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Home My WebLink About2024 Commercial Change of Occupancy app TWIN FALLS City of Twin Falls Building Safety Department 203 Main Ave. E. (2nd floor) Phone: 208-735-7238 °a P.O. Box 1907 Fax: 208-736-2256 <F SERA NG Q� Twin Falls, ID 83303-1907 www.tfid.org Certificate of Occupancy Only Permit Application • Separate permits may be required for HVAC, plumbing,and electrical as needed. • Certain uses may require a special use permit. See a City Planner for specifics. • THIS PAGE IS NOT REQUIRED WHEN APPLYING THROUGH THE PORTAL • This certificate of occupancy application may only be used where no proposed remodeling of the building or space is occurring. This application is only used where the use of the space has more stringent life safety elements than the previous tenant or this is a 1st time occupancy of the space. Examples of more stringent uses may include: Medical offices,halfway houses,daycares,schools,hair salons, restaurants,assembly uses,woodworking shops,vehicle repair garages,painting,and storage or factory uses. NEW 11/21/23 PROJECT INFORMATION Project Address: 516 Hansen St S, Twin Falls, ID 83301 New Business/Tenant using space: TF Brlckhouse Previous business name at this location: TF Brickhouse Previous business type of use: Restaurant/Event Center Type of use of proposed business: Restaurant/Event Center PROPERTY OWNER INFORMATION CONTRACTOR INFORMATION Business Name: Downtown Renaissance, LLC Contact Name: Contact Name: Jeff Hepworth Address: Address: PO BOX 2815 City, State,Zip: City, State,Zip: Boise, ID, 83701-2815 Phone: Phone: Email: h State Registration# Email: Jhe pwort @IdalaW er.com y &Expiration Date: ARCHITECT INFORMATION ENGINEER INFORMATION Business Name: Laughlin Ricks Architecture Business Name: Contact Name: Colby Ricks Contact Name: Address: 134 3rd Ave E Address: City, State,Zip: Twin Falls ID, 83318 City, State,Zip: Phone: 208-736-8050 Phone: Email: Colby@lrallc.com Email: PROJECT SPECIFICS: Previous Occupancy Class: B, A-2, S-1 Multi-Family Units(#): N/A Fire Sprinkler: Yes ✓❑No ❑ Proposed Occupancy Class: B, A-2, S-1 #of stories in building: 4 Fire Alarm: Yes ✓❑ No ❑ Building Area/Sq. ft.: 21,308 Elevator: Yes ✓❑ No ❑ Historic Building: Yes ✓❑ No ❑ Residential.to Commercial? Yes ❑ No ✓❑ Are you painting/spraying? Yes ❑ No ✓❑ Dust collection system: Yes ❑ No ✓❑ Will there be a kitchen? Yes ✓❑ No ❑ Will there be a type I hood? Yes ✓❑ No ❑ Are you doing nails? Yes ❑ No ✓❑ High Piled Storage: Yes ❑ No ✓❑ Sand/grease interceptor? Yes ✓❑ No ❑ Source capture system? Yes ❑ No ✓❑ Will there be welding? Yes ❑ No ✓❑ Hazardous materials: Yes ❑ No ✓❑ Classified areas(NFPA)Yes ❑ No ✓❑ ***FYI...Fire sprinklers, and alarm plans to be submitted to the State for review.*** General Requirements Checklist for all plan submittals (to be FOR CONSTRUCTION): Digital Plans: Plans saved "to scale" (to be printed for onsite copy) as a PDF &combined together. We prefer plans to be saved directly from CAD (instead of scanned) so the file is "intelligent". Digital signatures OK. Apply online through PORTAL or email to bsdPermits@tfid.org. Call 208-735-7238 for permitting help. ***ARCHITECT OR ENGINEER TO GO THROUGH LIST AND CHECK OFF EACH BOX THAT ALL REQUIREMENTS HAVE BEEN PROVIDED ON PLANS. ***MISSING ITEMS BELOW WILL DELAY ISSUANCE OF THE C OF 0 BUILDING PERMIT*** ❖ Mark N/A besides any item that you think does not apply to your project. Do not leave blank. ® Civil Site Plan (This is REQUIRED separate from the architectural site plan when there is a change of use/occupancy.To include: ❑❑ Scale and format to be standard scale at between 1:10 to 1:60 scale; ❑❑ Paper size typically 2436, but other sizes may be approved on a case by case basis. ❑❑ Legal description and/or record of survey for the property,a vicinity map and north arrow; ❑❑ Show right-of-way improvements,both existing and proposed(If adding a new or expanding a solid surface parking