HomeMy WebLinkAbout3515-3525 Lewis Street3 LIF -Os 9�--- INSPECTION RECORD
INSPECTION ONLINE FORM: http://www.ci.wheatridge.co.us/inspection
INSPECTION REQUEST LINE: (303) 234-5933
Occupancy/Type
Inspections will not be performed unless this card is posted on the project site.
**Request an inspection before 11:59 p.m. (midnight) to receive an inspection the following business day.**
Inspector Must Sign ALL Spaces pertinent to this project
Foundation Inspections Date
Inspector Comments
Initials
Pier
Sewer Service
Concrete Encased Ground (CEG)
Plumbing
Foundation / P.E. Letter
Mid -Roof
Do Not Pour Conr_rpfp Prinr Tn Annrnual (W The Ahn..n
Underground/Slab Inspections
Date Inspector Comments
Initials
Electrical
Comments
Sewer Service
Plumbing
uu IMUL Louver unuerarouno or nipiownn_.,%ian vvnrl[ wrinr I n Annrnuml "f The shwa �r.c.......�:......
Rough Inspections
Date
Inspector
Initials
Comments
Wall Sheathing
Mid -Roof
Lath / Wall Tie
!,
Rough Electric'
Rough Plumbing/Gas Line
Rough Mechanical
Rough Framing
Rough Grading
Insulation
Drywall Screw/ Nail
Final Inspections
Date Inspector
Initials
Comments
Landscaping & Parking / Planning Dept.
Inspections from these entities should be requested
one week in advance. For landscaping and parking
inspections call 303-235-2846. For ROW and drainage
inspections call 303-235-2861. For fire inspections
contact the Fire Protection District for your project.
ROW & Drainage / Public Works Dept.
Floodplain Inspection (if applicable)
Fire Inspection / Fire Protection Dist.
Final Electrical
Final Plumbing
Final Mechanical
Roof
Final Window/Doors
Final Building
NOTE: All items must be completed and approved by Planning, Public Works, Fire and Building before a Certificate
of Occupancy is issued. Approval of the Final Building inspection does not constitute authorization of occupancy.
— V -0%1c l,cI 111na - rIVOaU UG AUIC UICIL IUU911 1115pecUon5 are compimea Tram the Tire uistnct ano electrical low voltage
by the Building Division.
Occupancy Is Not Permitted Until A Certificate of Occupancy Is Issued
Protect This Card From The Weather
City of Wheat Ridge
Residential Roofing PERMIT - 201703058
3ERMIT NO: 201703058 ISSUED: 07/01/2017
JOB ADDRESS: 3515 Lewis ST EXPIRES: 07/01/2018
JOB DESCRIPTION: Residential Re -roof to install Owens Corning Duration 30 year asphalt
shingles with 49.02 sq.
*** CONTACTS ***
JWNER (720)334-7017
LINKE JAMES
SUB (720)328-1971
Todd Halaburka
110084 Aspen Roofing & Exteriors LLC
*** PARCEL INFO ***
ZONE CODE:
UA / Unassigned
USE: UA / Unassigned
SUBDIVISION CODE:
2403 / APPLEWOOD
VILLAGES, PROSPECT V BLOCK/LOT#: 0 /
*** FEE SUMMARY ***
ESTIMATED
PROJECT VALUATION: 12,598.14
FEES
Total Valuation
0.00
Use Tax
264.56
Permit Fee
251.85
** TOTAL **
516.41
COMMENTS ***
*** CONDITIONS ***
Effective December 1, 2014, asphalt shingle installations require an approved midroof
inspection, conducted when 25-75 percent of the roof covering is installed, prior to final
approval. Installation of roof sheathing (new or overlay) requires an approved inspection
prior to installation of ANY roof coverings and is require on the entire roof when spaced
or board sheathing with ANY gap exceeding one half inch exists. Asphalt shingles are
required to be fastened to the roof deck with a minimum of 6 nails per shingle. Ice and
water shield is required. Eave and rake metal is required. A ladder extending 3 feet above
the roof eave and secured in place is required to be provided for all roof inspections.
Roof ventilation is required to comply with applicable codes and/or manufacturer
installation instructions, whichever is more stringent. In order to pass a final inspection
of elastomeric or similar type roof coverings, a letter of inspection and approval from the
manufacturer technical representative stating that "the application of the roof at (project
address) has been applied in accordance with the installation instruction for (roof
material brand name) roof covering" is required to be on site at the time of final
inspection.
