Addendum 09/16/1992
. ,
ADDENDUM TO AGREEMENT
(Courthouse Janitorial ContrrfLtp[1 ;- fW R~-[:ORf'.
THIS ADDENDUM TO AGREEMENT is made and entered into this
16th day of September, 1992, between the .gpUJAWfl -ElF 1:t1P~~E and
ACE BUILDING MAINTENANCE in order to amend that certaln agteement
between the parties dated October 25, 1991, asnfollows:
1 j f-\N : i'
1. In accordance with Article X of afor~~~J~~~~lagr~ement,
the County hereby exercises its option to r~'r'!ew' sa~a I 1 Agt'eement
and hereby amend Article X to read as follows:
"X. RENEWAL The Owner shall have the option to renew this
agreement after the second year, for one (1) additional one year
period. The term is effective October 25, 1992 through October
24, 1993. The contract amount agreed to herein may be adjusted
annually in accordance with the percentage change in the Consumer
Price Index (CPI) for Wage Earners and Clerical Workers in the
Miami, Florida area index, and shall be based upon the annual
average CPI computation from January 1 through December 31 of the
previous year."
2. Payment by the County to Ace Building Maintenance for the
performance of said service remains at $21,360.00 per year to be
paid $1,780.00 per month.
3. In all other respects, the agreement between the parties
dated October 25, 1991 remains in full force and effect.
IN WITNESS WHEREOF, the parties have hereunto set their
hands and seal, the day and year first written above.
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
(Seal)
. .. ~\ ~
By: ~ .~~.e.-:.,.. .-- ____, ,~-~
Attest: DANNY L. KOLHAGE, CLERK
By:~~f-
Depu Clerk
~
ACE
BUILDING MAINTENANCE ~
~
~
By:
Wi
o J..'rAv. "--A\)~
~tness
By
A.tt'ttl...
CERTIFICATE.OF INSURANCE
ISSUE DATE (MMIDD/YY)
THE PORTER ALLEN COMPANY
513 SOUTHARD STREET
KEY WEST, FLORIVA 33040
(305) 294-2542
08/11/92
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
PRODUCER
COMPANIES AFFORDING COVERAGE
~~~~NY A INSURANCE COMPANY OF NORTH AMERICA
INSURED
~~T~~NY B
~~T~~NY D
D sa /\,J
o G ~\1/~
JUVY EAVY VBA ACE BUILVING &
PO BOX 2763
KEY WEST, FLORIVA 33040
MAINTENANCE COMPANY C
LETTER
~~T~~NY E
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE (MM/DD/YY) DATE (MMIDD/YY)
GENERAL LIABILITY GENERAL AGGREGATE $ 500,000.
A X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ 500,000.
CLAIMS MADE X OCCUR. SVP V24594324 03/11/92 03/11/93 PERSONAL & ADV. INJURY $ 500,000.
OWNER'S & CONTRACTOR'S PROTo EACH OCCURRENCE $ 500,000.
FIRE DAMAGE (Anyone fire) $ 50,000.
MED, EXPENSE (Anyone person) $
AUTOMOBILE LIABILITY COMBINED SINGLE
ANY AUTO LIMIT $ 300,000.
A ALL OWNED AUTOS BODILY INJURY
X SVP V24594324 08/11/92 03/11/93 (Per person) $
SCHEDULED AUTOS
HIRED AUTOS BODILY INJURY
$
NON-OWNED AUTOS (Per accident)
GARAGE LIABILITY
PROPERTY DAMAGE $
EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION STATUTORY LIMITS
EACH ACCIDENT $
AND
DISEASE-POLICY LIMIT $
EMPLOYERS' LIABILITY
DISEASE-EACH EMPLOYEE $
OTHER
A EMPLOYEE VISHONESTY SVP V24594324 03/11/92 03/11/93 $5,000.
