HomeMy WebLinkAboutPermit M03-173 - SABRIE RESIDENCESABRIE RESIDENCE
16221 45THAVENUE
SOUTH
EXPIRED
MAR 3 0 2005
M03 -173
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Parcel No.: 9314900120
Address: 1622145 AV S TUKW
Suite No:
Tenant:
Name: SHARIFFA SABRIE
Address: 16221 45 AV S, TUKWILA WA
Owner:
Name: SHARIFFA SABRIE
Address: 16221 45TH AVE S, TUKWILA WA
Contact Person:
Name: DONNA JACK
Address: 4601 S 134TH PLACE, TUKWILA, WA
Contractor:
Name: BRENNAN HEATING CO INC
Address: 4601 S 134 PL, TUKWILA, WA
Contractor License No: BRENNHC077NC
DESCRIPTION OF WORK:
INSTALL NEW GAS FURNACE (100K BTU'S) IN PLACE OF OIL FURNACE AND NEW HOT WATER
HEATER (40K BTU'S). RELOCATION NEW HOT WATER HEATER 5' TO OTHER SIDE OF
FURNACE. BOTH LOCATED IN BASEMENT OF HOME.
Value of Construction: $5,789.00 Fees Collected: $69.90
Type of Fire Protection: N/A Uniform Mechnical Code Edition: 1997
Permit Center Authorized Signature:
I hereby certify that I have read and examined this permit and know the same to be true and correct. All provisions of law and
ordinances governing this work will be complied with, whether specified herein or not.
The granting of this permit does not presume to give authority to violate or cancel the provisions of any other state or local laws
regulating con AEI on or the perform fwork. I am authorized to sign and obtain this mechanical permit.
t ��� . tii i,i Date: tV tb
Signature:
Print Name:
doc: Mech
City of Tukwila
Department of Community Development / 6300 Southcenter BL, Suite 100 / Tukwila, WA 98188 / (206) 431 -3670
\ 2g-13
MECHANICAL PERMIT
M03 -173
Permit Number: M03 -173
Issue Date: 10/20/2003
Permit Expires On: 04/17/2004
Phone:
Phone: 206 248 -7900
Phone: 206 - 248 -7900
Expiration Date:03 /01/2004
Date:
This permit shall become null and void if the work is not commenced within 180 days from the date of issuance, or if the work is
suspended or abandoned for a period of 180 days from the last inspection.
Printed: 10 -20 -2003
:3';;:..xd c�...>.. i:@•`.::,✓ �t:$ i" aBtdA `;.+?r�'Ft'_+irrtr,:xue <�:':fi ..�.''nr::,�� "ri:.
City of Tukwila
Department of Community Development / 6300 Southcenter BL, Suite 100 / Tukwila, WA 98188 / (206) 431 -3670
Parcel No.: 9314900120
Address: 1622145 AV S TUIKW
Suite No:
Tenant: SHARIFFA SABRIE
PERMIT CONDITIONS
1: ** *BUILDING DEPARTMENT CONDITIONS * **
2: No changes will be made to the plans unless approved by the Engineer and the Tukwila Building Division.
3: All permits, inspection records, and approved plans shall be available at the job site prior to the start of any
construction. These documents are to be maintained and available until final inspection approval is granted.
4: All construction to be done in conformance with approved plans and requirements of the Uniform Building Code (1997
Edition) as amended, Uniform Mechanical Code (1997 Edition), and Washington State Energy Code (1997 Edition).
5: Validity of Permit. The issuance of a permit or approval of plans, specifications, and computations shall not be
construed to be a permit for, or an approval of, any violation of any of the provisions of the building code or of any
other ordinance of the jurisdiction. No permit presuming to give authority to violate or cancel the provisions of this
code shall be valid.
6: Manufacturers installation instructions required on site for the building inspectors review.
7: Fuel burning appliances may not be installed in sleeping rooms, U.M.C. 304.5.
8: Appliances which generate flame, spark or glowing ignition, shall be elevated 18 inches above the floor (U.M.C.
303.1.3.).
9: Water heater shall be anchored to resist earthquake (U.P.C. 510.5).
I hereby certify that I have read these conditions and will comply with them as outlined. All provisions of law and
governing this work will be complied with, whether specified herein or not.