City of Wheat Ridge
Residential Roofing PERMIT - 201703058
PERMIT NO: 201703058 ISSUED: 07/01/2017
JOB ADDRESS: 3515 Lewis ST EXPIRES: 07/01/2018
JOB DESCRIPTION: Residential Re -roof to install Owens Corning Duration 30 year asphalt
shingles with 49.02 sq.
*** CONTACTS ***
OWNER (720)334-7017 LINKS JAMES
SUB (720)328-1971 Todd Halaburka 110084 Aspen Roofing & Exteriors LLC
*** PARCEL INFO ***
ZONE CODE: UA / Unassigned USE: UA / Unassigned
SUBDIVISION CODE: 2403 / APPLEWOOD VILLAGES, PROSPECT V BLOCK/LOT#: 0 /
*** FEE SUMMARY *** ESTIMATED PROJECT VALUATION: 12,598.14
FEES
Total Valuation 0.00
Use Tax 264.56
Permit Fee 251.85
** TOTAL ** 516.41 PAID
*** COMMENTS ***
*** CONDITIONS ***
Effective December 1, 2014, asphalt shingle installations require an approved midroof
inspection, conducted when 25-75 percent of the roof covering is installed, prior to final
approval. Installation of roof sheathing (new or overlay) requires an approved inspection
prior to installation of ANY roof coverings and is require on the entire roof when spaced
or board sheathing with ANY gap exceeding one half inch exists. Asphalt shingles are
required to be fastened to the roof deck with a minimum of 6 nails per shingle. Ice and
water shield is required. Eave and rake metal is required. A ladder extending 3 feet above
the roof eave and secured in place is required to be provided for all roof inspections.
Roof ventilation is required to comply with applicable codes and/or manufacturer
installation instructions, whichever is more stringent. In order to pass a final inspection
of elastomeric or similar type roof coverings, a letter of inspection and approval from the
manufacturer technical representative stating that "the application of the roof at (project
address) has been applied in accordance with the installation instruction for (roof
material brand name) roof covering" is required to be on site at the time of final
inspection.
City of Wheat Ridge
Residential Roofing PERMIT - 201703058
PERMIT NO: 201703058 ISSUED: 07/01/2017
JOB ADDRESS: 3515 Lewis ST EXPIRES: 07/01/2018
JOB DESCRIPTION: Residential Re -roof to install Owens Corning Duration 30 year asphalt
shingles with 49.02 sq.
1, by my signature, do hereby attest that the work to be performed shall comply with all accompanying approved plans and specifications,
applicable building codes, and all applicable municipal codes, policies and procedures, and that I am the legal owner or have been authorized
by the legal owner of the property and am authorized to obtain this permit and perform the work described and approved in conjunction with
this permit. I further attest that I am IeQally authorized to include all entities named within this document as partes to the work to be
performed and that all work toe -permed is disclosed in this document and/or its' accompanying approved plans and specifications.
Signature of' OWNER or CONTRACTOR (Circle one) Date
1. This permit was issued based on the information provided in the permit application and accompanying plans and specifications and is
subject to the compliance with those documents, and all applicable statutes, ordinances, regulations, policies and procedures.
2• This. permit shall expire 365 days after the date of issuance regardless of activity. Requests for extension must be made in writing and
received prior to the date of expiration. An extension of no more than 180,days made be granted at the discretion of the Chief Building
Official and may be subject to a fee equal to one-half of the original permit fee.
3, If this permit expires, a new permit may be required to be obtained. Issuance of a new permit shall be subject to the standard
requirements, fees and procedures for approval of any new permit. Re -issuance or extension of expired permits is at the sole discretion of
the Chief Building Official and is not guaranteed.
4• No work of any manner shall be performed that shall results in a changeof the natural flow of water without prior and specific approval.
5. The permit holder shall notify the Building and Inspection Services Division in accordance with established policy of all required
inspections and shall not proceed or conceal work without written approval of such work from the Building and Inspection Services
Division.
6. The issuance or granting of a permit shall not be construed to be a permit for, or an approval of, any violation of any provision of any
apple de or any ordinance or regulation of this jurisdiction. Approval of work is subject to field inspection.