COVERAGE LIMIT:
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/SPECIAL ITEMS
AVVITIONAL INSUREV: MONROE COUNTY BOARV OF COUNTY COMMISSIONERS
JOB SITE: COURT HOUSE , KEY WEST, FLORIVA
CERTIFICATE HOLDER
CANCELLATION
PUBLIC WORKS
PO BOX 1029
KEY WEST, FLORIVA 33040
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT \,JRE ,n)' AiL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
,/ .
L1ABILlT F A .KIN PON THE COMPANY, ITS AGENTS OR REPRESENTATIVES,
ACORD 25-S (7/90)
@ACOAD CORPORATION 1990
SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a),
FLORIDA STATUTF..s, ON PUDUC ENTI1Y CRIMES
TillS FORM MUST DE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
1. This sworn statement is suhmitttd to m (jN~~' tv {jU c UJIjl.Jcs
by ~u h . ~t<k 0 I JFJ~me of the public entity]
(print dlvldua~ nome nd title) , . ~ /LA J
for - \OlJ L 1 ~ .., I' 11 'v
g sworn stotement]
whose business address is
----t{~()() C ~ ll-\h ~~~~~"
()~l. (,~~'l
and (tr applicable) Its Federal Employer ldentincation Number (FEIN) Is
(Ir the entity has no FEIN, Include the Social Security Number of the Individual signing this
sworn statement:
.)
2. I understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florldo Statutes, means a
violation of any state or federal law by a person with respect to and directly related to the transaction of
business with any public entity or wilh an agency or polilical subdivision of any other state or of the United
States, including, but not limited to, any bid or contract for goods or services to be provided to any public
entity or an agency or political subdivision of any other state or of the United States and involving antitrust,
fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.
3. I understand that "convicted" or "conviction" as defined In Paragraph 287.133(1)(b), Florida Statutes. means
a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any
federal or stille trial court of record relllting to charges brought by Indictment or Information after July 1,
1989, liS a result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.
4. I understand that an "affiliate" as defined in Paragraph 487.133(1)(0), Florida Statutes, means:
:t\:~;~. ~.
.. .n li~rJ.~;A-.jpr~sor or successor of a person convicted of a public.entity crime; or
'li' (,~r.2,;)!!)o~Jt~,('lDder the conlrol of any natural person who Is acllve In the management of the entity and
,'~ ,; I, Wm.~llhll$f_1f convicted of a public entity crime. The term "affiliate" includes those officers, directors,
executives, partners, shareholders, employees, members, and agents who are active in the management of
an affiliate, The ownership by one person of shares constituting a controlling interest In another person,
or a pooling of equipment or income among persa"s when not for fair market value under an arm's length
agreement, shall be a prima facie case that one person controls another person. A person who knowingly
enters into a joint venture with a person who has been convicted of a public entity crime In Florida during
the preceding 36 months shall be considered an affiliate.
5. I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural
person or entity organized under the laws of any state or of the United States with the legal power to enter
inlo a binding contract and which bids or applies to bid on contracts for the provision of goods or services
let by a public entlly, or which otherwise transacts or applies to transact business with a public entity. The
term "person" includes those officers, directors, executives, partners, shareholders, employees, members, and
agents who are active in management of an entity.
.: ,)C
6. Based on information and belief, the statement which I have marked below Is true In relaUon to the entity
submitting this sworn statement. (IndiCAte which stAtement npplles.] .
X Neither the entity submitting this sworn statement. nor any of Its officers, directors. executives.
partners. shareholders. employecs. members, or agents who are active In the management of the entity. nor
any armlale or the entity has been charged with and convicted of a public entity crime subsequent to July
1. 1989. _
- The entity submitting this sworn statement. or one or more of its officers. directors, executives,
p:utners, shareholders. employee.c;, members. or agents who are active In the management of the entity, or
an affiliate or the entity has been charged with and convicted of a public entity crime subsequent to July
1. 1989.
