HomeMy WebLinkAbout10900 W 41st Avenue� ► � i City of Wheat Ridge
-.A Residential Mechanical PERMIT - 202101160
PERMIT NO: 202101160 ISSUED: 06/03/2021
JOB ADDRESS: 10900 W 41st Ave EXPIRES: 06/03/2022
JOB DESCRIPTION: New installation of a Evaporative cooler on roof - 4800 cfms
Electrical needed for re -hook
*** CONTACTS ***
OWNER (303)371-7663 JOHNSON KR I S T I NE E
SUB (303)798-8783 ERIC BEARDEMPHL/DARRIN ERDAHL 018464 COFFMAN & CO HEATING AND A/C
SUB (720)579-3017 JOHN F. GORDON 018057 MODELCO ELECTRIC CORP
*** PARCEL INFO ***
ZONE CODE: UA / Unassigned USE: UA / Unassigned
SUBDIVISION CODE: 2403 / APPLEWOOD VILLAGES, PROSPECT V BLOCK/LOT#: 0 /
*** FEE SUMMARY *** ESTIMATED PROJECT VALUATION: 71580.00
FEES
Total Valuation 0.00
Use Tax 159.18
Permit Fee 172.60
** TOTAL ** 331.78
*** COMMENTS ***
*** CONDITIONS ***
Work shall comply with 2018 IRC & 2020 NEC. Smoke alarms shall comply with 2018 IRC Section
134. Interior alterations, repairs, fuel -fired appliance replacements, or additions, any of
which require a building permit, occurs or where one or more rooms lawfully used for
sleeping purposes shall have an operational carbon monoxide alarm installed within fifteen
feet of the entrance to each room lawfully used for sleeping purposes.
1* � 4 41'
PERMIT NO:
JOB ADDRESS:
JOB DESCRIPTION:
City of Wheat Ridge
Residential Mechanical PERMIT - 202101160
202101160
10900 W 41st Ave
New installation
Electrical needed
ISSUED:
EXPIRES:
of a Evaporative cooler on roof -
for re -hook
06/03/2021
06/03/2022
4800 cfms
I, 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�permrt. I further attest that I am leg ally authorized to include all entities named within this document as parties to the work to be
performed and that all work to be performed 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 change of 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 requ�ired
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, anviolation of any provision of any
�pplicabje code or any ordinance or regulation of this jurisdiction. Approval of work is subject to field inspection.
06/03/2021
Signature of Chief Building Official Date
REQUESTS MUST BE MADE BY 11:59PM ANY BUSINESS DAY FOR INSPECTION THE FOLLOWING BUSINESS DAY.
From: no-reolv(alci.wheatridae.m. us
To: CommDev Pets
Subject: Online Form Submittal: Air Conditioner/Evaporative Cooler Permit Application
Date: Wednesday, June 2, 2021 10:40:18 AM
Air Conditioner/Evaporative Cooler Permit Application
This application is exclusively for AIR CONDITIONER OR EVAPORATIVE
COOLER.
YOU MUST ATTACH THE ELECTRONIC PAYMENT FORM IN ORDER FOR
THE PERMIT TO BE PROCESSED.
Your Permit will be emailed to the email address provided below once it is
processed.
THIS APPLICATION DOES NOT CONSTITUTE A PERMIT. DO NOT BEGIN
WORK UNTIL PERMIT HAS BEEN ISSUED.
PROPERTY INFORMATION
Is this a new install or New Unit Installation
replacement for an
existing AC unit?
Is this Residential or Residential
Commercial?
Property Address 10900 W 41st Ave
Property Owner Name
Property Owner Phone
Number (enter WITH
dashes, eg 303-123-
4567)
Geoffrey Johnson
rALei I -T, 3iM-1V
Property Owner Email N/A
Address
Attach City of Wheat 10900 W 41 st Ave - Credit Card Authorization Form. odf
Ridge Electronic
Payment Form - "DO
NOT ATTACH A
PICTURE OF A
CREDIT CARD"
CONTRACTOR INFORMATION
Contractor Business Coffman & Company Heating and AC LLC
Name
Contractor's License
18464
Number (This is a 5 or
6 digit number for the
City of Wheat Ridge)
Contractor Phone
303-366-1112
Number (enter WITH
dashes, eg 303-123-
4567)
Contractor Email
pschmidt@coffmanco.com
Address
Retype Contractor
pschmidt@coffmanco.com
Email Address
DESCRIPTION OF WORK
What type of
Evaporative Cooler
replacement unit are
you installing?
How many tons is the
n/a
unit?