Signature of Chief Building Official Date
REQUESTS MUST BE MADE BY 11:59PM ANY BUSINESS DAY FOR INSPECTION THE FOLLOWING BUSINESS DAY.
Inspection time requests will be accepted by email only. Please email requests to insptimerequest@ci.wheatridge.co.us
between 7:30am and 8:00am, the morning of the inspection. Please put the address of the inspection in the subject line.
Dane Lovett `"' 17 -3 b ��
From: no-reply@ci.wheat ridge.co.us
Sent: Tuesday, June 20, 2017 10:50 AM
To: Permits CommDev
Subject: Online Form Submittal: Residential Roofing Permit Application
Residential Roofing Permit Application
This application is exclusively for new permits for residential roofs and for licensed
contractors only. This type of permit is ONLY being processed online --do not come
to City Hall to submit an application in person. Permits are processed and issued in
the order they are received. YOU WILL BE CONTACTED WHEN YOUR PERMIT
IS READY FOR PICK-UP AND WILL BE GIVEN A SPECIFIC DATE AND TIME
WINDOW TO COMPLETE THE TRANSACTION. You will be notified if your
contractor's license or insurance has expired, and you may update those
documents at the time you are issued your permit. Permits are currently being
processed within 3-5 business days, subject to change based on volume.
For all other requests:
Homeowners wishing to obtain a roofing permit must apply for the permit in person
at City Hall. Revisions to existing permits (for example, to add redecking) must be
completed in person at City Hall. All other non -roofing permits must be completed in
person at City Hall. The Building Division will be open from 7:30-10:30 a.m.,
Monday through Friday to process these types of requests.
THIS APPLICATION DOES NOT CONSTITUTE A PERMIT. DO NOT BEGIN
REROOFING UNTIL PERMIT HAS BEEN ISSUED.
Is this application for a Yes
residential roof?
How many dwelling units Duplex
are on the property?
PROPERTY INFORMATION
Property Address
Property Owner Name
Property Owner Phone
Number
Property Owner Email
Address
3515 Lewis St
James Linke
7203347017
Field not completed.
Do you have a signed Yes
contract to reroof this
property?
It will need to be
provided at the time of
permit pick-up.
CONTRACTOR INFORMATION
Contractor Name
Contractor's License
Number (for the City of
Wheat Ridge)
Contractor Phone
Number
Aspen Roofing & Exteriors
110084
7203281971
Contractor Email Address Elizabeth.aspenroofing@gmail.com
(permit pick-up
instructions will be sent
to this email)
Retype Contractor Email Elizabeth.aspenroofing@gmail.com
Address
DESCRIPTION OF WORK
Are you re -decking the
roof?
Description of Roofing
Material
Select Type of Material:
If "Other" is selected
above, describe here:
No V
Owens Corning Duration 30yr
Asphalt
Field not completed.
How many squares of the 49.02
material selected above?
Does any portion of the
property include a flat
roof?
If yes, how many squares
on the flat roof?
No V/
Field not completed.
2
TOTAL SQUARES of all
roofing material for this
project
Provide additional detail
here on the description of
work. (Is this for a house
or garage? What is the
roof pitch? Etc)
49.02 `�
Duplex with majority 4/12 pitch
Project Value (contract --
value or cost of ALL `
materials and labor)
SIGNATURE OF UNDERSTANDING AND AGREEMENT
I assume full Yes
responsibility for
compliance with
applicable City of Wheat
Ridge codes and
ordinances for work
under any permit
issued based on this
application.
I understand that this Yes
application is NOT a
permit. I understand I will
be contacted by the City
to pay for and pick up the
permit for this property.
I understand that work Yes
may not begin on this
property until a permit
has been issued and
posted on the property.
I certify that I have been Yes
authorized by the legal
owner of the property to
submit this application
and to perform the work
described above.
Name of Applicant Elizabeth Pinder
Email not displaying correctly? View it in your browser.