- The entity submitting this sworn statement, or one or more of Its officers, directors, executIves,
partners. shareholders. employee.c;. members. or agents who are active In the management of the entity, or
an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July
I, 1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida,
Division or Administrative Hearings and the Final Order entered by the Hearing Officer determined that
it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor
list. (AUneh n COllY or the nnnl order]
I UNDERSTAND TIIAT TilE SUBMISSION OF TIllS FORM TO TIlE CONTRAC11NG OFFICER FOR TIlE
PUBLIC ENTllY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND,
THAT TIllS FORM IS VALID TIIROUGII DECEMBER 31 OF TilE CALENIlAR YEAR IN WillCUtT IS FILED.
I AUiO UNDERSTAND THAT I AM REQUIRED TO INFORM TilE PUBLIC ENTITY PRIOR 1'0 ENTERING
INTO A CONTRAC. IN EXCE..~S OF TIlE TIIRESIIOLI) AMOUNT PROVIDED IN SECTION 287.017, FLORIDI\
STATUTES FOR CATr~(;OJty lWO OF ANY CHANGE IN TilE INFORMATION CONTAINED IN TillS FORM.
'.. <.:
. , ~'
(~ ~ C3~^'
'U [signature]
Sworn to and subscribed before' me this
/I~
day of
~
.19ll
Personally known () tA~ ~
OR Pred',ce4 hlefltirl€8tioll ,....
-h/'7)tL.
Notary Public - State orJ~(~Tf OF Ft~IDA
MY COMMISSION EXP. JULY 30,,1993
BONDED THRU GENERAL INS, uNO,
~$tP~
(Type of identification)
(. " ~
(Printed or st ped
commlsslo ed nam or notary public)
rI(;1~ Key-~I-
N~ k-'1- ~ rv.-h ku
JIll /; f / 157
Form PUR 7068 (Rev. 06/18192)
"
6. Bascd on information and bclicf, the statcment 'which I have markcd below Is true In relation to the entity
submitting this sworn statcment. (Indltnte which statement npplles.]
X Neither the entity subrnilling this sworn statement, nor any of Its officers, directors, executlvC.'l,
partners, shareholders,; employees, members, or agents who are active In the management of the entity, nor
any affiliate oC the entity has been charged with and convicted of a public entity crime subsequent to July
1, 1989. -
_ The entity submitting this sworn statemcnt, or one or more of its of(iceTll, directors, executives,
partners, shareholders, employee.,;, members, or agents who are active In the management of the entity, or
an afliliate of the entity has been chnrged with and convicted of a public entity crime subsequent to July
1, 1989.
----:.. TIie entity submitting this sworn statement, or one or more of ftsomcers. directors, executives,
partners, shareholders, employees, members, or agents who are active in the management or the entity, or
an arlillate of the entity has been charged with and convicted of a public entity crime subsequent to July
1, 1989. However, there has been a subsequent proceeding bcCore a Hearing Ofliccr or the State of FIoridn,
Division of Administrative Hcarings and the Final Ordcr entered by the Hearing Orliccr determined that
it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor
list. [nttnch n cory or the nnnl order]
I UNDERSTAND THAT TIlE SUDMISSION OF TillS FORM TO TilE CONTRACI1NG OFFICER FOR TIlE
PUDUC ENTITY IDENTIFIED IN rARAGRAPII 1 (ONE) ADOVE IS FOR THAT rUDUC ENTITY ONLY AND,
THAT TlIIS FORM IS VALID TIIROUGII DECEMDER 31 OF TilE CALENDAR YEAR IN WIIICIIIT IS FILED.
I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM TilE rUDLlC ENTITY PRIOR TO ENTERING
INTO A CONTRA(.iIN EXCESS OF TilE THRESHOLD MIOUNT PROVIDED IN SECIION 287.017, FLORIDA
STATUTES FOR CATEGORY 1WO OF ANY CIlANGE IN TilE INFORMATION CONTAINED IN TillS FORM.
