12-142 Mehrdad Mojgani and Homa Mojgani Agreement, 22717 San Juan Rd APN 342-17-025RECORDING REQUESTED BY
City of Cupertino
WHEN RECORDED MAIL TO
City Clerk's Office
City of Cupertino
10300 Torre Avenue
Cupertino, CA 95014 -3255
23615953
~!~tiani 1e!:0tc~~ta~ Clerk-Recorder
04/04/2017 09:52 AM
Tilles: 1 Pages: 3
Fees : 10.00 Taxes : 0
Total: 0 .00
1111 w,1~_.n1~ 1,1r.1ti',.,ll.:l'l'ii'~\1~:,~,\1M~,~, """'',~*','', 11111
(SPACE ABOVE THIS LINE FOR RECORDER'S USE)
NO FEE IN ACCORDANCE
WITH GOV. CODE 27283
NOTICE OF COMPLETION
CITY PROJECT NAME: 22717 San Juan Rd., Cupertino CA 95014
APN 342-17-025
Original
D For Fast Endorsement
..
CUPERTINO
Recording Requested By:
When Recorded Mail To :
City of Cupertino
10300 Torre Ave.
Cupertino, CA 95014
SPACE ABOVE THIS LINE IS FOR RECORDER'S USE
NOTICE OF COMPLETION
Civil Code§§ 8182 , 8184 , 9204 , and 9208
NOTICE IS HEREBY GIVEN THAT:
1 . The undersigned is the agent of the owner of the project described below.
2 . Owner's full name is: City of Cupertino
3. Owner's address is: City Hall, 10300 Torre Avenue, Cupertino , CA 95014
4. Construction work on the project performed on the owner's behalf is generally described as
follows : City Project Name: 22717 San Juan Rd., Cupertino, CA 95014
APN 342-17-025
5. The project was completed on: ____ October 1, 2016 _____ _
6. The project is located at: _22717 San Juan Rd ., Cupertino, CA 95014 ______ _
Verification : In signing this document , I, the undersigned , declare under penalty of perjury under the laws
of the State of California that I have read this notice, and I know and understand the contents of this
notice , and that the facts stated in this notice a~e ~d :r eel
·1J I~ f 1"1 ; Santa Clara County __;J-
Date and Place a ... tu"'"re...._-~--------
Timm Borden
Director of Public Works and City Engineer
"NO FEE"
City of Cupertino
NOTICE OF COMPLETION is hereby given in order to comply with the provisions of
Section 27283 of the Government Code.
This is to certify that the Notice of Completion dated March 30, 2017 for
CITY PROJECT NAME: 22717 San Juan Rd., Cupertino, CA 95014
APN 342-17-025
and the City of Cupertino, a governmental agency is hereby accepted by the City of Cupertino
on March 31, 2017 and the grantee consents to recordation thereof by its duly authorized
officer.
I certify under Penalty of Perjury under the laws of the State of California that the foregoing
paragraph is true and correct.
Dated:
By:
March 31, 2017
Lauren Sapudar
Senior Office Assistant
AGREEMENT
22717 San Juan Road, Cupertino, CA 95014
APN 342•.17-025
This AGREEMENT made and entered into this y day of ae 2012, by
and between the CITY OF CUPERTINO, a municipal corporation of the State of California,
hereinafter designated as CITY, and Mehrdad Mojgani and Homa Mojgani, Trustees or their
successors in TRUST, under the Mojgani Family Trust dated July 15, 2005, and amendments
thereto,hereinafter designated as DEVELOPER.
WITNESSETH
WHEREAS, the DEVELOPER has made application to the CITY to secure a Building Permit
to construct a single family dwelling hereinafter referred to as "Project".
WHEREAS, CITY hereby approves the improvement plans and specifications prepared by
SMP Civil Engineering for the Project, a true cony of which are on file in the office of the City
Engineer of Cupertino; and
WHEREAS, the same are incorporated herein by reference,the same as though set out in full;
NOW, THEREFORE, said improvement plans and specifications shall be hereinafter called the
Plans", and the work to be done under the Plans shall be called the "Work".