3
-
R & E x ite r i o r s
7500 W. Mississippi Ave
Suite 8-145
Denver, Colorado 80226
(303) 900-4116 r I@
Locally O%med and Operated www.AsMnRoofineandExteriors.com Fully Licensed and Insured
PROPOSAL RESPECTFULLY SUBMITTED TO:
Name
Address fZS- L.6w4J? >`-�S/s
City, St. 4D -0-0
Telephone 72
Alt. No z&1
SCOPE OF WORK:
Re- Roof ONew Construction
Tear Off Existing Roof WtWaste
Type — Layers /
Replacece go�tltottea/ Da Decking as necessary
CDX �B COOLPLY
ffFe,
t Paper 15#
—30# SYN
Closed Valley System
20" Galvanized Valley Flashing
l-,-?'% and Water Shield in _Valley (s) Chimnev (s)
lF- [-M_etat Drip Edge Color
2'x2" 2"x4'
Roofing Nails 1 '/<" 1 1/2"
9S—ATDish
Starter Strip �//�
ReFlash Chimneys) 11and other walls as
(`needed Wood Brick
IBJ
Reflash Skylights #Z
License info on back
WORK TO BE PERFORMED AT:
Date j,/—/LO t Ll,., Date
Address
City, St.
Material Location
Insurance Company
❑ Ventilation
Ridge Vent
Air Hawks
Wind Turbines Power Vent
Remove
Replace
Keep
Q Pipe lack 1 Y2" Z 2- L
3" 4„
Roof Vents 4" 8"
aint all Vents to Match Shingle Color
,_Remove ALL Trash from Gutters/ Job Site
Magnetic Nail Sweep Yard and Driveway
Pool Cover
7Aspen Roofing & Exterior Sign in Yard
Yr. Workmanship W
Notes:— + t/1&7-=,6 —4•
Contractor is entitled to Overhead and Profit when
claims involves 3 or more crudes
MANUFACTURER: HIP & RIDGE WARRANTY
GAF ELK - Certainteed- Atlas High Ridge 3 Tab
Aj��- TAM 3 Tab (standard) 25 yr.
SHINGLE COLOR: y (Length) r hitectural�
( NOTES/ EXTRA: / JJ 40 30
yr
yr
[ 50 yr/ lifetime
ADDITIONAL DETAILS:
Property Owner is ✓ / is not intending to make payment
From the proceeds of a property and casualty insurance policy
Cust initials
a% Processing fee may aPPtr -.
® WA:
Respectfully Submitted By:
TOTAL PROPOSAL PRICE: S ZlfgY - q6
DUE UPON ACCEPTANCE: S Z2 78
DUE UPON COMPLETION: s.-.3,3--/� ��
*Plus Permit & Supplements °rcust int
Aspen Roofing & Exteriors Saks Rep (sigekin¢e) Aspen Roofing & Exteiots Saks Rep (Primo
Sates Rep Cell #
By signing this co c) knowledge all terms and conditions on the reverse side. "Know Your Rights and Duties-
4`/moi/ l? .)AAA 5
ignaarre Date Homeowner (Print name)
Homeowner Signawre
Daze
Hrimeow,ner (Print name)
17i CITY OF WHEAT RIDGE
Building Inspection Division
(303) 234-5933 Inspection line
(303) 235-2855 Office • (303) 237-8929 Fax
INSPECTION NOTICE
Inspection Type: /V? 0
Job Address: 3V 11- t vL,; S=
Permit Number: 2 -17u �,) 'IF Y
❑ No one available for inspection: Time 9/PM required: Yes
90
When corrections have been made, call for re -inspection at 303 -234 -
Date: "( ,t7 Inspector: � k.
DO NOT REMOVE THIS NOTICE
CITY OF WHEAT RIDGE
( Building Inspection Division
(303) 234-5933 Inspection line
(303) 235-2855 Office • (303) 237-8929 Fax
INSPECTION NOTICE
%
Inspection Type: Y _ uF
Job Address: 3 / F � -Pw; S
Permit Number: 2 0/ 7 v �y f
❑ No one available for inspection: Time
M
Re -Inspection required: Yes ((, Noo
When corrections have been made, c ftt or re -inspection at 303-234- 933
Date:. Inspector/(/;
DO NOT REMOVE THIS NOTICE
INSPECTION RECORD- GCCDD
'INSPECTION LINE: (303) 234 -5933
Inspections will not be made unless this card is posted on the building site
Call by 3:00 PM to receive inspection the following business day.