'\ -0,:
~G~
· "[signature] "
. ....-.-.
. ~" ,', :~ --I ,
Sworn to and subscribed before'me this
/I~
day of
~
. 19!iJ- '.'
_i ....of.'.'
, ,
Personally known q &id) ~
SR PFed"ced itlefttil4eatiolJ ~
fo /7)tL ·
~ota?, ~ubllc - State O,fHO~~({TAfE OF FlO~IDA
, MY COMMISSION EXP. JULY 3D, 1993
BONDED THRU GENERAL INS, UNO.
~tM~
; ",
(Typ~ or identincation) ,
P, :" ;".
"'ni'~.":
..' : ,~! ~.: C-, :
.r.,'S,
, (Printed or st ped
commissfo Cd nam or notary public)
WertL' K~ -'~ ~
NJ ~~ ~.4l<v . '
, ,
!I(l6 f /15"7
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i'
Form PUR 7068 (Rev. 06/18192)
50016139012
No.
OCCUPATIONAL LICENSE
City of Key West, Florida
LICENSE YEAR
1991-1992
NO REFUNDS
09/30/92
THIS LICENSE MUST BE PROMINENTLY DISPLAYED
:GINNING 1 0 101/91 THROUGH
PENALTY SCHEDULE
REel f,ir.2~e5i TRI i324
ID CCE ~CHI f.29 LOC eKYW
CRll16 WI 11/eS/91 16:64
ACCTi5iil-b139-81-2
ACE BUILDINS-~A;NTENANCE
AHOUNT PAID: 55.~e
156 OCC.LIe
1
62.50
JANUARY
TOiAL-UNITS
6 O. OD
DECEMBER
57.50
NOVEMBER
50.00
LICENSE FEE
CL EANING
~
COMMERCIAL
SOX 2763
RESIDENTIAL AND/OR
P.o.
6Q
BUSINESS
ADDRESS:
TYPE
LICENSE:
foe
eB
5S
FIN'ANCE~~~A~~MENT45
DIVISION OF REVENUE
--
BUSINESS /
NAME: {
JVOs/
COUNTY OCCUPATIONAL LICENSE 1991-1952
A~ 0 W ROE COUNTY-STATE OF FLORIDA
THIS LICENSE EXPIRES S E r.1 ~ E E R 30, 1992
8UIlDING MAINTENANCE
ACE BUILDING ~AINTEWANCE
JUDY & BRUCE 308ICK
2768
FL 33040
ACE
P.O.EDX'
KEY WEST
OWNER:
ADDRESS:
CITY:~
kJ
~
os:t
c-
~~
(")0
f'l"': m
c~
"',m
.,.-
,...(1)
Q'"
"'S
!;:z
u;i:ii
~ffi
cO
fiiz
(I)
o
TAX
COST AND
PENALTY
471-009-~3
N ,,- UNITS: 5
E~f~t RENT NUr.8ER OF UNITS
HERE:
PLEASE SEE BACK OF FORM
THE AaOVE L1CENSEE IS HERESY
LICENSED.TO ENGAGE IN THE BUSINESS
PROfESSION OR OCCUPATION Of :
p r, .J.AtPl n.R :IA,L.,o; $,FR.Y I (E ~'S.O ,-,.,' . J ...,<:' :c;,J ';;t;..'r~t i ^t(,r,(;{,,')(,j;r.r;(lC',",.
f-~.1. ;)/:.~ jh~\r\. ,..-: 1\1"( J. ;;n I :r;~ t.. . ".oJ t,r,. .1. lo/ VoJl f J. _-.J-T...JI~ i' ~IS F6RM'B~COQES)( FfEe~T'dNLY WHEN VALIDATED BY RECEIPTlNG
MACHINE SHOWING TRANSACTION NU"SEF. DATE. ""'0 .....OUNT PAlO.