The granting of this permit does not presume to give authority to violate or cancel the provision of any other work
regulating construction or the performa . e of work.
Signature:
Print Name:
doc: Conditions
4, - Nleler -1 A L
M03 -173
Permit Number:
Status:
Applied Date:
Issue Date:
M03 -173
ISSUED
10/20/2003
10/20/2003
ordinances
Date: (b/ca-0/0
or local laws
Printed: 10-20-2003
Site Address: 1,;)a.../..1 4 5-n4
Tenant Name:
Property Owners Name: GI4ARIEF BA6r4t
Name:Et.1*-Ah1 14€.:A I KL
1+ - TI A
Mailing Address:
E-Mail Address:
Company Name: - 352ENIMA7\1 (-fl kitir
Mailing Address: 4(00) 2 ' T ' L
Company Name:
Mailing Address:
Contact Person:
E-Mail Address:
Company Name:
Mailing Address:
Contact Person:
E-Mail Address:
\applicationsNpcnnit application (3.2003)
3/2003
CITY OF TUKWILA
Community Development L.epartment
Public Works Department
Permit Center
6300 Southcenter Blvd., Suite 100
Tukwila, WA 98188
ENGINEER OF RECORD -r Alt plans must be wet 4aMiied.hyEnginee17 Record
•-•—• --••• " '• ''',• • •
Page 1
Applications and plans must be complete in order to be accepted for plan review.
Applications will not be accepted through the mail or by fax.
**Please Print**
SITEI;OCATI
King Co Assessor's Tax No.: q s 401 oc,
Suite Number:
Floor:
New Tenant: D .... Yes E ..No
Mailing 1 L
City State Zip
Day Telephone: 79 OD
-- TF*1-3 LPO V3A 9[ (OZ
City State Zip
Fax Number:
-- TZ) 4,3 i LA 0 9810?
City State Zip
Day Telephone: a.144 c- - - 790D
Fax Number: ( 9Lt-g - - - 79bS -
Expiration Date: 3-1- o4-
Contact Person: 10)...k.kiPt
E-Mail Address:
Contractor Registration Number : 15RE&INII-ir
**An original or notarized copy of current Washington State Contractor License must be presented at the time of pennit issuance**
City
Day Telephone:
Fax Number:
State
Zip
City State Zip
Day Telephone:
Fax Number:
UILD!ING " yON 206=431.36
4. �r,.ii"`.} M t'(; \t Fi tt: ,t }�, r. �K, "�•"'r. J �. „ , i :.l N.�,, � ;E:. ., ,..
Valuation of Project (contractor's bid price): $
Scope of Work (please provide detailed information):
Will there be new rack storage? ❑ ..Yes ❑ .. No If "yes ", see Handout No. for requirements.
Provide All Building Areas in Square Footage Below
I' Floor:
2 " Floor
3` Floor '
;Floors
thru
Basement
Accessory Structure*.
Attached Garage
•
Detached Garage.'
Attached Carport
Detached Carport '
Covered Deck..
Uncovered Deck:
Existing ..
'Interior
Remodel
Addition to •
Existing
Structure
Type of
Construction
per UBC
Type of
Occtipancy'per
`UBC
PLANNING DIVISION:
Single- family building footprint (area of the foundation of all structures, plus any decks over 18 inches and overhangs greater than 18 inches)
*For an Accessory dwelling, provide the following:
Lot Area (sq ft): Floor area of principal dwelling: Floor area for accessory dwelling:
*Provide documentation that shows that the principal owner lives in one of the dwellings as his or her primary residence.
Number of Parking Stalls Provided: Standard:
Will there be a change in use? ❑ ....Yes ❑ ..No If "yes ", explain:
FIRE PROTECTION/HAZARDOUS MATERIALS:
❑ .. Sprinklers ..Automatic Fire Alarm ❑..None ❑ . Other (specify)
Will there be storage or use of flammable, combustible or hazardous materials in the building? ❑..Yes ❑.. No
If "yes", attach list of materials and storage locations on a separate 8-1/2 x 11 paper indicating quantities and Material Safety Data Sheets.
tapplicationa\pamil application (3.2003)
3/2003
Page 2
Existing Building Valuation: $
Compact: Handicap:
pU ?$i?Y.�RK $`PERMITpINI � M ATI O N`.
i �IIQh+ , Af. Fe... Y.
