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CESM Backup 08/04/2017 CODE ENFORCEMENT SPECIAL MAGISTRATE MEETING BACKUP DOCUMENTS AUGUST 4, 2017 HEARING OF THE COLLIER COUNTY SPECIAL MAGISTRATE AGENDA DATE: August 4,2017 at 9:00 A.M. LOCATION: Collier County Government Center,3299 East Tamiami Trail,Building F,3rd Floor,Naples,Florida 34112 NOTE: ANY PERSON WHO DECIDES TO APPEAL A DECISION OF THE SPECIAL MAGISTRATE WILL NEED A RECORD OF THE PROCEEDINGS PERTAINING THERETO, AND THEREFORE MAY NEED TO ENSURE THAT A VERBATIM RECORD OF THE PROCEEDINGS IS MADE,WHICH RECORD INCLUDES THE TESTIMONY AND EVIDENCE UPON WHICH THE APPEAL IS TO BE BASED. NEITHER COLLIER COUNTY NOR THE SPECIAL MAGISTRATE SHALL BE RESPONSIBLE FOR PROVIDING THIS RECORD. I. CALL TO ORDER—Special Magistrate Brenda Garretson presiding A. Hearing rules and regulations II. APPROVAL OF AGENDA III. APPROVAL OF MINUTES—June 2,2017 IV. MOTIONS A. Motions for Continuance B. Motions for Extension of Time V. STIPULATIONS VI. PUBLIC HEARINGS A. Hearings 1. CASE NO: SO183132-CEEX20170009545 OWNER: RICHARD SARASA OFFICER: DEPUTY ALLEN VIOLATIONS: CODE OF LAW&ORD., SEC. 130-66(1)(H) FIRE LANE VIOLATION ADDRESS: WAL MART,3451 TAMIAMI TRAIL,NAPLES 1 2. CASE NO: PR050835-CEEX20170009761 OWNER: RICK SANDERS OFFICER: PARK RANGER CAROL BUCKLER VIOLATIONS: CODE OF LAW&ORD., SEC. 130-55 FAILURE TO DISPLAY A PAID PARKING RECEIPT. VIOLATION ADDRESS: SOUTH MARCO ACCESS,MARCO ISLAND 3. CASE NO: PR058030-CEEX20170008910 OWNER: AMY NILOFF OFFICER: PARK RANGER JIMMY ALANIZ VIOLATIONS: CODE OF LAW&ORD., SEC. 130-55 FAILURE TO DISPLAY PAID PARKING RECEIPT OR A VALID BEACH PERMIT. VIOLATION ADDRESS: BAREFOOT ACCESS,NAPLES 4. CASE NO: PU5385-CEEX20170011649 OWNER: AN TRINH AND MARIA NGUYEN OFFICER: INVESTIGATOR ROBIN GOLDSBORO VIOLATIONS: CODE OF LAWS&ORDINANCES SECTION 118-64 SHOPPING CART,TEN COUCH CUSHIONS,AND GUITAR ON THE GROUND OUTSIDE OF DUMPSTER ENCLOSURE AREA.BAGS OF OPEN GARBAGE,FOOD,BOTTLES, USED BABY DIAPERS ON GROUND INSIDE DUMPSTER ENCLOSURE AREA.FLIES AND FOUL SMELL PRESENT. FOLIO NO: 35748080001 VIOLATION ADDRESS: 1962 46TH TER SW,NAPLES 5. CASE NO: PU5502-CEEX20170010471 OWNER: MINTO COMMUNITIES LLC OFFICER: INVESTIGATOR THOMAS KEEGAN VIOLATIONS: CODE OF LAWS&ORDINANCES CHAPTER 134-62,SECTION 1.9. WATER HOSE CONNECTED TO REAR LEG OF RPZ.UNDER NO CIRCUMSTANCES SHALL ANY PERSON OTHER THAN A COUNTY EMPLOYEE OPERATE VALVES, MAKE SERVICE TAPS,OR OTHERWISE TAMPER WITH COUNTY DISTRIBUTION SYSTEM. FOLIO NO: 78541807228 VIOLATION ADDRESS: 1272 DUNDEE LN,LOT 37,NAPLES 6. CASE NO: PU5177-CEEX20170010366 OWNER: TUSCAN ISLE COMMUNITY LTD OFFICER: INVESTIGATOR ROBIN GOLDSBORO VIOLATIONS: CODE OF LAWS&ORDINANCES SECTION 118-66(A)(D) BAGS OF SOLID WASTE TRASH ON THE GROUND SURROUNDING COMPACTOR AREA.FOOD ITEMS,BOTTLES,CANS,ETC.ON GROUND IN SAME AREA.BULK ITEMS SUCH AS A TABLE,LARGE CARDBOARD BOX,AND SHOPPING CARTS IN COMPACTOR AREA. FOLIO NO: 00296840003 VIOLATION ADDRESS: 8650 WEIR DRIVE,NAPLES 2 7. CASE NO: DAS22521-CEEX20170009348 OWNER: JAYNE RICE OFFICER: HANNAH MCQUEEN VIOLATIONS: CODE OF LAWS&ORDINANCES SECTION 14-34(1)(B) DOG WITNESSED IN ROADWAY. VIOLATION ADDRESS: WESTPORT