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Dated this day of 01)J , 201-1 <br />Contractor/W4 der (Firm) <br />pj�_J _ <br />Si of Contractm/hi der or Its Agent <br />&Q 0"e <br />g g <br />Printed Name and Title <br />Subscribed and sworn to before me this ____! day of NVe 20 <br />My Commission Expires ��Z'Zt;-"Z�ZZ _�Ve,114 d9' <br />-Notary Public <br />County of Residence P) . Y Y�j <br />KARA RISNER <br />NOTARY PUBLIC - STATE OF MICHIGAN <br />COUNTY OF BA RY <br />My Commission Expires t- CZ Z <br />Acting in the County of —F4—_ <br />