A < �t �' ;GS;}? ,im;3•p. i.Jc.1; 'a��7 1 �:',n� •••: ir..:::� . n >.,a:.
Scope of Work (please provide detailed information):
Please'refer to Public:Works Bulletin #1 for fees sheef
Water District
❑ ...Tukwila ❑...Water District #125
❑ ...Water Availability Provided
Sewer District
❑ ...Tukwila 0... ValVue ❑ .. Renton ❑ ...Seattle
❑...Sewer Use Certificate 0... Sewer Availability Provided ❑ .. Approved Septic Plans Provided
❑ ...Septic System - For onsite septic system, provide 2 copies of a current septic design approval by King County Health Department.
Submitted with Application (mark boxes which apply):
❑ ...Civil Plans (Maximum Paper Size — 22" x 34 ")
❑...Technical Information Report (Storm Drainage) ❑ .. Geotechnical Report ❑...Traffic Impact Analysis
❑ ...Bond ❑ .. Insurance ❑ .. Easement(s)
Proposed Activities (mark boxes that apply):
❑ ... Right -of -way Use - Nonprofit for less than 72 hours
❑ ...Right -of -way Use - No Disturbance
❑ ...Construction/Excavation/Fill - Right -of -way
Non Right -of -way
❑ ...Total Cut
❑ ...Total Fill
cubic yards
cubic yards
❑..:Sanitary Side Sewer
❑ ...Cap or Remove Utilities
❑ ...Frontage Improvements
❑ ...Traffic Control
❑ ...Backflow Prevention - Fire Protection
Irrigation
Domestic Water
❑ ...Permanent Water Meter Size...
❑ ...Temporary Water Meter Size..
❑ ...Water Only Meter Size
❑...Sewer Main Extension Public
❑ ...Water Main Extension Public
\applicationalpermit application (3.2003)
3/2003
❑ .. Abandon Septic Tank
❑ .. Curb Cut
❑ .. Pavement Cut
❑ .. Looped Fire Line
ff
11
Call before you Dig: 1- 800 - 424 -5555
11
W O#
WO#
WO#
Private
Private
Page 3
❑ .. Highline
❑ ...Renton
0 .. Maintenance Agreement(s) ❑...Hold Harmless
❑ .. Right -of -way Use - Profit for less than 72 hours
❑ .. Right -of -way Use — Potential Disturbance
❑ .. Work in Flood Zone
❑ .. Storm Drainage
❑ .. Grease Interceptor
❑ .. Channelization
❑ .. Trench Excavation
❑ .. Utility Undergrounding
❑...Deduct Water Meter Size
FINANCE INFORMATION
Fire Line Size at Property Line
❑...Water ❑...Sewer
Monthly Service Billing to:
Name:
Mailing Address:
Water Meter Refund/Billing:
Name:
Mailing Address:
Number of Public Fire Hydrant(s)
❑ ...Sewage Treatment
Day Telephone:
City
State
Zip
Day Telephone:
C ity
State
Zip
Unit Type:
Qty
Unit Type:
Qty
Unit Type:
Qty
Boiler /Compressor:
Qty
Furnace <100K BTU
1
Air Handling Unit
>= 10,000 CFM
Other Mechanical
Equipment
0 -3 HP /100,000 BTU
Furnace>100K BTU
Evaporator Cooler
3 -15 HP /500,000 BTU
Floor Furnace
Ventilation Fan
15 -30 HP /1,000,000 BTU
Suspended /Wall /Floor
Mounted Heater
Ventilation System
30 -50 HP /1,750,000 BTU
Appliance Vent
Hood
50+ HP /1,750,000 BTU
Heat/Refrig /Cooling
System
Incinerator - Domestic
Air Handling Unit
<= 10,000 CFM
Incinerator — Comm /Ind
•MECHANICAL PERMIT.;INFOT ATION 206 -431 3670:
MECHANICAL CONTRACTOR INFORMATION
.Eo s Ali egg (K & r
Mailing Address: 460i S ( 144 - Ft_
Contact Person: - bMil\141 JA
Company Name:
E -Mail Address:
Contractor Registration Number: 612Er4■1 Expiration Date: 5- ■ - OZ.
* *An original or notarized copy of current Washington State Contractor License must be presented at the time of permit issuance **
Valuation of Project (contractor's bid price): $ 5
1 t .