INSPECTOR MUST SIGN ALL SPACES PERTAINING TO THIS JOB
FOUNDATION INSPECTIONS
DATE
INSPECTOR
INITIALS
COMMENTS:
Footings /Caissons
In sulation
-
Stemwall / (CEG) Concrete
Encased Ground
r
Drywall Screw
-
Reinforcing or Monolithic
Rough Electric
Weatherproof/ French Drain
-
Rough Plumbing
Sewer Service Lines
Gas Piping
Water Service Lines
Rough Mechanical
CONCRETE SLAB FLOOR
Electrical
Plumbing (Underground)
ROUGHS
Sheathing
Lath / Wall tie
In sulation
-
Mid -Roof
r
Drywall Screw
Electrical Service
Rough Electric
Building Final -
-
Rough Plumbing
Fire Department
Gas Piping
R.O.W & Drainage
Rough Mechanical
Parking & Landscaping
ABOVE INSPECTIONS TO BE SIGNED PRIOR TO PROCEEDING
x'.
Framing
z,`s!
In sulation
Mechanical
r
Drywall Screw
Roof
FINALS
Electrical
Plumbing
Mechanical
Roof
Building Final -
Fire Department
I
'
R.O.W & Drainage
INSPECTIONS FOR PLANNING & ZONING, FIRE AND PUBLICE WORKS
SHOULD BE CALLED AT LEAST ONE WEEK PRIOR TO FINAL INSPECTIONS.
Parking & Landscaping
` * NOTE: ALL ITEMS MUST BE COMPLETED AND APPROVED BY PLANNING AND ZONING, BUILDING AND PUBLIC WORKS BEFORE A
CERTIFICATE OF OCCUPANCY IS ISSUED. FINAL INSPECTION BY THE BUILDING DIVISION DOES NOT CONSTITUTE AUTHORIZAT ION.
OF A CERTIFICATE OF OCCUPANCY NOR PERMISSION FOR OCCUPANCY.
OCCUPANCY NOT PERMITTED UNTIL CERTIFICATE OF OCCUPANCY IS ISSUED
PROTECT THIS CARD FROM THE WEATHER
♦ i CITY OF WHEAT RIDGE
Building Inspection Division
(303) 234-5933 Inspection line
(303) 235-2855 Office • (303) 2378929 Fax
INSPECTION NOTICE
Inspection Ty e:
Job Address:
Permit Number: i 12.6zC~
A,No one available for inspection: Time AMO
Re-Inspection required: Yes No
When corrections have been made, calf for re-inspection at 303-2345933
Date: _ " /V Inspector: I9V
DO NOT REMOVE THIS NOTICE
♦ i CITY OF WHEAT RIDGE
Building Inspection Division
(303) 234-5933 Inspection line
(303) 235-2855 Office • (303) 237-8929 Fax
INSPECTION NOTICE
r
Inspection Type: /1 i Goa 7
Job Address: 2 S~/ S - 5r ST
Permit Number: 42, 0 ,
l
l
❑ No one available for inspection: Time AM/PM
Re-Inspection required: Yes No
When corrections have been made, call for re-inspection at 303-234-5933
Date: 1~o c) Inspector:
DO NOT REMOVE THIS NOTICE
♦ i CITY OF WHEAT RIDGE
Building Inspection Division
(303) 234-5933 Inspection line
(303) 235-2855 Office (303) 237-8929 fax
INSPECTION NOTICE
Inspection Type: 61 r d, +tfc0 f
Job Address: 7; 15 , ~5a5
Permit Number: f,,T
❑ No one available for inspection: Time f} Ml M
Re-Inspection required: Yes No
*When corrections have been made, call for re-inspection at 303-2345933
Date: /-5-0q Inspector: pnp_ ._r%~ kel
DO NOT REMOVE THIS NOTICE
City of Wheat Ridge
Residential Roofing PERMIT - 093026
PERMIT NO: 093026 ISSUED: 10/06/2009
JOB ADDRESS: 3515-3525 Lewis St. EXPIRES: 04/04/2010
DESCRIPTION: T/o: Install 53 sqs of O.C. 30yr.
CONTACTS
owner 720/982-7378 Marjorie Bucek
gc 303/458-0727 Derek Hendricks 06-0033 Brickey Construction
PARCEL INFO
ZONE CODE: UA USE': UA
SUBDIVISION: 0634 BLOCK/LOT#: 0/
FEE SUMMARY ESTIMATED PROJECT VALUATION: 26,374.01
FEES
Permit Fee 534.96
Total Valuation .00
Use Tax 474.73
TOTAL 1,009.69
Conditions:
6 nail installation & mid-roof inspection required. Board sheathing spaced more
than a 1/2 of an inch apart requires plywood overlay on entire roof. Ice and
water shield required from eave edge to 2' inside exterior walls.