lot). Right-of-way details to access,easements, utilities,drainage,wastewater, right of way to be dedicated. ❑❑ Accessible route of travel from parking spaces to the building entrance and connecting to the public right-of-way. ❑❑ Show that Fire department has all weather access(access must be 20 feet wide with a 75,000 pound load capacity and reach within 150 feet of any/or all portions of the exterior walls of the building(s). ❑❑ Fire hydrants within 1000 feet&fire line location must be shown on the site plan;a water model may be required to determine fire flow. ❑❑ Any areas used for the storage or use of materials regulated by the IFC; (med gas, paints,chemicals,etc.) ❑❑ Utility services—Number of water services including size and location;sewer location and proposed connection to the main; irrigation service size and location,grease interceptor(including a detailed design)for all food service occupancies; ❑❑ Parking lot layout, including fully dimensioned space&aisle layout,detailed handicapped parking spaces&accessible route. Show existing and proposed. 11711 Storm Drainage Calculations—(When adding a new parking lot). Show on site retention design,and or waterways. To be designed&stamped by an Idaho Registered Civil Engineer or Landscape Architect. ❑❑ Water tap size if needed for building sprinkler system. ❑❑ Proposed and existing curb,gutter,sidewalk,and driveway approaches. Architectural Site Plan (This is REQUIRED for change of use or new TI in addition to the civil site plan)Drawing to include: ❑❑ Scale typically 1/8"per foot for large projects and 1/4"per foot for smaller ones. Other sizes allowed on a case by case basis. ❑❑ Show required square footage of Landscaping—Including all types and locations of landscape areas showing berms,trees,bushes, fencing,and retaining walls. ❑❑ Exterior lighting fixtures showing lumens per foot(City Code 10-11-4) ❑❑ Show trash enclosure/mechanical equipment areas with method of screening, loading docks, storage areas,&pedestrian ways. ❑❑ Parking lot design—Showing parking islands,endcaps, minimum parking space count,&ADA accessible parking layout. 171 CODE/PLAN ANALYSIS—Required information is detailed on the example Plans/Code Analysis form within the application. Example plans analysis to only be used as a guide,and not the actual plans analysis. 11t time TI to be designed per IBC code,remodels or change in occupancy to be designed per IEBC. • Show any adjacent occupancies&list fire separations if needed. • Specify current and previous occupancy&use. 171 Floor Plan— Include all exit schemes,travel distances/path, exterior wall openings,door swings,use designation for each room,exit signage,location of fire extinguishers,high pile storage areas,and square footage. Indicate the existing occupancy classification of tenant spaces adjacent to tenant space. ® Electrical Plans(if changing lighting)—Exit signage, lighting schedule with fixture, bulb and ballast type,number of bulbs per fixture,and fixture wattage;exterior lighting bulb and ballast type,and type of control. Location of exit signage and emergency lighting shall coordinate with the floor plan or the reflected ceiling plan. ® Classified areas Plan(if applicable)—Floor plan showing boundaries of any classified areas per NFPA&NEC. Provide detailed explanation on plans for classified or unclassified areas and if you use mechanical ventilation to make the space"unclassified". 