Scope of Work (please provide detailed information):
Signature:
■
Use: Residential:
Commercial:
Fuel Type: Electric
New ... Replacement .... ❑
New ....❑ Replacement ....❑
BUILDING 0 OW' SR AUTHORIZED A
..1 , _ .1_ ° WO
Print Name: c k. E.A ice! RUL1 .L
Mailing Address: trot S 1341 - 3 Fl
tappliationstpermit application (3.2007)
3/2003
Page 4
I`- BTU`S
City State
Day Telephone: -2`1 O0
LA ()JA °(-l(075
Fax Number: -Q - — 7 005
13Tv S
Day Telephone: 4!-" OD
BASE V4E0, - '
Zip
❑ Gas. Other:
Indicate type of mechanical work being installed and the quantity below:
Value of Construction — In all cases, a value of construction amount should be entered by the applicant. This figure will be reviewed and is subject
to possible revision by the Permit Center to comply with current fee schedules.
Expiration of Plan Review — Applications for which no permit is issued within 180 days following the date of application shall expire by limitation.
The Building Official may extend the time for action by the applicant for a period not exceeding 180 days upon written request by the applicant as
defined in Section 107.4 of the Uniform Building Code (current edition). No application shall be extended more than once.
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION AND KNOW THE SAME TO BE TRUE UNDER
PENALTY OF PERJURY BY THE LAWS OF THE STATE OF WASHINGTON, AND I AM AUTHORIZED TO APPLY FOR THIS PERMIT.
Date: lb - o'Z.o - o,
— TJKw\ -� qZ5I(.0q
City State Zip
Date Application Accepted:
/0 , -o 3
Date Application Expires:
` 4vz0 — 04 /
Staff Initials:
1
Parcel No.: 9314900120
Address: 1622145 AV S TUKW
Suite No:
Applicant: SHARIFFA SABRIE
Receipt No.: R03 -01263 Payment Amount: 69.90
Initials: SKS Payment Date: 10/20/2003 11:34 AM
User ID: 1165 Balance: $0.00
Payee: SHAWNEAN ALLEN
TRANSACTION LIST:
Type Method Description Amount
Payment Check 534
ACCOUNT ITEM LIST:
Description
doc: Receipt
City of Tukwila
6300 Southcenter BL, Suite 100 / Tukwila, WA 98188 / (206) 431 -3670
MECHANICAL - RES
RECEIPT
Permit Number: M03 -173
Status: PENDING
Applied Date: 10/20/2003
Issue Date:
69.90
Account Code Current Pmts
000/322.100 69.90
Total: 69.90
39.1. i .10/21 9716 TOTAL 129.15
Printed: 10 -20 -2003
Projes c
a•ice ,A2i(deoct
Type of Insp
1.- - 1( 1 4
A dres ( , f �)
(€ ` I ' I t t� r \�
Date Calle ^� s-� r
/(1_i!J 0
S ecial Instructions:
Date Wanted: , .c�
2. 1 `
•
Requeste •
Ph�eNo:�\ -24'F ~ 7CtD
INSPECTION NO.
CITY OF TUKWILA BUILDING DIVISION
6300 Southcenter Blvd., #100, Tukwila, WA 98188
El Approved per applicable codes.
INSPECTION RECORD
Retain a copy with permit
I 11
CQIVIMENTS:
Corrections required prior to approval.
477.
547.0 EINSPECTION'REQUIRED. Pr or to inspection, fee m st be
paid at 6300 Southcente Ivd., Suite 100. CaII to schedule reinspection.
Receipt No.:
Date:
Proje / z
Type of Inspection: ' -:, I- , /
Address:
/6,2..2/ - /<S "& S
Date Called: ' 1
//` ,-. .
Special Instructions:
�,,
GEC
. k t`•
Date Wanted
a.m.
R equesters
.--• t�fG��
Phone No: v'
7.,-,.-.4e7'6)
//3
INSPECTION RECORIY
Retain a copy with permit
CITY OF TUKWILA BUILDING DIVISION
6300 Southcenter Blvd., #100, Tukwila, WA 98188 i.- (2.6)431 -3670
INSPECTION NO.
E ApprOved per applicable codes.
Corrections required prior to approval.