***Contractor/Property owner shall provide ladder(s) secured in place for.
inpsections.
Subject to field inspection.
I hereby certify that the setback distances proposed by this permit application are accurate, and do not violate applicable
ordinances, rules or regulations of the City of Wheat Ridge or covenants, easements or restrictions of record; that all
.....measurements shown, and allegations made are accurate; that I have read and agree to abide by all conditions printed on this
application and that I assume full responsibility for compliance with the Wheat Ridge Building Code (I.B.C) and all other
applicable Wheat Ridge Ordinances, for work under this permit. Plans subject to field inspection.
Signature of contractor/owner date
1. This permit was issued in accordance with the provisions set forth in your application and is subject to the laws of the
State of Colorado and to the Zoning Regulations and Building Codes of Wheat Ridge, Colorado or any other applicable
ordinances of the City.
2. This permit shall expire 180 days from the issue date. Requests for an extension must be received prior to expiration
date. An extension may be granted at the discretion of the Building Official.
3. If this permit expires, a new permit may be acquired for a fee of one-half the amount normally required, provided no
changes have been or will be made in the original plans and specifications and any suspension or abandonment has not
exceeded one (1) year. If changes have been or if suspension or abandonment exceeds one (1) year, full fees shall
be paid for a new permit.
4. No work of any manner shall be done that will change the natural flow of water causing a drainage problem.
5. Contractor shall notify the Building Inspector twenty-four (24) hours in advance for all inspections and shall receive
written approval on inspection card before proceeding with successive phases of the job.
6. The issuance of a permit or the approval of drawings and specifications shall not be construed to be a permit for, nor
an approval of a v tion of the provisions of the building codes or any other ordinance, law, rule or regulation.
All plan rev' ject to field inspections.
Signature of C f Building Official date
INSPECTION REQUEST LINE: (303)234-5933 BUILDING OFFICE: (303)235-2855
REQUESTS MUST BE. MADE BY 3PM ANY BUSINESS DAY FOR INSPECTION THE FOLLOWING BUSINESS DAY.
~oF""E'T9o City of Wheat Ridge Building Division
m 7500 W. 29th Ave., Wheat Ridge, CO 80033
Office: 303-235-2855 * Fax: 303-237-8929
c~toRPd~ inspection Line: 303-234-5933
Property Address: 3544 ~257
Property Owner (please print): /)9,4 Tof; e_ IJUL' e-K Phone: 7 Z0 9O Z 7 3 78
Mailing Address: (if different than property address)
Address: 351.5" A 3S2--5 /e~Wl,5 5+
City, State, Zip: W°hgJ`01t --im!jt✓ Co eMJ 3 3
Building Permit Application
Date:
Plan
Permit
Contractor /iG~C~C font
Contractor License Phone: 30 Zf j3 _d Z2-7
Sub Contractors:
Electrical City License
Company:
Plumbing City License
Company
Mechanical City License
Company:
Exp. Date: Exp. Date: Exp. Date:
Approval: Approval: Approval:
Use of space (description): Lo j Construction Value: $112(e,_37 f
DBSCrIPtlon of WoI'IC (as calculated per the Buildinq Valuation Data sheet)
/ o D r o ,y" l Plan Review (due at time ofsubmittat): $
1
Sq. Ft./L.Ft added: Squares BTU's Gallons Amps
OWNERICONTRACTOR SIGNATURE OF UNDERSTANDING AND AGREEMENT
I hereby certify that the setback distances proposed by this permit application are accurate, and do not violate applicable ordinances,
rules or regulations of the City of Wheat Ridge or covenants, easements or restrictions of record; that all measurements shown, and
allegations made are accurate; that I have read and agree to abide by all conditions printed on this application and that I assume full
responsibility for compliance with the Wheat Ridge Building Code (I.B.C) and all other applicable Wheat Ridge Ordinances, for work
under this permit. Plans subject to field inspection. -
CIRLCE ONE:: (OWNER) pp(CONTRACTOR) or PERSONAL REPRESENTATIVE of (OWNER) (CONTRATOR)
PRINT NAME: -fav) OrooX 5 SIGNATURE: AaL 1~7 Date: lD-/a -09