LANE,NAPLES 8. CASE NO: DAS22523-CEEX20170009349 OWNER: JAYNE RICE OFFICER: HANNAH MCQUEEN VIOLATIONS: CODE OF LAWS&ORDINANCES SECTION 14-34(1)(B) DOG WITNESSED IN ROADWAY. VIOLATION ADDRESS: WESTPORT LANE,NAPLES 9. CASE NO: DAS21383-CEEX20170011935 OWNER: RICHARD ORTEGA OFFICER: ALBERTO RIVERA VIOLATIONS: CODE OF LAWS&ORDINANCES SECTION 14-36(3)(D) FAILURE TO RENEW DANGEROUS DOG REGISTRATION.FIFTH OFFENSE. VIOLATION ADDRESS: 2110 21ST STREET SW,NAPLES 10. CASE NO: CELU20170007160 OWNER: VANDERBILT NAPLES HOLDINGS LLC OFFICER: INVESTIGATOR JON HOAGBOON VIOLATIONS: COLLIER COUNTY LAND DEVELOPMENT CODE 04-41,AS AMENDED,SECTIONS 10.02.03, 10.02.06(B)(1)(A),AND 1.04.01(A).UNAUTHORIZED OUTDOOR SEATING. FOLIO NO: 79122440003 VIOLATION ADDRESS: 9020 GULF SHORE DRIVE,NAPLES 11. CASE NO: CEPM20170007818 OWNER: TARPON IV LLC OFFICER: INVESTIGATOR JOHN CONNETTA VIOLATIONS: COLLIER COUNTY CODE OF LAWS AND ORDINANCES,CHAPTER 22,ARTICLE VI, SECTION 22-231(12)(C)AND 22-231(12)(B).VACANT DWELLING WITH ROOF DAMAGE ALONG WITH EXTERIOR WALL DAMAGE. FOLIO NO: 65070800000 VIOLATION ADDRESS: 616 PALMETTO AVENUE,IMMOKALEE 12. CASE NO: CEAU20160006890 OWNER: THOMAS J.AVERY AND JOANN D.AVERY OFFICER: INVESTIGATOR DEE PULSE VIOLATIONS: COLLIER COUNTY LAND DEVELOPMENT CODE 04-41,AS AMENDED,SECTION 10.02.06(B)(1)(A),(E),AND(I). STRUCTURE ON PROPERTY WITH NO COLLIER COUNTY BUILDING PERMITS OBTAINED. FOLIO NO: 41886440005 VIOLATION ADDRESS: 5771 BUR OAKS LANE,NAPLES 3 13. CASE NO: CEPM20170009035 OWNER: UV CITE II LLC OFFICER: INVESTIGATOR JOHN CONNETTA VIOLATIONS: COLLIER COUNTY CODE OF LAWS AND ORDINANCES,CHAPTER 22,ARTICLE VI, SECTION 22-231(12)(C), SECTION 22-231(12)(N),AND SECTION 22-231(15).VACANT DWELLING WITH POOL WATER VIOLATION,TORN/RIPPED SCREENS ON POOL ENCLOSURE AND DAMAGED ROOF SOFFIT. FOLIO NO: 80445301559 VIOLATION ADDRESS: 7710 SANTA MARGHERITA WAY,NAPLES 14. CASE NO: CESD20170001945 OWNER: PELICAN RIDGE OF NAPLES ASSOCIATION INC. OFFICER: INVESTIGATOR MICHELE MCGONAGLE VIOLATIONS: COLLIER COUNTY LAND DEVELOPMENT CODE 04-41,AS AMENDED,SECTION 10.02.06(B)(1)(A), 10.02.06(B)(1)(E),AND 10.02.06(B)(1)(E)(I). REPLACED RAILROAD TIE RETAINING WALL WITH BRICK PAVER RETAINING WALL WITHOUT OBTAINING REQUIRED COLLIER COUNTY PERMITS. FOLIO NO: 67390720004 VIOLATION ADDRESS: 800 MEADOWLAND DRIVE,BUILDINGS 23 AND 24,NAPLES 15. CASE NO: CEPM20170007030 OWNER: TBW MNGMT BACKED TRUST OFFICER: INVESTIGATOR JOHN CONNETTA VIOLATIONS: COLLIER COUNTY CODE OF LAWS AND ORDINANCES,CHAPTER 22,ARTICLE VI, SECTION 22-231(12)(N),SECTION 22-231(15),AND SECTION 22-242.VACANT UNSECURED DWELLING WITH POOL WATER VIOLATION AND RIPPED/TORN SCREENS ON POOL ENCLOSURE. FOLIO NO: 80445016501 VIOLATION ADDRESS: 2022 LAGUNA WAY,NAPLES 16. CASE NO: CENA20170007225 OWNER: DAKY INC. OFFICER: INVESTIGATOR COLLEEN DAVIDSON VIOLATIONS: COLLIER COUNTY CODE OF LAWS AND ORDINANCES,CHAPTER 54,ARTICLE VI, SECTION 54-181.LITTER CONSISTING OF BUT NOT LIMITED TO SODA CANS, STYROFOAM,PLASTIC BAGS,FOOD CONTAINERS,ETC. FOLIO NO: 388760004 VIOLATION ADDRESS: 2265 TAMIAMI TRAIL E,NAPLES B. Emergency Cases: 4 VII. NEW BUSINESS A. Motions for Reduction/Abatement of Fines: 1. CASE NO: CEPM20170003025 OWNER: SIMON WONG OFFICER: INVESTIGATOR STEVE ATHEY VIOLATIONS: COLLIER COUNTY CODE OF LAWS AND ORDINANCES,CHAPTER 22,ARTICLE VI, SECTION 22-231(19).MOLD IN DWELLING. FOLIO NO: 31156005724 VIOLATION ADDRESS: 1240 WILDWOOD LAKES BLVD,UNIT 106,NAPLES B. Motions for Imposition of Fines and Lien: 1. CASE NO: CEPM20170003025 OWNER: SIMON WONG OFFICER: INVESTIGATOR STEVE ATHEY VIOLATIONS: COLLIER COUNTY CODE OF LAWS AND ORDINANCES,CHAPTER 22,ARTICLE VI, SECTION 22-231(19).MOLD IN DWELLING. FOLIO NO: 31156005724 VIOLATION ADDRESS: 1240 WILDWOOD LAKES BLVD,UNIT 106,NAPLES 2. CASE NO: CEPM20160010488 OWNER: RONALD ABEL OFFICER: INVESTIGATOR JOHN CONNETTA VIOLATIONS: COLLIER COUNTY CODE OF LAWS AND ORDINANCES,CHAPTER 22,ARTICLE VI, SECTION 22-231(5),SECTION 22-231(11),SECTION 22-231(12)(C),SECTION 22- 231(12)(N), SECTION 22-231(13),AND SECTION 22-231(15). POOL WATER IS GREEN IN COLOR,SCREENS ON POOL CAGE ARE TORN/RIPPED,EXPOSED ELECTRICAL WIRES,ROOF SOFFIT DAMAGE,KITCHEN APPLIANCES THAT DO NOT WORK AND THERE ARE APPROXIMATELY NINE UNRELATED ADULTS LIVING IN THIS SINGLE FAMILY HOME. FOLIO NO: 35780080001 VIOLATION ADDRESS: 2172 41ST TERRACE SW,NAPLES 3. CASE NO: CELU20160015851 OWNER: TYLINSKI PROPERTIES LLC OFFICER: INVESTIGATOR FRANK BALZANO VIOLATIONS: COLLIER COUNTY LAND DEVELOPMENT CODE 04-41,AS AMENDED,SECTION 1.04.01(A)AND 2.02.03. ILLEGAL OUTSIDE STORAGE CONSISTING OF BUT NOT LIMITED TO DECORATIVE TYPE CLAY/LANDSCAPE POTS,CONSTRUCTION MATERIAL,WOODEN PALLETS,AND OTHER VARIOUS TYPES OF LOOSE MATERIALS. FOLIO NO: 60782160004 VIOLATION ADDRESS: 11342 TAMIAMI TRAIL EAST,NAPLES 5 4. CASE NO: CEV20170002645 OWNER: ELLA III LLC OFFICER: INVESTIGATOR JOHN CONNETTA VIOLATIONS: COLLIER COUNTY CODE OF LAWS AND ORDINANCES, CHAPTER 130,ARTICLE III, SECTION 130-95.UNLICENSED/INOPERABLE VEHICLE PARKED ON THE PROPERTY. FOLIO NO: 133480005 VIOLATION ADDRESS: 459 SOUTH 8TH STREET,IMMOKALEE 5. CASE NO: CEV20160017996 OWNER: RAYMUND T.TREJO OFFICER: INVESTIGATOR JONATHAN MUSSE VIOLATIONS: COLLIER COUNTY CODE OF LAWS AND ORDINANCES,CHAPTER 130,ARTICLE III, SECTION 130-95. INOPERABLE VEHICLE WITH EXPIRED TAGS. FOLIO NO: 62090440003 VIOLATION ADDRESS: 5213 CARLTON STREET,NAPLES VIII. OLD BUSINESS A. Motions to Amend Previously Issued Order: B. Motions to Rescind Previously Issued Order: IX. CONSENT AGENDA A. Request for Special Magistrate to Impose Nuisance Abatement Liens on Cases Referenced in Submitted Executive Summary. B. Request to Forward Cases to County Attorney's Office as Referenced in Submitted Executive Summary. X. REPORTS XI. NEXT MEETING DATE: September 1, 2017, at 9:00 A.M. located at the Collier County Government Center, 3299 East Tamiami Trail,Building F,3rd Floor,Naples,Florida XII. ADJOURNMENT 6 j -w BOARD OF COUNTY COMMISSIONERS Collier County, Florida, Petitioner Investigator Robin Goldsboro Vs. Public Utilities Department Case No.: PU5177-CEEX20170010366 Tuscan Isle Community, Respondent(s) STIPULATION/AGREEMENT COMES NOW, the undersigned, [^n. ctr }h f , on behalf of herself/himself or TuJct,—, ,��h`,r,l, L?f) as representative for Respondent and enters into this Stipulation and Agreement with Collier County as to the resolution of