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ACKNOWLEGED BY: <br />Structure Owner <br />Date <br />STATE OF <br />COUNTY OF <br />The foregoing was acknowledged before me this day of , 20, by <br />as of <br />My Commission Expires: <br />Notary Public <br />r-R <br />ri <br />t:13 <br />Ui <br />ru <br />D <br />ru <br />D <br />D <br />D <br />D <br />ru <br />rn <br />ri <br />D <br />P-- <br />U.S. Postal ServiceTM <br />CERTIFIED MAILTM RECEIPT <br />(Domestic Mail Only; No Insurance Coverage Provided) <br />For delivery information visit our website at www.usps.come <br />City, State, ZIP <br />:c <br />mark <br />S <br />Street, Apt. No.; <br />, ^ ` ill/ WOW <br />or PO Box No. <br />PS Form 3800, August 2006 See Reverse tor Instructions <br />Postage <br />Certified Fee <br />Return Receipt Fee <br />(Endorsement Required) <br />Restricted Delivery Fee <br />(Endorsement Required) <br />Total Postage & Fees <br />NOTARY FOR STRUCTURE OWNER <br />) ss. <br />Title <br />Name <br />Cooley & Sons Excavating ,Inc. <br />Permit Number M- 2011 -034 <br />Structure Agreement <br />