-) 0
Fee Schedule on Reverse Side
25$ of Building Permit Fee
$.50/$1,000 Valuation
$475 per SAC Unit
Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary [ ]
!S -C) ®, 10AX)
/0�( / S' ao
ai3O()
sueJEci
I
PERMIT NO.
City of Fridley
2 � 6 4 3
, ,5 -TT4 F THE TWINS
BUILDING
PER�IIIT
• COMMUNITY DEVELOPMENT DIY.
n
r i rr _ a__
INSPECTION
r PROTECTIVE INSPECTION SEC
���
e
NUMBER
REV
DATE
PAGE OF
APPROVED BY
CITY HALL FRIDLEY 55432
612-571-3450
gi0-F15
11/24198
JOB ADDRESS 4832 2nd Street NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
91 10
1pi 0111-b
SHEET
—4
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Donald Brausen572-0298
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
Four Season Roofing & Rem LLC 7930 Unjv,-rsqjf3; Aup NT? Frid3py
5543 2-
4 ARCHITECT OR DESIGNER MAIL ADDRESS
ZIP PHO E LICENSE NO.
5 ENGINEER MAIL ADDRESS
ZIP PHONE LICENSE NO
6 USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW O ADDITION ❑ ALTERATION jj REPAIR O MOVE O REMOVE
8 DESCRIBE WORK
Reroof house (13 Sq) Tear -off
9 CHANGEOFUSEFROM TO
STIPULATIONS
Underlayment must comply with the State Building Code.
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING.
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
$1114
.56
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SACCH GE
PR VISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
S R CT N E PERFORMANCE OF CONSTRUCTION
$40.25
Fir C 1.11
�ImUkl
CHECK FE
TOA 'FEu/
/PLAN
,�Li
e
5 .92
SIGNATURE OF NrRACTOR Op AUTHORIZED AGENT iDAfE,
HEN RO
THIS IS F
t :�-
S.GNATUAE OF OWNERoF OWNER BUILDER, tDATE,
BLD 'NSP
MATE
NEV " [ ] EffecEive 1/1/98
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION n�
ConstructionAddress: G e
Legal Description: �d
Owner Name & Address: , ; o„ Tel. # Y72 -0A%6
Contractor: MN LICENSE #
Address: Tel. #
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
LIVING AREA: Length Width Height Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECK AREA: Length Width Hgt/Ground Sq. Ft.
OTHER: /' 3-P U s L
r r
Construction Type:tweln(;r-4 C� k6� Estimated Cost: $ / l
(Fee Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $
1
1 0
DATE: I APPLICANT: ►� ¢' Tel. #V 67
� .�
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
$
$ too
Park Fee $
Sewer Main Charge
TOTAL
STIPULATIONS:
$ 146.9,2
CITY USE ONLY
Fee Schedule on Reverse Side
.001 of Permit Valuation (1 / 10th %)
$.50/$1,000 Valuation
$1000 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
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432
572-36U4 YAX: (763) 571-IZ87
ADDRESS 4832 2ND ST NE
PIN 263024320049
LEGAL DESC UNAVAILABLE
LOT BLOCK
PERMIT TYPE ELECTRICAL
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : ADDITION/ALTERATION
PERMIT NO.: 2004-00901 4301bo
DATE ISSUED: 06/15/2004
VALUATION
NOTE: ELECTRICAL PERMIT BECOMES VOID 12 MONTHS AFTER PERMIT ISSUE DATE. WIRE FURNACE AND AIR
CONDITIONER.
# INSPECTIONS 1
APPLICANT
DEPENDABLE ELECTRIC INC
2619 COON RAPIDS BLVD NW
COON RAPIDS, MN 55433
BRAUSEN BRIAN E & NANCY N
4832 2ND ST NE
FRIDLEY, MN 55421
AGREEMENT AND SWORN STATEMENT
This permit becomes null and void if work or construction
authorized is not commenced witin 60 days or if construction
or work is suspended or abandoned for a period of 120 days
at any time after work is commenced.
I hereby certify that I have read and examined this
application and know the same to be true and correct. All
provisions of laws and ordinances governing this type of worl
will be complied with whether specified herein or not. The
granting of a permit does not presume to give authority to
violate or cancel the provisions of any other state or local law
regulating construction or the performance of construction.
Applicant Date
Bldg Insp Date
ELEC PERMIT FEE - MIN (RESI) 20.00
STATE SURCHARGE, ELEC FLAT 0.50
TOTAL 20.50
PAID WITH CHECK # 28516
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
CITY OF FRIDLEY
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432
r63) 572-3604 FAX: (763) 571-1287
REPRINTED ON 6/21/2004
ADDRESS : 4832 2ND ST NE
PIN : 263024320049
LEGAL DESC : PLYMOUTH
: LOT 9 BLOCK 4
PERMIT TYPE : HEATING
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : ADDITION/ALTERATION
PERMIT N .: 2004-00941
DATE ISSUE /21/2004
VALUATION : $ 1,500.00
NOTE: AIR CONDITIONERS CAN NOT BE PLACED IN A SIDE YARD WITHOUT WRITTEN PERMISSION FROM
ADJOINING PROPERTY OWNER. COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A.