the Citation in reference, Case No. PU5177, dated the 15th day of June 2017. In consideration of the disposition and resolution of the matters outlined in said Citation for which a hearing is currently scheduled for Friday, August 4, 2017, to promote efficiency in the administration of the code enforcement process; and to obtain a quick and expeditious resolution of the matters outlined therein, the parties hereto agrees as follows: 1) The violations noted in the referenced Citation are accurate and I stipulate to their existence. 2) The violations are that of Code of Laws Section(s) 118-66 (a) (d) and are described as Storage of Litter. THEREFORE, it is agreed between the parties that the Respondent shall; 1) Pay operational costs in the amount of$50.00 incurred in the prosecution of this case. 2) Pay administrative fee of$5.00 incurred in the processing of this case. 3) Pay civil penalty of$500.00. 4) Total Charges are $555.00. Respondent or Representative (Sign) Officer's Signature 114'cc4 lint +ic + G'B1 f • .04/ZO/G1 Respondent or Representative (Print) Officer's Printed Name aper of of A . nGS.rrn.- F d' -q'< Representative Title Date ',f`(fr7 Date REV 7/1/08 BOARD OF COUNTY COMMISSIONERS Collier County, Florida Petitioner, vs. Case No. CELU20170007160 VANDERBILT NAPLES HOLDINGS LLC Respondent(s), ST1PLI ATIONAGREEMENT rgrtN.... himself or �� � . t\o\cit-v. tat COMES NOW, the undersigned, , on behalf of V O kS as 4 representative for Respondent and enters into this Stipulation and Agreement with Collier County as to the resolution of Notices of Violation in reference (case) number CELU20170007160 dated the 10th day of July, 2017. In consideration of the disposition and resolution of the matters outlined in said Notice(s) of Violation for which a hearing is currently scheduled for August 04, 2017; to promote efficiency in the administration of the code enforcement process; and to obtain a quick and expeditious resolution of the matters outlined therein the parties hereto agree as follows: The violations noted in the referenced Notice of Violation are accurate and I stipulate to their existence. THEREFORE, it is agreed between the parties that the Respondent shall; 1) Pay operational costs in the amount of$115.10 incurred in the prosecution of this case within 30 days of this hearing. 2) Abate all violations by: Must cease all unauthorized outdoor seating use by removing all unauthorized outdoor seating from the property and Collier County Right-of-Way: specifically the (6) picnic tables located on the western aspect of the property. All unauthorized outdoor seating must be removed within 60 days of this Hearing or a civil penalty of$250.00 shall be imposed for each day the violation is observed. 3) Respondent must notify Code Enforcement within 24 hours of abatement of the violation and request the Investigator perform a site inspection to confirm compliance. (24 hours notice shall be by phone or fax and made during the workwock. If the violation is abated 24 hours prior to a Saturday,Sunday or legal holiday,then the notification must be made on the next day that is not a Saturday,Sunday or legal holiday.) 