11711 Mechanical Plans&Ventilation Calcs—Equipment schedule listing the make and model of the equipment and other information pertinent to compliance with IECC;duct insulation R-values, mechanical system control schematic load calculations. Show Information regarding all fire rated penetrations,smoke dampers,fire dampers,etc. Ventilation design&calculations required on all new HVAC systems or change of use or occupancy. Mechanical engineered plans may be required on certain projects such as paint booths,vehicle repair garages,parking garage,wood working shops,etc. Hair and nail salons also have special exhaust requirements. (Provide calculations on plans for either natural or mechanical ventilation). See: IBC section 1202.1 &IMC section 402&403 ® Plumbing Plans—Plumbing layout plan,grease/sand interceptor details,and calculations to determine actual interceptor sizing according to the requirements in the Idaho State/Uniform Plumbing Code. Be sure to include the sewer connection location,type and location of reduced pressure backflow devices(s),gas line piping materials and calculations,water line piping layout and materials,and drain/waste/vent piping layout and materials. El Additional Handicap Accessibility Information—1st time TI--Define accessibility access features for new construction per the current International Building Code,and current ANSI Al 17.1. For remodels&changes in occupancy,the area of improvement shall comply with the access requirements in the International Existing Building Code. An accessible route of travel will be required to the remodeled/improved area. rO Permanently fixed furniture—Provide floor plan designs and elevations for all permanently affixed cabinets,counters, reception counters, sales counters, lockers,seating,or shelving. This cannot be a deferred submittal. rO Fire Department Requirements—Location and type of fire extinguishers,smoke detectors,exit signs,emergency lighting,fire alarms, hoods,sprinkler system,etc. Sprinkler plans to be submitted to the State of Idaho for review. rO MSDS Sheets—Completed Material Safety Data Sheets and the location and quantities of storage of such materials shall be provided with the building permit submittal where any chemicals or hazardous materials may be present. ❑❑ Completed Waste Water Survey(see survey in this application) 0 Completed Sewer Capacity Fee Worksheet(see the form in this packet)(If adding new fixtures). 0 Health district approval is required for all buildings where food is being prepared. Provide an approval letter from the Health District. 1(the designer in responsible charge, Architect or Engineer) hereby certify that I have read and examined the above checklist, and that all of the information provided and items checked are included as part of the initial permit application submittal and are true to the best of my knowledge. Write N/A next to those items that don't apply. Digitally signed by R.Colby Ricks R. Colby R�CkS DN:C=us,I=_=colby@kallc.com,C=Laughlin 1/23/2025 Ricks Architecture,CN=R.Colby Ricks Signature -0ate:2025.01.23 10:00:52-07'00' Date ***NOTICE*** All permits expire 180 days from the date of their issuance or the date of the last inspection. Expired permits will require reactivation at such time that the responsible party decides to complete the project. Reactivation fees will be required on all permits. Furthermore,any application that has not been issued or picked up after 180 days will become null and void. ***Plan review where all the required submittals have been provided are not expected to exceed 2-3 weeks for the initial review,but could take longer depending on needed revisions or current workload. Please let the Building Department know if there are any unusual time constraints and we will work with you to move your project forward as quickly as possible. Please keep in mind that any missing information from the above checklist will cause delays in the review&processing of the permit application. In accordance with Idaho State Statute 54-5209,please check the box that you will have a registered contractor or identify which exemption applies to you below. To see the statute, CLICK HERE. I certify that: I am providing a registered contractor for all work being performed. I am not providing a contractor registration number because I am exempt per Idaho Code 54-5205 per item letter By signing below,you acknowledge that the information provided on this application is true and correct to the best of your knowledge: Digitally