WHEREAS, pursuant to the provisions of this AGREEMENT, the CITY hereby established
the amounts of Bonds, Fees, and Deposits as set forth in the following schedule:
SCHEDULE OF BONDS, FEES, AND DEPOSITS
Street Improvement Category:
PART A. Faithful Performance Bond: 5,830.00
110-2211
PART B. Labor and Material Bond: 5,830.00
110-2211
PART C. Checking and Inspection Fee: 2,593.00
110-4538
PART D. Development Maintenance Deposit: 1,000.00
110-2211
PART E. Storm Drainage Fee—Basin 2 3,078.00
215-4072
PART F. Street Light—One-Year Power Cost:N/A
110-4537
PART G. Map Checking Fee:N/A
110-4539
PART H. Park Fee: Zone II 15,750.00
280-4082
PART I.Reimbursement Fee N/A
Page 2 of 11
NOW, THEREFORE, IT IS HEREBY MUTUALLY AGREED by and between the parties
hereto as follows, TO WIT:
1. DEDICATION
A. DEVELOPER offers to dedicate the real property shown on Exhibit "A", which is
attached hereto and made a part hereof by reference. Said dedicated property shall be free
and clear of all liens or encumbrances except those, which the CITY shall waive in writing.
DEVELOPER agrees not to revoke said offer of dedication, and to keep said offer open until
CITY accepts offer by resolution.
B. Upon execution of this AGREEMENT, DEVELOPER agrees to deliver a properly
executed grant deed to the CITY of the real property described in Exhibit "A", and such
other executed conveyances, or instruments necessary to convey clear title as herein
required. DEVELOPER shall provide, at the DEVELOPER'S sole cost and expense, to the
City:
i.A preliminary title report issued by a title insurance company relating to the
property offered for dedication.
ii. A standard policy of title insurance issued by a title insurance company and
insuring the CITY in the sum of N/A, and which shall show said property free and
clear of all liens or encumbrances except those as the CITY shall expressly waive in
writing; said policy shall be furnished at the time of acceptance of dedication and
recordation of deed.
C. Upon the condition precedent that the DEVELOPER shall perform each and every
covenant and condition of this AGREEMENT, the CITY agrees to accept said real property
offered for dedication.
2.INSTALLATION OF WORK
It is further agreed that:
A. DEVELOPER shall install and complete the Work within one (1) year from the date
of execution of this AGREEMENT, or such longer period as may be specifically authorized
in writing by the City Engineer. In the event the DEVELOPER fails or refuses to complete
the Work within the specified period of time, the CITY, at its sole option, shall be
authorized to complete the Work in whatever manner the CITY shall decide. In the event
the CITY completes the Work, the CITY may recover any and all costs incurred thereby
from the DEVELOPER or the DEVELOPER'S surety or both. No final inspection shall be
granted or street improvements shall not be accepted unless all the requirements for safety
purposes are installed, such as sidewalks, handicap ramps, street lights, etc.
B. DEVELOPER shall install and complete the Work in a good and workmanlike
manner in accordance with the plans as op proved by the City Engineer of Cupertino. The
Work shall be done in accordance with existing ordinances and resolutions of the CITY and
Page 3 of 11
in accordance with all plans, specifications, and standards approved by the City Engineer.
The Work shall be done in accordance with-, all State and County Statutes applicable hereto.
The decision of the City Engineer shall be final as to whether any material or workmanship
meets the plans, specifications, and standards as set forth.
C. It is further agreed that the Work shall be done in accordance with the most current
Standard Specifications of the Department of Public Works, California Department of
Transportation, State of California, and in accordance with the specifications of the
Cupertino Sanitary District where applicable.
D. Wherever the words "State" or "California Division of Highways" are mentioned in
the State Specifications, it shall be considered as referring to the City of Cupertino; also
wherever the "Director" or "Director of Public Works" is mentioned, it shall be considered
as referring to the City Engineer.
E. In case of conflict between the State Specifications and the specifications of the
CITY, and/or the Cupertino Sanitary District, the specifications of the CITY and/or the
Cupertino Sanitary District shall take precedence over and be used in lieu of such conflicting
portions.
3.QUITCLAIM DEED
It is further agreed that the DEVELOPER, when requested by the CITY, shall quitclaim all
his/her rights and interests in, and shall grant to CITY authorization to extract water from
the underground strata lying beneath said project. DEVELOPER agrees to execute a
Quitclaim Deed and Authorization" in favor of CITY, when presented to him/her for
signature.