4) That if the Respondent fails to abate the violation the County may abate the violation using any method to bring the violation into compliance and may use the assistance of the Collier County Sheriff's Office to enforce the provisions of this agreement and all costs of abatement shall be assessed to the property owner. '-spondent • Representative (sign) W. Eric Short, Supervisor for Michael Ossorio, Director Code Enforcement Division WcC6/ 6 kl/-2 / / 1 Respondent or Representative (print) Date Am--51- z ?o f? Date BOARD OF COUNTY COMMISSIONERS Collier County, Florida Petitioner, vs. Case No. CESD20170001945 Pelican Ridge of Naples Association Inc. Respondent(s), STIPULATION/AGREEMENT COKA NOW, the undersigned, / 'e-S-e - lQ /2-Q7 , on behalf of himself or �� as representative for Respondent and enters into this Stipulation and Agreement with Collier County as to the resolution of Notices of Violation in reference (case) number CESD20170001945 dated the 12th day of April, 2017. In consideration of the disposition and resolution of the matters outlined in said Notice(s) of Violation for which a hearing is currently scheduled for August 4, 2017; to promote efficiency in the administration of the code enforcement process; and to obtain a quick and expeditious resolution of the matters outlined therein the parties hereto agree as follows: 1) The violations noted in the referenced Notice of Violation are accurate and I stipulate to their existence. Replaced railroad tie retaining wall with brick paver retaining wall without obtaining required Collier County permits THEREFORE, it is agreed between the parties that the Respondent shall; 1) Pay operational costs in the amount of$115.40 incurred in the prosecution of this case within 30 days of this hearing. 2) Abate all violations by: Obtaining all required Collier County Building Permit(s) or Demolition Permit, inspections, and Certificate of Completion/Occupancy within 60 days of this hearing or a fine of $50.00 per day will be imposed until the violation is abated. 3) Respondent must notify Code Enforcement within 24 hours of abatement of the violation and request the Investigator perform a site inspection to confirm compliance. (24 hours notice shall be by phone or fax and made during the workweek. If the violation is abated 24 hours prior to a Saturday,Sunday or legal holiday,then the notification must be made on the next day that is not a Saturday,Sunday or legal holiday.) 4) That if the Respondent fails to abate the violation the County may abate the violation using any method to bring the violation into compliance and may use the assistance of the Collier County Sheriff's Office to enforce, e provisions of this agreement and all costs of abatement shall be assessed to the property owne Respond or Repr: ent. ive (sign) Eric Short, Supervisor for Michael Ossorio, Director Code Enforcement Division r2 r/ r f /7 Respondent or Representative (print) Date 017/ Date REV 3-29-16 IVO- )4110E LTV 20 (--) 0 CD cvS-143-- Ara41-xyd-FiyoroosivENIENcE R.L'AOE.ft.NB*,;TiOENYELOPE,:;otFFli STAMP AND MAIL OR BRING TO ADDRESS INDICATED ON FACE OF ENVELOPE. (MAKE CHECKS PAYABLE TO CCBCC) __ _ PARKING VIOLATION CITATION PARKING VIOLATION CITATION _ 4 SHERIFF'S OFFICE so. 183132 -"" SHERIFF'S OFFICE SO. 183132 .:try, ,,,W,o, :COLLIER COUNTY, FLVgIVED JUN 0 7 2017 COLLIER COUNTY, FLORIDA NAME(Last) _ (First) (Initial) 1 NAME(Last) (First) (Initial) r .,..1 ,Gt-AsA O- ' C f.