For AC - what is the
4800 cfms
SEER?
For Evaporative
Coolers, what is the
CFMs?
Where is the unit
roof
located (for example,
rooftop, backyard on
ground etc)?
Is electrical needed for
Yes
re -hook?
Provide Electrical
18057
Contractor's Wheat
Ridge License No.
Project Value (contract
7580
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 work Yes
may not begin on this
property until a permit
has been issued and
posted on the property.
I certify that I have Yes
been authorized by the
legal owner of the
property to submit this
application and to
perform the work
described above.
I attest that everything Yes
stated in this
application is true and
correct and that
falsifying information in
this application is an
act of fraud and may
be punishable by fine,
imprisonment, or both.
Person Applying for Patricia J Schmidt
Permit
Email not displaying correctly? View it in your browser.
� ► � i City of Wheat Ridge
-.A Residential Mechanical PERMIT - 202101160
PERMIT NO: 202101160 ISSUED: 06/03/2021
JOB ADDRESS: 10900 W 41st Ave EXPIRES: 06/03/2022
JOB DESCRIPTION: New installation of a Evaporative cooler on roof - 4800 cfms
Electrical needed for re -hook
*** CONTACTS ***
OWNER (303)371-7663 JOHNSON KR I S T I NE E
SUB (303)798-8783 ERIC BEARDEMPHL/DARRIN ERDAHL 018464 COFFMAN & CO HEATING AND A/C
SUB (720)579-3017 JOHN F. GORDON 018057 MODELCO ELECTRIC CORP
*** PARCEL INFO ***
ZONE CODE: UA / Unassigned USE: UA / Unassigned
SUBDIVISION CODE: 2403 / APPLEWOOD VILLAGES, PROSPECT V BLOCK/LOT#: 0 /
*** FEE SUMMARY *** ESTIMATED PROJECT VALUATION: 71580.00
FEES
Total Valuation 0.00
Use Tax 159.18
Permit Fee 172.60
** TOTAL ** 331.78
*** COMMENTS ***
*** CONDITIONS ***
Work shall comply with 2018 IRC & 2020 NEC. Smoke alarms shall comply with 2018 IRC Section
134. Interior alterations, repairs, fuel -fired appliance replacements, or additions, any of
which require a building permit, occurs or where one or more rooms lawfully used for
sleeping purposes shall have an operational carbon monoxide alarm installed within fifteen
feet of the entrance to each room lawfully used for sleeping purposes.
1* � 4 41'
PERMIT NO:
JOB ADDRESS:
JOB DESCRIPTION:
City of Wheat Ridge
Residential Mechanical PERMIT - 202101160
202101160
10900 W 41st Ave
New installation
Electrical needed
ISSUED:
EXPIRES:
of a Evaporative cooler on roof -
for re -hook
06/03/2021
06/03/2022
4800 cfms
I, 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�permrt. I further attest that I am leg ally authorized to include all entities named within this document as parties to the work to be
performed and that all work to be performed 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 change of 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 requ�ired
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, anviolation of any provision of any
�pplicabje code or any ordinance or regulation of this jurisdiction. Approval of work is subject to field inspection.
06/03/2021
Signature of Chief Building Official Date
REQUESTS MUST BE MADE BY 11:59PM ANY BUSINESS DAY FOR INSPECTION THE FOLLOWING BUSINESS DAY.
City of Wheat Ridge
Residential Roofing PERMIT - 201700991
PERMIT NO: 201700991 ISSUED: 05/30/2017
JOB ADDRESS: 10900 W 41st AVE EXPIRES: 05/30/2018
JOB DESCRIPTION: Reroof 12 squares 3/12 pitch
*** CONTACTS ***
OWNER (303)371-7663 RANDALL KENNETH W
SUB (303)371-7663 Chris Garland 120228 Safe House Exteriors
*** PARCEL INFO ***
ZONE CODE: UA / Unassigned USE: UA / Unassigned
SUBDIVISION CODE: 2403 / APPLEWOOD VILLAGES, PROSPECT V BLOCK/LOT#: 0 /
*** FEE SUMMARY *** ESTIMATED PROJECT VALUATION: 3,084.00
FEES
Total Valuation 0.00
Use Tax 55.51
Permit Fee 109.20
** TOTAL ** 164.71
*** 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 k1/2 -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&€'BMs 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's 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 - 201700991
PERMIT NO: 201700991 ISSUED: 05/30/2017
JOB ADDRESS: 10900 W 41st AVE EXPIRES: 05/30/2018
JOB DESCRIPTION: Reroof 12 squares 3/12 pitch
I, 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 legally authorized to include al
entities named within this document as parties to the work to be
per ormed and that all wank to be per ormed 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 change of 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.