4.BONDS AND OTHER SECURITY
A. Upon the execution of this AGREEMENT, the DEVELOPER shall file with the
CITY a faithful performance bond to assure his/her full and faithful performance of this
AGREEMENT. The penal sum of said faithful performance bond is as set forth in Part A of
the SCHEDULE OF BONDS, FEES AND DEPOSITS. In the event that improvements are
to be made under this AGREEMENT, the DEVELOPER shall, in addition to said faithful
performance, file with the CITY, a labor and materials bond in a penal sum as set forth in
Part B of the SCHEDULE OF BONDS, FEES AND DEPOSITS. Said bonds shall be
executed by a surety company authorized to transact a surety business in the State of
California and have been approved by the City Attorney as to form and by the City Engineer
as to sufficiency. In the event that the DEVELOPER shall fail to faithfully perform the
covenants and conditions of this AGREEM ENT, or to make any payment, or any dedication
of land, or any improvements herein required, the CITY shall call on the surety to perform
this AGREEMENT or otherwise indemnify the CITY for the DEVELOPER'S failure to do
so.
Page 4 of 11
B. In lieu of a surety bond, the DEVELOPER may elect to secure this AGREEMENT
by depositing with the CITY:
i.Cash; or,
ii. A cashier's check, or a certified check payable to the order of the City of
Cupertino; or,
iii. A certificate of deposit, or instrument of credit meeting the requirements of
Government Code Section 66499 (b) or(c).
C. The amount of said cash, checks, certificate of deposit, or instrument of credit shall
be as designated by the City Engineer, and shall be the equivalent to that which would have
been required had the DEVELOPER furnished the CITY with a faithful performance surety
bond. In the event that the DEVELOPER shall fail to faithfully perform the covenants and
conditions of this AGREEMENT, or to make any payment, or any dedication of land, or any
improvements herein required, the CITY may apply the proceeds of said security thereto.
D. No release of surety bond, cash deposit, check or certificate of deposit shall be made
except upon approval of the City Council. Schedule for bond and insurance release for
paper bonds are as follows:
i.Release of 90 percent of the faithful performance bond upon acceptance by
City Council.
ii. Release of the remaining 10 percent of the performance bond at one year
from acceptance after all deficiencies have been corrected and in the absence of any
claim against such bond.
iii. Release of the entire labor and material bond at six months from acceptance
after all deficiencies have been corrected and in the absence of any claim against
such bond.
iv. Liability insurance, provided by the DEVELOPER to hold the CITY
harmless in the event of liability arising from the project, to be retired at the end of
one year if all deficiencies have been corrected and in the absence of any claim
against such insurance.
5.CHECKING AND INSPECTION FEE
It is further agreed that the DEVELOPER shall pay any and all necessary direct expenses for
inspection, checking, etc. incurred by CITY in connection with said Project, and that
DEVELOPER shall have deposited with CITY, prior to execution of this AGREEMENT,
the amount as set forth herein at Page 2 (Part C). Should construction cost vary materially
from the estimate from which said sum is calculated, the City Engineer shall notify
DEVELOPER of any additional sum due and owing as a result thereof
Page 5 of 11
6. DEVELOPMENT MAINTENANCE DEPOSIT
It is further agreed that the DEVELOPER shall pay to the CITY, prior to execution of this
AGREEMENT, the amount set forth herein at Page 2 (Part D) as a development
maintenance deposit. The deposit may be used at the discretion of the City to correct
deficiencies and conditions caused by the DEVELOPER or his/her contractor that may arise
during or after the construction of the development. The deposit shall also be used for
copies of approved plans for the CITY's files. If the cost exceeds the amount deposited the
DEVELOPER is required to pay actual overage prior to return of original plans. Any
unexpended amount will be returned to the DEVELOPER at the time all bonds are released
in accordance with paragraph 4 of this agreement.
7.STORM DRAINAGE FEE
It is further agreed that the DEVELOPER shall deposit with the CITY, prior to execution of
this AGREEMENT, a storm drainage charge in connection with the said Project in
accordance with the requirements established in Resolution 4422, March 21, 1977, in the
amount as set forth herein at Page 2 (Part E).
8.STREET LIGHT- ONE YEAR POWER COST
It is further agreed that the DEVELOPER shall pay to the CITY, prior to execution of this
AGREEMENT, the amount as set forth herein at Page 2 (Part F), which amount represents
the power cost for street lights for one year.
9.MAP CHECKING FEE
It is further agreed that the DEVELOPER shall deposit with CITY, prior to execution of this
AGREEMENT, for office checking of final map and field checking of street monuments, in
compliance with Section 4:1 of Ordinance No. 47 (Revised 12/04/61) of CITY, the amount
as set forth herein at Page 2 (Part G).