--1 AP-0,, Street Address OStreet Address ...A /),-2, I Go AA N\ oN u.ka L,--01 ci a/42_0 r-' /7 "2 Li 3 Apx ,,./N 0„,. tu a L...11 i'..._. I_ -4Y 2...,)3 _ 1") City State Zip Code City State Zip Code 3 -I rj 3 Li 0 (-) ..---7) Ap Le,f 7Thoria, p, IP Lirse Plate Number Date Expires License Plate 0 Numbe-rr- '' 13 14 Date Expires es- Ai 0 p i./ A/ V ( „—' 41 q -7 11) CD State , 7)rIP L ej L r Decal Number State Decal Number e9 -- .\ I: c, d, Id. 0 Make Model Color J Make Model, Color — C.- De_p)- L/8Pe--- \\ 1-I ' ) *---- < r VIOLATION DESCRIBED AS FOLLOWS: ) VIOLATION DESCRIBED AS FOLLOWS: Date Location _„,..., , . , ,_, ; ..,..71..4., J Date / i i Location _5/2.i'i)1 _3'K.57 --T t- AA // ) .m. Time a nL.p c.) • - Time am' (74 S—U <On si y crrD. , UNLAWFUL AREA-$30.00 fine[Ord.Sec.130-66] III UNLAWFUL UNLAWFUL AREA-$30.00 fine[Ord.Sec.130-66] c, Specifically: Specifically: Li ERE LANE-$30.00 fine[Ord. Sec. 130-66(1)(h)] s'3 El FIRE LANE-$30.00 fine[Ord.Sec. 130-66(1)(h)] ''' r El HANDICAPPED SPACE-$250.00 fine[Ord.Sec.130-67] El HANDICAPPED SPACE-$250.00 fine[Ord.Sec.130-67] • OTHER: `----\ Ei OTHER: ---- ,-, Deputy's Name: ' / 1 c" A, Deputy's Name: A i 1 c---/'/ , ID#: 3 ' // -: /)1„ ." ID#:3)---v Signature: 7 )/17,0_,-->„7-0_,Z7------ ;--- Z -,, FAILU TO RESPOND TO THIS CITATION WILL FAILURE/TO RESPOND TO THIS CITATION WILL RESULT IN IMMEDIATE ACTION (CH.316.1967 ES.) RESULT IN IMMEDIATE ACTION (CH.316.1967 F.S.) INSTRUCTIONS: INSTRUCTIONS: You must elect one of the following options within thirty You must elect one of the following options within thirty ,, (30) days of the date of this citation. (30) days of the date of this citation. \ 1. Pay the scheduled fine in person, • 1. Pay the scheduled fine in person, , - 2. Pay the scheduled fine by mail, or ... 2. Pay the scheduled fine by mail, or 3. Request a hearing by completing the Plea Form 3. Request a hearing by completing the Plea Form at the bottom and mailing. You will be notified by at the bottom and mailing. You will be notified by return mail of the Hearing date. return mail of the Hearing date. IF YOU ELECT A HEARING,YOU MAY HAVE A IF YOU ELECT A HEARING,YOU MAY HAVE A PENALTY IMPOSED NOT TO EXCEED$100.00 OR PENALTY IMPOSED NOT TO EXCEED $100.00 OR $250.00 FOR HANDICAPPED PARKING. $250.00 FOR HANDICAPPED PARKING. PLEA FORM El I Plead Guilty&Pay Fine PLEA FORM 11 I Plead Guilty&Pay Fine El I Plead Not Guilty and a Hearing is Requested ,Kkplead Not Guilty a Hearing is Requested , NAME(Last) (First) (Initial) NAME(Last) .,,. ne__. c..(Qrst) / I (Initial) 77: Street Address 1 Street Address • /4 L i ep,a4/10 A) 44- A PrA . City State Zip Code City WA IA State r/oLd, Zip Code 3 y/16 Signature: Signature: 7. v 1 4 il A, A 0 1 1 FORM#162-S0 REV.12/2006-0212 .. , . , .. .. . gm. --,,,.---• --,•,:,•L. 7:-...-:---i!' --` i ,'',-.- '..,...„,„., . 1 't 1. 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