5. 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
applicable code or any ordinance or regullat`ion� of this jurisdiction. Approval of work is subject to field inspection.
tm
" 0 i e,_ - N QA
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.
City of
W heat j�idge
COMMUNITY DEVELOI'MENT
Building & Inspection Services Division
7500 W. 29h Ave., Wheat Ridge, CO 80033
Office: 303-235-2855 * Fax: 303-237-8929
Inspection Line: 303-234-5933
Email: permits ci.wheatridge.co.us
FOR OFFICE USE ONLY
Date:
Plan/Permit #
Plan Review Fee:
Building Permit Application
*** Please complete all highlighted areas on both sides of this form. Incomplete applications may not be processed. ***
Property Address: _ V qoo R\S�
Property Owner (please print): binja—u-Phone: 'jd3-
Property Owner
Mailing Address: (if different than property address)
Address:
City, State, Zip:
Architect/Engineer: �) 4A
Architect/Engineer E-mail:
Phone:
Contractor: AA � ,
Contractors City License #: 1 ;)COIR Phone: 2213
Contractor E-mail Address: t
Sub Contractors:
Electrical:
W.R. City License #
Other City Licensed Sub:
City License #
Plumbing:
W.R. City License #
Other City Licensed Sub:
City License #
Mechanical:
W.R. City License #
Complete all information on BOTH sides of this form
❑ COMMERCIAL RESIDENTIAL
Description of work: (Check all that apply)
❑ NEW COMMERCIAL STRUCTURE ❑ ELECTRICAL SERVICE UPGRADE
❑ NEW RESIDENTIAL STRUCTURE ❑ COMMERCIAL ROOFING
❑ COMMERCIAL ADDITION RESIDENTIAL ROOFING
❑ RESDENTIAL ADDITION LT WINDOW REPLACEMENT
❑ COMMERCIAL ACCESSORY STRUCTURE (Garage, shed, deck, etc.)
❑ RESIDENTIAL ACCESSORY STRUCTURE (Garage, shed, deck, etc.)
❑ MECHANICAL SYSTEM/APPLIANCE REPAIR or REPLACEMENT
❑ PLUMBING SYSTEWAPPLIANCE REPAIR or REPLACMENT
❑ ELECTRICAL SYSTEM/APPLIANCE REPAIR or REPLACEMENT
❑ OTHER (Describe)
(For ALL projects, please provide a detailed description of work to be performed, including current use of areas,
proposed uses, square footage, existing condition and proposed new condition, appliance size and efficiency, type and
amount of materials to be used, etc.)
Sq. Ft./LF
Amps
Btu's
Gallons
Squares , -0\ Other
Project Value: (Contract value or the cost of all materials and labor included in the entire project)
C,)
OWNER/CONTRACTOR 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 1 have read and agree to abide by all conditions printed on this application and that I assume full responsibility for compliance
with applicable City of Wheat Ridge codes and ordinances for work under any permit issued based on this application; that I am the legal owner
or have been authorized by the legal owner of the property to perform the described work and am also authorized by the legal owner of any
entity included on this application to list that entity on this application. 1, the applicant for this building permit application, warrant the
truthfulness of the information provided on the application.
CIRCLEONE: (OWNER) (CONTRACTOR) o AUTHORIZ REPRESENTATIk'E of (OWNER CONTRACTOR
1
Electronic Signature {first and last n e : DATE: f)
ZONING COMMENTS:
Reviewer:
BUILDING DEPARTMENT COMMENTS:
Reviewer:
DEPARTMENT USE ONLY
OCCUPANCY CLASSIFICATION:
Building Division Valuation: $ Lm
i CITY OF WHEAT RIDGE
_:�9�Building Inspection Division
(303) 234-5933 Inspection line
(303) 235-2855 Office • (303) 237-8929 Fax
INSPECTION NOTICE
Inspection Type:
Job Address: 10 ,0 w 1 �U
Permit Number: Z v
❑ No one available for inspection: Time . C11) AM/F
Re -Inspection required: Yes f
10
When corrections have been made, call for re -inspection at 303-234-
Date:70d—I& 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: go
Job Address: IUlvb W,
Permit Number: 'Z117UU'j
❑ No one available for inspection: Timei ;AIV,I/PM
Re -inspection required: Yes o�
V
When corrections have been made, call for re -inspection at 303-234-5933
Date: Inspector: K&
DO NOT REMOVE THIS NOTICE
i CITY OF WHEAT RIDGE
_:�9�Building Inspection Division
(303) 234-5933 Inspection line
(303) 235-2855 Office • (303) 237-8929 Fax
INSPECTION NOTICE
Inspection Type: UF
Job Address: 1006 til/ . r V
Permit Number: 2 117UU (I
❑ No one available for inspection: Time �f, �t A /PM
Re -Inspection required: Yes o } V
When corrections have been made, call for re -inspection at 303-234-5933
Date: 9 Inspector: 11',W
DO NOT REMOVE THIS NOTICE
•
Pf one��kfe;)c) —33W5
City, State, Zip:
Contractor License #:
g
Phone:
Sub Contractors:
Electrical City License #: Plumbing City License Mechanical City License #:
Company: Company Company.