10. THE INSTALLATION OF STREET TREES
It is further agreed that the DEVELOPER shall, at such time as deemed appropriate by the
City Engineer, plant street trees in conformance with the standards of the City of Cupertino.
Variety of tree shall be selected from the CTTY approved list.
11. PARK FEES
It is further agreed that the DEVELOPER shall pay such fees and/or dedicate such land to
the CITY, prior to execution of this AGREEMENT, as is required within Section 18-1.602,
Park Land Dedication, Cupertino Municipal Code, and which is further stipulated herein at,
Page 2 (Part H). Fees are also in accordance with action adopted by the City Council on
March 19, 1991 and Chapter 14.05 or Section 18-1.602 of the Cupertino Municipal Code.
Page 6 of 11
12. REIMBURSEMENT FEE
It is further agreed that the DEVELOPER shall deposit with the CITY, prior to execution of
this AGREEMENT, a reimbursement fee for the street improvements that have been
installed by the City, or by another property owner. Developer shall pay the City for the
cost of the land at the cost to the City, or another property owner, and shall pay a street
improvement reimbursement charge for :he improvements which the City or another
property owner, installed on the street abutting or included in the benefited property, in an
amount equal to the total improvement costs for each particular benefited property as set
forth in a reimbursement agreement, in the amount as set forth herein at Page 2 (Part I).
Payments for both land and improvements, shall include simple interest in the amount of
seven percent per year, to be calculated in the following manner:
A. Land Cost. Interest to accrue from the date the street improvements are accepted by
the City to the date the street improvements reimbursement charge is paid, or if the land is
purchased by the City for a City project, from the date of purchase to the date the charge is
paid.
B. Improvement Cost. Interest to accrue from the date the street improvements are
accepted by the City to the date the street improvement reimbursement charge is paid, or if
installed by the City, from the date installation commenced to the date the charge is paid.
C. Provided, however, that the interest shall be waived if the adjoining property owner
dedicates or has dedicated to the City land necessary for the street improvements, or where
no such dedication is necessary.
13. MAINTENANCE OF WORK
It is further agreed that the DEVELOPER shall maintain the Work until all deficiencies in
the Work are corrected to conform to the Plans and the City Standards and Specifications for
the Work. The DEVELOPER shall, upon written notice thereof, immediately repair or
replace, without cost or obligation to the City of Cupertino, and to the entire satisfaction of
said CITY, all defects and imperfections ad sing out of or due to faulty workmanship and/or
materials appearing in said Work.
14. SANITARY DISTRICT
It is further agreed that the DEVELOPER shall file with the CITY, upon execution of this
AGREEMENT, a letter from the Cupertino Sanitary District stating that the DEVELOPER
has submitted plans for review by the District and that sanitary sewers are available to serve
all lots within said Project.
15. GOVERNMENT COSTS
Page 7 of 11
It is further agreed that the DEVELOPER shall file with the CITY, upon execution of this
AGREEMENT, substantial evidence that all provisions of Section 66493, Article 8, Chapter
4 of the Government Code, pertaining to special assessments or bonds, have been complied
with.
16. PACIFIC GAS AND ELECTRIC/AT&T
It is further agreed that the DEVELOPER shall pay to Pacific Gas and Electric Company
and/or to AT&T, any and all fees required for installation of overhead and/or underground
wiring circuits to all electroliers within said property and any and all fees required for
undergrounding as provided in Ordinance No. 331 of CITY when the DEVELOPER is
notified by either the City Engineer or Pacific Gas and Electric Company and/or AT&T that
said fees are due and payable.
17. EASEMENTS AND RIGHT-OF-WAY
It is further agreed that any easement and right-of-way necessary for completion of the
Project shall be acquired by the DEVELOPER at his/her own cost and expense.
It is provided, however, that in the event eminent domain proceedings are required, the
CITY for the purpose of securing said easement and right-of-way, that the DEVELOPER
shall deposit with CITY, a sum covering the reasonable market value of the land proposed to
be taken and, to be included in said sum, shall be a reasonable allowance for severance
damages, if any. It is further provided that in addition thereto, such sums as may be required
for legal fees and costs, engineering, and other incidental costs in such reasonable amounts
as the CITY may require, shall be deposited with the City of Cupertino.