INSTALL A RUUD, 70,000 BTUS AIR CONDITIONER.
# A/C UNITS 1 VALUE OF APPL OR WORK 0
#FURNACES
# GAS RANGES
APPLICANT
RIVER CITY SHEET METAL
9928 BLUEBIRD ST NW
COON RAPIDS, MN 55433-
(763)754-2199
OWNER
CRAIG MURPHY
4832 2ND ST NE
FRIDLEY, MN 55421
0 # GAS DRYERS 0
0
AGREEMENT AND SWORN STATEMENT
This permit becomes null and void if work or construction
authorized is not commenced witin 60 days or if construction
or work is suspended or abandoned for a period of 120 days
at any time after work is commenced.
I hereby certify that I have read and examined this
application and know the same to be true and correct. All
provisions of laws and ordinances governing this type of wort
will be complied with whether specified herein or not. The
granting of a permit does not presume to give authority to
violate or cancel the provisions of any other state or local law
regulating consction or the performance of construction.
ADAlican>; Date I 1
Bldg
HEATING PERMIT MINIMUM FEE
0.00
FURNACE SHELL/DUCT WORK
0.00
GAS RANGE FEE
0.00
GAS DRYER FEE
0.00
AIR CONDITIONING FEE
25.00
HEATING REPAIRS/ALTERATIONS
0.00
STATE SURCHARGE, MECH FLAT
0.50
TOTAL
25.50
PAID WITH CHECK # 13337
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
CITY OF FRIDLEY BUILDING INSPECTION
•6431 University Ave NE
Fridley, MN 55432
763-572-3604 FAX 763-571-1287
RATE SCHEDULE
Residential
Furnace Shell and Duct Work, Burner &
also Replacement Furnace
Gas Piping (New Furnace, Fireplace, Insert)
Gas Range
Effective 4/1/2004
APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION
REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES
Fee Total
$35.00 $
$10.00 $
$10.00 $
Gas Dryer $10.00 $
*Air Conditioning - All Sizes $25.00 $ a ,D
I& MA 1)4K46 e ®a y
All Other Repairs or Alterations (List on Back)
1% of Value of Appliance or Work $
Minimum Fee $15.00 for Residential or 5% of cost of
Improvement whichever is greater
Commercial/Industrial/Institutional
1.25% of Value of Appliance or Work (List on Back)
Minimum Fee $35.00 for Commercial/Industrial/Institutional
State Surcharge
TOTAL FEE
REINSPECTION FEE $50.00/HOUR
JOB ADDRESS 03 a Z,,e 9f_ A 1 -
Owner
Building Used AseSe
ESTIMATED COST PERMIT NO '7i -/ ccl
DESCRIPTION OF FURNACE AND BURNER
# of Heating Units Circle One (Steam) (Hot Water)(Warm Air
Trade Name RIX l my QO �% Size No.
BTU —70 '1coo HP EDR
Fuel NSG Total Connected Load
Burner Trade Name Size No.
BTU '9D., ®o n HP EDR
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.
•%✓�
*Air Conditioners can not be placed in side yard without written approval
from adjoining property owner - copy to City
FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE
Approved by Rough -in Date Final Date
FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS
COMMON VENT, VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
When replacina an existing furnace, the undersigned hereby verifies that the
venting has been examined and is free from rust, deterioration, obstructions,
and is securely supported and firestopped where required. Yes No( )
The venting system is plastic/PVC and meets all current codes and manufacturer
specifications including sizing, length, number of elbows and termination.
Yes () No
The undersigned also verifies that the replacement unit is a listed assembly
and meets the current codes and manufacturer's specifications. This does
include AGA-GAMA Category I Central Furnace Venting Tables for fan
assisted and natural draft appliances.
Ye No ( )
The existing combustion air is sized and installed to meet the current codes
and manufacturer's specifications.
YesNo ( )
When required to install a new combustion air, it 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 listed assembly and meets the current codes and manufacturer's
specifications. This does include AGA-GAMA Category I Central Furnace
Venting Tables for fan assisted and natural draft appliances.
Yes No( )
Is the common vent and vent connectors sized and installed correctly after
an appliance has been removed from the common vent and vented
separately as per current codes.
Yes) No( )
Appliance Type and Size/Common Vent and Vent Connector Information
Appliance #1 Type v6e*je BTU InputP� 900 Fan Assisted or Nat
Appliance #2 Type jjz� BTU Input, Fan Assisted or Nat
Appliance #3 Type BTU Input Fan Assisted or Nat
Total Appliances Total Btu Input ,
Common Vent Type Vent Height Z6 Diameter inches
Appliance #1 Vent Connector Height ft Length ft Diameter in Type
Appliance 42 Vent. Connector Height ft Length ft Diameter in Type
Appliance #3 Vent Connector Height ®® ft Length ft Diameter in Type
ALTERATIONS: (Describe)
.P,ei v -7�ic
HEATING CO:
C�(d / —f r/ I
,�_ y
Date
Signed By: e 20 0 �Z 10:1