I
Sq. Ft./L.Ft added; _ Squares __,_ BTU's - Gaflons,__ Amps
�0� P, A 1311T M -N-T1 15�-,PNLY
ZONINGOMMENM
2oning,
reviewer:
PUBLIC WORKS COMMENTS:
Reviewer:
FIRE DERkRTMENT:: - 0 4pproved-,W/ COMM I
etits -(3 ois�,approved 0 no review, required
♦ i CITY OF WHEAT RIDGE
Building Inspection Division
(303) 234 -5933 Inspection line
(303) 235 -2855 Office • (303) 235 -2857 Fax
INSPECTION NOTICE
Inspection Type: t g1 r 4- s,n >r�rG
Job Address: ,a v w V1 f- ' ,A✓s
Permit Number: 0!5�1330
❑ No one available for inspection: Time AM /PM
Re- Inspection required: Ye No
* When corrections have been made, call for re- inspection at 303 - 234 -5933
Date: 9 &W -ee Inspector:
DO NOT REMOVE THIS NOTICE
♦ ♦ CITY OF WHEAT RIDGE
Building Inspection Division
61F 10
(303) 234 -5933 Inspection line
(303) 235 -2855 Office • (303) 235 -2857 Fax
INSPECTION NOTICE
Inspection Type: t "`
Job Address: Q 9y(o
Permit Number: 0 2 1331
❑ 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
i Date: Inspector:
DO NOT REMOVE THIS NOTICE
♦ i CITY OF WHEAT RIDGE
Building Inspection Division
(303) 234 -5933 Inspection line
(303) 235 -2855 Office • (303) 235 -2857 Fax
INSPECTION NOTICE
NOTICE
Inspection Type: II ✓ Z_
JobAddress:
Permit Number: a ,* 4°
❑ 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: lhspector:
DO NOT REMOVE THIS NOTICE
♦ i CITY OF WHEAT RIDGE
Building Inspection Division
(303) 234 -5933 Inspection line
(303) 235 -2855 Office • (303) 235 -2857 Fax
INSPECTION NOTICE
Inspection Type: a cx i va c
IL
Job Address:
Permit Number:
❑ 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: //� Inspector: 4 �.�.
DO NOT REMOVE THIS NOTICE
°FWHEgT City of Wheat Ridge Building Division Date:
7500 W. 29th Ave., Wheat Ridge, CO 80033
o m Office: 303-235-2855 * Fax: 303-235-2857 Plan
c o Inspection Line: 303-234-5933
o<oaP° Permit
Building Permit Application
Property Address: 10900 td& 7/ +r Avc
Property owner (please print): K&)n1ETr4 '2W44z,( Phone: C3oc3) 1/ZZ-37V5-
Mailing Address: (if different than property address)
Address:
City,
Contractor: At)G&C (.~'a~lGF3nl7
Contractor License M-01ZZ Phone: (-ZZp') 219-917-S-1
Sub Contractors:
Electrical City License
Company:
Plumbing City License
Company
Mechanical City License
Company:
Exp. Date:
Exp. Date:
Exp. Date:
Use of space (description): L~&Sit rL Construction Value: $41'7=[T 7-an
Description of work: (as calculated per the Building Valuation Data sheet)
Rf Q 15 SW ZO yk [~y1lp SpJI i/Ef / W~~Lt Fan Review (due at time of submittal): $
pi R 4/.8 as rA)G
RrZ /x jbWu )c t,trudow l Ux/n Xit) 4tw4 i2COA4
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 aaLainspection.
CIRLCEONE:: (OWNER) CONTRACTOR or PERSONAL REPRESENTATI of(O ER) (CONTRATOR)
PRINT NAME: ~9rn1 SIGNATURE: Date: 7-zg-d~