18. HOLD HARMLESS
It is further agreed that, commencing with the performance of the Work by the
DEVELOPER or his/her contractor and continuing until the completion of the maintenance
of the Work, the DEVELOPER shall indemnify, hold harmless and defend the CITY from
and against any or all loss, cost, expense, damage or liability, or claim thereof, occasioned
by or in any way arising out of the performance or nonperformance of the Work or the
negligence or willful misconduct of the DEVELOPER or the DEVELOPER'S agents,
employees and independent contractors, except to the extent any of the foregoing is caused
by the negligence or willful misconduct of the CITY or the CITY'S agents, employees and
independent contractors.
19. INSURANCE
It is further agreed that: the DEVELOPER shall take out, or shall require any contractor
engaged to perform the Work to take out, and maintain at all times during the performance
and maintenance of the Work called for or required to be done hereunder, a policy of
insurance naming the CITY and members of the City Council of the City of Cupertino
individually and collectively, and the officers, agents and employees of the CITY
Page 8 of 11
individually and collectively, as insured. Said separate policy shall provide bodily injury
and property damage coverage to the foregoing named CITY and individuals covering all
the Work performed by, for, or on behalf of said DEVELOPER. Both bodily injury and
property damage insurance must be on an occurrence basis; and said policy or policies shall
provide that the coverage afforded thereby shall be primary coverage to the full limit of
liability stated in the declarations, and if the CITY, its members of the City Council
individually and collectively, and the officers, agents and employees of the CITY,
individually and collectively, have other insurance against the loss covered by said policy or
policies, that other insurance shall not be called upon to cover a loss under said additional
policy.
The insurance carrier shall provide proof of their ratings. All ratings should be Best's Guide
Rating of A, Class VII or better or that is acceptable to the CITY.
A. Each of said policies of insurance shall provide coverage in the following minimum
amounts: for general liability for bodily injury, personal injury and property damage
1,000,000 each occurrence, with an aggregate limit of not less than $2,000,000.
B. The DEVELOPER shall file with the City Engineer at or prior to the time of
execution of this AGREEMENT by the DEVELOPER such evidence of said foregoing
policy or policies of insurance as shall be satisfactory to said City Engineer. Each such
policy or policies shall bear an endorsement precluding the cancellation or reduction in
coverage without giving the City Engineer at least ten(10) days advance notice thereof. The
CITY shall be shown as additionally insured on a separate "Additional Insured Owners,
Lessees or Contractors" (Form A) or (Form B) Endorsement provided along with the
evidence of said foregoing policy of policies of Insurance.
C. In the event that the Project covered herein should be mutually situated in or affect
the area of jurisdiction of a separate municipality or political subdivision of the State of
California, the policies of insurance required herein and above shall co-name such
municipality or political subdivision and the provision set forth herein and above for the
protection of the CITY shall equally apply to municipality and political subdivision.
D. DEVELOPER to use City supplied forms for proof of insurance and endorsements to
policy as specified above.
20. MAPS AND/OR IMPROVEMENT PLANS
It is further agreed that the CITY shall obtain the following map and/or plans at the
DEVELOPER'S expense:
A. A mylar blackline and five(5)prints of fully executed parcel map.
B. A mylar blackline and twelve (12)prints of fully executed improvement plans.
C. A scan in raster format of all executed improvement plans and map.
Page 9 of 11
D. One (1) V2 size prints of fully executed plans and map.
The DEVELOPER agrees to pay the CITY from the development maintenance deposit the
cost for all prints of plans and maps. If costs exceed the amount deposited the
DEVELOPER is required to pay actual overage prior to return of original plans.
Page 10 of 11
21. SUCCESSORS
This AGREEMENT shall bind the heirs, administrators, executors, successor, assignee and
transferees of the DEVELOPERS. The assignment of this AGREEMENT shall not be made
without approval by the City Council of the City of Cupertino.
IN WITNESS WHEREOF, CITY has caused its name to be hereunto affixed by its Mayor
and City Clerk, thereunto duly authorized by resolution of the City Council and said
DEVELOPER has hereunto caused their name to be affixed the day and year first above
written.