COMMENTS:
1/7 (4.4";,17),--
n'O 1-
'13) (5 lust e,(_
j -�-d
Dater / ✓� ✓' 3
$47.00l INSPECTION FEE REQUIRED. Prior to inspection, fee must be
paid at 6300 Southcenter Blvd., Suite 100. Call to schedule reinspection.
Receipt No.:
'Date:
`% iJ�. f, �Yx'* IHiN• Ty'.• 4V1 ;�t ?'.cn:'y7r.xuN+- CStI+'..«zw—
02 -07 -2005
DONNA JACK
4601 S 134 PL
TUKWILA WA 98168
RE: Permit No. M03 -173
16221 45 AV S TUKW
Dear Permit Holder:
City of Tukwila Steven M. Mullet, Mayor
Department of Community Development Steve Lancaster, Director
In reviewing our current records the above noted permit has not received a final inspection by the City of Tukwila Building Division.
Per the International Building Code and/or the International Mechanical Code, every permit issued by the Building Division under the
provisions of this code shall expire by limitation and become null and void if the building or work authorized by such permit is not
commenced within 180 days from the date of such permit, or if the building or work authorized by such permit is suspended or
abandoned at any time after the work is commenced for a period of 180 days.
Based on the above, you are hereby advised to:
Call the City of Tukwila Permit Center at 206 -431 -3670 to arrange for the next or final inspection.
This inspection is intended to determine if substantial work has been accomplished since issuance of the permit or last inspection; or if,
the project should be considered abandoned.
If such determination is made, the Building Code does allow the Building Official to approve a one - time extension up to 180 days.
Extension requests must be in writing and provide satisfactory reasons why circumstances beyond the applicants control have
prevented action from being taken.
In the event you do not call for the above inspection and receive an extension prior to 03/21/2005, your permit will become null and
void and any further work on the project will require a new permit and associated fees.
Thank you for your cooperation in this matter.
Sincerely,
Stefania Spencer,
Permit Technician
xc: Permit File No. M03-173
Bob Bcncdicto, Building Official
6300 Southcenter Boulevard, Suite #100 • Tukwila, Washington 98188 • Phone: 206 - 431 -3670 • Fax: 206 - 431 -3665
August 4, 2004
Donna Jack
4601 South 134th Place
Tukwila, WA 98168
RE: Permit Application No. M03 -173
16221 45th Avenue South
Dear Permit Holder:
In reviewing our current records the above noted permit has not received a final inspection by the City of Tukwila
Building Division. Per the International Building Code, International Residential Code and /or the International
Mechanical Code, every permit issued by the Building Official under the provisions of this code shall expire by
limitation and become null and void if the building or work authorized by such permit is not commenced within
180 days from the date of such permit, or if the building or work authorized by such permit is suspended or
abandoned at any time after the work is commenced for a period of 180 days.
Based on the above, you are hereby advised to:
This inspection is intended to determine if substantial work has been accomplished since issuance of the permit
or last inspection; or if the project should be considered abandoned.
If such determination is made, the Building Code does allow the Building Official to approve a one -time
extension up to 180 days. Extension requests must be in writing and provide satisfactory reasons
why circumstances beyond the applicants control have prevented action from being taken.
In the event you do not call for the above inspection or request and receive an extension prior to September 27,
2004, your permit will become null and void and any further work on the project will require a new permit and
associated fees.
Thank you for your cooperation in this matter.
Sincerely,
Stefania Spencer
Permit Technician
Xc: Permit File No. M03 -173
Bob Benedicto, Building Official
City of Tukwila
Steven M. Mullet, Mayor
Department of Community Development Steve Lancaster, Director
• Call the City Of Tukwila Permit Center at (206) 431 -3670 to arrange for the next or final
inspection.
-1 .....hi
6300 Southcenter Boulevard, Suite #100 • Tukwila, Washington 98188 • Phone: 206-431-3670 • Fax: 206 - 431 -3665
April 28, 2004
Ms. Donna Jack
Brennan Heating & Air Conditioning
4601 South 134 Place
Seattle, WA 98168
RE: Request for Extension — Permit No. M03 -173 —16221 45` Avenue South
Dear Ms. Jack:
This letter is in response to your written request for an extension to Permit No. M03 -173. Based on the
information received, the City of Tukwila Building Division will be extending your permit to
September 27, 2004.