ACE eUILDING ,~Alh7ENANCE
EADY JUDY OWNER
? 0 eo x 27 63
KEY.WEST Fl 33040
TRANSFER FEE
TOTAL DUE
STATE CERTIFICATE NUMBER
~ HARRY F. KNIGHT, '.f.C.
.TAX COLLECTOR Z94-e403
p.o. 30X1129
KEY,WfST, fL 33041~1129
~:1
lCCCUNTNUMBER!S 20566
lCCATION: _~OBILE UNIT
THIS LICENSE MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS
,'. C ,\{STRUCTIONINDUSffiY
NOTICE OF ELECTION TO BE EXEI'IIPT FROr,'1
THE PROVISIONS OF THE FLORIDA '\70RKERS" COMPENSATION LA'''!
:30 ~\ ~~ l~~~t TY~t )~(~INT:
RF.: _-=P\ c..[ 2J\)'1 U~ ~l\J LL ['() A.-i ~\ ~ f\-N CJL-
Il...,al Dv.\"\,, "'~I\\ol So:, Prorric1onh):; 1'onn4~Ip. Of Cll'lp<<'llonl, ~^ 1f ^tl~'..)
'to ,tt,jX ..) 'llo -=2 . . ~,Q b d-(>-+1" I ~ f\~
,"10,10,,& ^"d""l ~ (:S\lu:l J.Gdn.u. U ,1ijT<~
t~'l Wc.S-,- -fLoR\ t\A )3D'10 ' .d.-{1 ~J C{l{ f5q 0
,C,rrI (SIOI,) (LIp) (r..cl<nJ ~ ~~ tlII,d.u)
Nature: or Dusiness or Tradc: ,JA, tJ rrV R I A L . ....') -e .t!.l/, e..e.-
i.>-rKfE US1:: ONLY
o 1&4 (q v 'PoSTMARK DATI! --1 !
() 9 Gl J 0 'n,b notice l~.:dl be In tf!~ for ,....'0 (2) )"ttJs from \he
effwl"'O dale tIC' until .
0:' ul.itil n:...clttJ. ~Uchcvtr COmtJ flat.
.~I
MAll. TO: Department of Labor &. Employment Security
Dureau of W.C, Compliance .
2728 Centel\'iew Drive. 100 Forrest Bldg.
Tallahassee, Florida 32399-0661
. ofJ)" ~' L~
\"
}~ LJ lC'cz.')T'r._
.
As of 12;01 a.m. 30 days following the dale of the mailing of lhis form, you nre hereby notified that the following Sole Proprietor.
Panncr N Corporate Officcr of the abovc namcd business docs c.Icct 10 be acmf't from, .he prcvisioru of the Florida WOI"1.c.rs'
Con;pc;o5;Jtio;o uw. I unde~tand that by thi:; nclion I am not entitled 10 ocncn:... under chapter t. 40, Fiorit!a Statute::. By filing lhis
(orm I hJ\'e not exceeded the exemption limit of three Partners or three Corpomtc Officcr3, 1 Cu.<tllcr c:rtif)' tllat MY emplO)'ccs of the
business na"Olcd above arc covered by workers' compensation Insurt.nce,
The following arc: the certified or registered license! held b)' mCJ!ursuan, t to Chllptc.r:~rida Statu~3 (If none. so ttAte):
cW\ -ff-SCO 1 b 1.3~ old-- ''1 'Ie' ~
ll) T~pc:~ Number:-tt" (2) 1)'p-:: r1<1. ()\ ~v Number. cxE~..Jb(
INSl.!RANCE CARRIER INFORMATION (If Appllcable): A construction industry employer wIth one (I) Or more cmplo)Us must
maintain Workers' Compcns.ation covernge. Failure to comply will re:sul1ln'a th't-hundred ooliar ($:,00) fine and a one-h;mdred
dollar ($100) tine ror each d3)' of noncompliance (see seclion 440.43, F.S.),
Name,or Cmier
-.--
---
C~lTl'tr Address
...,............