CITY OF CUPERTINO:
Mayor
Approved as to form:
7144',Lbul-t.k'XF
it Attorney City Clerk
DEVELOPER:
Mehrdad Mojgani
DEVELOPER:
Signed: /7624.611/
Mr
Homa Mojgani
Attach Notary acknowledgement
Page 11 Df 11
EXHIBIT "A"
ALL that real property situated in the City of Cupertino, County
of Santa Clara, State of California, described as follows :
BEING a portion of that real property described in the Grant
Deed from Dale S. Baek and Soon Y. Baek, husband and wife as
community property to Mehrdad Mo=gani and Homa Mojgani, Trustees
or their successors in TRUST, under the Mojgani Family Trust
dated July 15, 2005, and any amendments thereto, particularly a
portion of Lot 168 as shown on that certain Map entitled "Map of
Inspiration Heights Monte Vista" , recorded in Book "P" of Maps
at Page 13, Santa Clara County Records and more particularly a
20 foot wide strip of land described as follows :
BEGINNING at the Southeasterly corner of said Lot 168, in the
centerline of San Juan Road, both described in the above
mentioned "Map of Inspiration Heights Monte Vista" ; thence along
the Southwesterly line of said Lot 168 and the centerline of San
Juan Road North 65°20' 55" West 80 .30 feet to the Southwesterly
corner of said Lot 168; thence along the said Northwesterly line
of said Lot 168 North 44°26' 16" East 24 . 66 feet; thence South
81°21' 54" East 24 . 63 feet; thence parallel with the
Southwesterly of said Lot 168, centerline of San Juan Road and
distant therefrom 30 . 00 feet measured at right angles South
65°20' 55" East 59 . 08 feet to the Southeasterly line of said Lot
168; thence South 44°27' 48" West 31 . 89 feet to the Point of
Beginning.
Containing an area of 0 . 054 Acres (2, 337 Sq. Ft . ) more or less .
See Accompanying Plat, attached hereto and made a part thereof .
End of Description.
This description was prepared by me or under my direction in
conformance with the requirements of the Land Surveyor' s Act .
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MANAGER
CALIFORNIA ALL-PURPOSE
CERTIFICATE OF ACKNOWLEDGMENT
State of California
County of fA-A f 4'C4-
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who proved to me on the basis of satisfactory evidence to be the person whose name(i) is/Casubscribed to
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capacity Ies and that by his/her eignatur0 on the instrument the perso (s or the entity upon behalf of
which the persol(s acted, executed the instrument.
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I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph 1
is true and correct.
R. C. SINGH
I Commission # 1953520
WITNESS my hand and official seal. Z1 sb
Notary Public -California Z
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My Comm.Expires Oct 21,2015
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1 Notary Seal)
Signature of Notary Public
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2008 Version CAPA v12.10.07 800-873-9865 www.NotaryClasses.com
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§1189
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On 1-.N-1- a , 20 l 3 before me, (</•:-s 1u, ,2c.,ec S vat rcc /\/o"r /v6/%c ,
Date Here Insert-Name and Title(Abe Officer I I
personally appeared 0c c iH /4• - h e
Name(si of Signer(s) k
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who proved to me on the basis of satisfactory z
evidence to be the person(,$) whose name(s)gare S
subscribed to the within instrument and acknowledged
to me that tshe/they executed the same in
i her/their authorized capacity(i9B), and that by s
hi her/their signature(-) on the instrument the
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person( '), or the entity upon behalf of which the 7
person( ) acted, executed the instrument. i
KIRSTEN RENEE SOUARCIA I certify under PENALTY OF PERJURY under the
Commission# 1906898
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laws of the State of California that the foregoing t
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f., !
Notary Public-California z paragraph is true and correct.i ip 9
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Santa Clara County
My Comm.Ex fires Oct 4,2014
WITNESS my hand and official seal.s
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Signature: X-e'"'ae 2 -'-.1-•.„.._
Place Notary Seal Above Signature of Notary Public iOPTIONALh
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document. P.
Description of Attached Document
1
Title or Type of Document:/4)rcesrtc., 7 2-27 1-2 ` ck ti,-i 4 h AZ/Aeni 2 it 2 -/7- 02s
Document Date:cG ,I cr /
f
L//o/ Z _ Number of Pages: / 3
Signer(s) Other Than Named Above: /1/e h i-c 4t Y A7 of)a n i / No"LI ck Mc.)y a vi t
Capacity(ies) Claimed by Signer(s)
Signer's Name: Signer's Name:P
t Corporate Officer—Title(s): II Corporate Officer—Title(s):
t Individual RIGHT THUMBPRINT _] Individual RIGHT THUMBPRINT
OF SIGNER OF SIGNER qq
Partner—Limited General Top of thumb here - Partner—Limited General Top of thumb here
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t Attorney in Fact Attorney in Fact
Trustee 11 Trustee
t 1J
Guardian or Conservator Guardian or Conservator
Other: II Other:
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Signer Is Representing: Signer Is Representing:
S 2010 National Notary Association•NationalNotary.org•1-800-US NOTARY(1-800-876-6827) Item#5907