Please be advised that this will be the only extension granted for this project and no further notice will
be give: prior to the expiration date. A new permit and associated fees will be required after the
above -noted expiration date.
If you should have any questions, please contact our office at (206) 431 -3670.
Sincerel
Ro . - rt Benedicto
Building Official
/sks
File: Permit No. M03 -173
City of Tukwila
Steven M. Mullet, Mayor
Department of Community Development Steve Lancaster, Director
•
6300 Southcenter Boulevard, Suite #100 • Tukwila, Washington 98188 • Phone: 206.431 -3670 • Fax: 206.431 -3665
BRENNAN
HEATING & AIR CONDITIONING
www.brennanheating.com
April 9, 2004
City of Tukwila
6300 Southcenter Blvd. #100
Tukwila, WA 98188
Attn: Stefania
We would like to request an extension on Mechanical Permit #M03 -173. Our
mechanical corrections have been completed but we still need to get an additional outlet
on our gas piping permit. As soon as that is taken care of we will be able to schedule our
final mechanical inspection. This will probably be taken care of before our expiration
date of May 5, 2004.
hank You, rm
Donna Jack
Office Coordinator
4/=7M
D.K. Jo 41;4 I
RECEIVED
err OF TUKWU A
APR 1 2004
PERMIT CENTER
4601 South 134th Place • Seattle, WA 98168.206 -362 -7665. 206 - 248 -7900. 1- 800 - 400 -2914
April 1, 2004
Donna Jack
4601 South 134th Place
Tukwila, WA 98168
RE: Permit Application No. M03 -173
16221 45th Avenue South
Dear Permit Holder:
City of Tukwila
Steven M. Mullet, Mayor
Department of Community Development Steve Lancaster, Director
In reviewing our current records the above noted permit has not received a final inspection by the City of Tukwila
Building Division. Per the Uniform Building Code and /or Uniform Mechanical Code, every permit issued by the
Building Official under the provisions of this code shall expire by limitation and become null and void if the
building or work authorized by such permit is not commenced within 180 days from the date of such permit, or if
the building or work authorized by such permit is suspended or abandoned at any time after the work is
commenced for a period of 180 days.
Based on the above, you are hereby advised to:
• Call the City Of Tukwila Permit Center at (206) 431 -3670 to arrange for the next or final
inspection.
This inspection is intended to determine if substantial work has been accomplished since issuance of the permit
or last inspection; or if the project should be considered abandoned.
If such determination is made, the Building Code does allow the Building Official to approve a one -time
extension up to 180 days. Extension requests must be in writing and provide satisfactory reasons why
circumstances beyond the applicants control have prevented action from being taken.
In the event you do not call for the above inspection or request and receive an extension prior to May 5, 2004,
your permit will become null and void and any further work on the project will require a new permit and
associated fees.
Thank you for your cooperation in this matter.
Sincerely,
Stefania spencer
Permit Technician
Xc: Permit File No. M03 -173
Bob Benedicto, Building Official
6300 Southcenter Boulevard, Suite 11100 • Tukwila, Washington 98188 • Phone: 206 - 431 -3670 • Fax: 206-431-3665
NOTARY
r'iS' C
t
REGISTERED AS PROVIDED BY LAW AS
CONST CONT GENERAL
REGIST. 4 EXP. DATE
CCO1 BRENNHC077NC'03 /01/20011
EFFECTIVE, DATE ; .. %08/03/1993
BRENNAN HEATING•CO INC'
4601 S 134TH .PL .
TUKWILA WAF 98168 -3240
Signature
Issued by 1) E - PARTMENT OF LA130R ND 1NDUST1UI. S
125.02•(00 (8J97)
DEPARTMENT OF LABOR AND INDUSTRIES
REGISTERED AS PROVIDED BY LAW AS
CONST CONT GENERAL
". ;REGIST # # EXP. DATE
CCO1 BRENNHC077NC 03/01/2004
EEFECTIVE,'.'DATE :•, 08/03/1993
BRENNAN•,HEATING CO INC
4601 S 134TH- PL. .
TUKWILA WA 98168 -3240'
I certify this is a true and cprrect copy of the original
document as presented to me on /h - / byJALr of rgENivreW ijc 7-?Ai C
J J
/•
GROEN
07.09 -2C102
y Public
Printed nm c of Notary Public
Residing at
My coin iision expires