~
Policy Number
~
~
--..-' '. '
.,..E~~yrDMIT~
"
. ... .-... .~.. ..
'..
Insurance Agent (Agency)
Agency Address
~
',.
.. 0...
~,
'/(U aL..-- '...........-. .. "') / 3 11 ( /1 cO /
T\. ... Social Sec:urity Numocr .::,....('~ --I ':j ,) 7 ~/,
I . L
'TYpe/Print Name ,U E.~ I (, "-
Position: Proprietor ~rtncr'--'orlomccr (litle) . <.
. ";'.
IMPORTANT: Individual Cltcmption filing fee, PUrsUD~t to Section 440.0.:5, f.S:; 'l~"~n doU~ &nd fifty cents (S1:~O) and is
['3)OIble only by money order or cuhier's check, to w.e. Administrative 1hJst Fund. Fnilurc to enclose fee will rc.sult in return of
re-que\l :10\.1 delay o( certification.
Signature
... :_.' '0',:'"
.,:., :.,
o BEFORE ME TIllS
/5f-
DA~'oF'71tfl~~:U/G
:;..~~ I"~
": t.<'t.,. '~/':, .:: .
.. .., ....... - ..
, ';:;:; , . ':-\ . ..
":: ./; :MY COMMI 0
Q"""l'\t'n T "r:t'"r
AT
.. '':'' ,./1' ,...... "-"\.1 ",.-"
w
ACE BUILDING MAINTENANCE
PROMPT PROFESSIONAL SERVICE
COMMERCIAL. RESIDENTIAL
LICENSED. INSURED
EXCLUSIVE "HOST DRY CLEAN" CARPET CLEANING
P.O. BOX 2763
KEY WEST, FLORIDA 33045
(305) 294-6206
August 4, 1992
Public Works Dept.
Jr. College Road
Key West, Fl 33040
ATTN: Cindy
REF:
Janitorial for KW Courthouse
Dear Cindy,
I received your letter in reference to
the janitorial service for the KW
courthouse.
We would be happy to continue to provide
the janitorial service for this building.
Thank you for giving us the opportunity
to be of service to the county.
Sincerely,
1/ ././
.~ i~wf~
Judy Bobick
Owner
SWORN STATEMENT UNDER ORDINANCE NO. 10-1990
MONROE COUNTY, FLORIDA
ETHICS CLAUSE .
sv~ S()(3tc!c
warrants that he/it has not employed,
retained or otherwise had act on he/its behalf any former County officer
or employee subject to the prohibition of Section 2 of Ordinance No.
10-1990 or any County officer or employee in violation of Section 3 of
Ordinance No. 10-1990. For breach or violation of this provision the
County may, in its discretion, terminate this contract without liability
and may also, in its discretion, deduct from the contract or purchase
price, or otherwise recover, the full amount of any fee, commission,
percentage, gift, or consideration paid to the former County officer or
Date:
}{:ur~
q)J$J z-
employee.
,
STATE OF
BMWfu
JY~
COUNTY OF
~e,o:9tq.2
-yYUJ .
P~SONALLY APPEARED B~FORE ME, the undersigned authority,
~\ l.(\~ ~00k.> who, after first being sworn by me,
affixed his/her signature (name of individual signing) in the space
\ ~ ~ day of ~L V.1''''''-.~ {o
..,. " ~ ~ 1.0 ~ 5 - . ---- 0- J.-1"'1A.) vv 1'-'
..dUGL~ lktL ~/~ Z;
!t[jf1laLI~ ~htf;
NOTARY PUBLIC STATE OF flORIDA fi A 5_
My commi ssion expires: MY COMMISSION EXP. JULY 30,1993
BONDED THRU GENERAL INS. UNO.