signed by R.Colby Ricks R. Colby Ricks R. Colby Ricks RcksAchitectum,NI=R.Colby Ri ksughlin 1/23/2025 (Annlicant) Date:2025.01.23 13:13:00-07'00' Print Name Signature Date SAMPLE PLANS ANALYSIS: THIS INFO TO BE PROVIDED ON PLANS ***MAY NOT BE ALL INCLUSIVE*** Applicable codes: (List all currently adopted codes in COTF on plans) OCCUPANCY CLASS(S): (A, B, M,S-1, E, R-2, ETC...) OCCUPANCY USE:(DAYCARE, HAIR SALON, DOCTORS OFFICE, ETC.) CONSTRUCTION TYPE: OCCUPANT LOAD: (SHOW FOR EACH STORY AND TOTAL) SEISMIC DESIGN CATEGORY: ALLOWABLE STORIES(SEE IBC TABLE 505.4): ALLOWABLE BUILDING HEIGHT: ALLOWABLE AREA INCLUDING CALC'S: (SEE IBC TABLE 506.2) ACTUAL AREA(SHOW AREA PER STORY AND TOTAL): BASEMENT: 1ST: TOTAL SQ. FOOTAGE: 2No; 3Ro: 4TH: 5TH: AUTOMATIC SPRINKLER SYSTEM? YES OR NO ALLOWABLE AREA SEPARATION REQUIRED? YES OR NO OCCUPANCY SEPARATION OR NON-SEPARATED USE? FIRE RATED WALLS REQUIRED? (SPECIFY TYPE&RATING) YES OR NO PENETRATIONS? SHOW APPROVED LISTED PRODUCTS ON PLANS: FIRE RESISTANCE RATINGS OF BUILDING ELEMENTS(SEE IBC TABLE 601) (IF YES, SPECIFY RATING) RATED STRUCTURAL FRAME(ROOF SUPPORTS ONLY): YES OR NO RATED BEARING WALLS-EXTERIOR: YES OR NO RATED BEARING WALLS-INTERIOR YES OR NO RATED BEARING WALLS-INTERIOR(ROOF SUPPORTS ONLY): YES OR NO RATED NONBEARING WALLS-EXTERIOR(>30' FIRE SEPARATION): YES OR NO RATED NONBEARING WALLS-EXTERIOR(10'-30' FIRE SEPARATION): YES OR NO RATED NONBEARING WALLS-INTERIOR YES OR NO RATED FLOOR CONSTRUCTION: YES OR NO RATED ROOF CONSTRUCTION: YES OR NO MINIMUM ROOF CLASS: (SEE IBC TABLE 1505.1) RATED CORRIDORS:(SEE IBC SECTION 1020.1) YES OR NO EXTERIOR WALL OPENINGS: SEE IBC 705.8 FIRE DOORS: IBC TABLE 716.1.2 FIRE ALARM SYSTEM:(SEE IBC 907.2) FIRE FLOW AND DURATION: FIRE HYDRANTS: SHOW LOCATIONS AND DISTANCE TO STRUCTURE BUILDING EXITING(REQUIRED EXITS PER OCCUPANT LOAD): SEE IBC TABLE 1006.3.2 EXITS REQUIRED PER FLOOR: CORRIDOR WIDTH: (SEE IBC TABLE 1020.2) FURTHEST TRAVEL DISTANCE: (SEE IBC TABLE 1006.2.1 &1017.2) AREAS OF REFUGE REQUIRED: (SEE IBC SECTION 1009.2,3,4) YES OR NO PORTABLE FIRE EXTINGUISHERS ON PLANS:(SEE IFC SECTION 906) YES OR NO CLASSIFIED AREAS? IF YES,SHOW ON PLANS&SHOW AREAS YES OR NO VESTIBULE REQUIRED? YES OR NO SPECIAL INSPECTIONS REQUIRED?: YES OR NO LIGHTING LAYOUT AND COM CHECK? YES OR NO The US Environmental Protection Agency requires that Renovation, repair and painting projects that disturb lead - based paint in pre-1978 homes, childcare facilities and schools must be performed by an EPA Certified Renovator working for an EPA Certified Firm and specific work practices must be implemented to prevent lead contamination . More information is available at 1800-424- LEAD [ 5323] or http : //www2 . epa . gov/lead Laurie Fay US Environmental Protection Agency Region 10 1200 Sixth Avenue Suite 900, MS AWT-128 Seattle, WA 98101 Phone: 206-553-1541 Fax: 206-553-8509 Email: fay.laurie(@epa.gov You may also find information about Asbestos at http : //www2 . epa . gov/asbestos or the State of Idaho has information on their website at http : //deg . idaho . gov/air- quality/air-pollutants/air-toxics/asbestos . aspx Please note that EPA R10 in Seattle handles asbestos in schools (AHERA regulation) . R10 Seattle no longer handles asbestos NESHAP issues - these are referred to Sohn Pavitt, EPA R10 Anchorage, AK office - his contact information is phone (907-271-3688) and/or email (pavitt . john(@epa . gov) . I i Jacobs JACO BS E 350 CANYON SPRINGS ROAD PO BOX 5158 TWIN FALLS, ID 83301 INDUSTRIAL WASTEWATER DISCHARGE SURVEY After reviewing the first wastewater discharge survey, additional information is needed by the City of Twin Falls to comply with Wastewater Plant's NPDES permit requirements. Please fill out the form completely and return it to the address listed above within 30 days of receipt. Completion of this survey is required under the Clean Water Act (CWA) and the Rules Regulating the Idaho Pollutant Discharge Elimination System Program (IDAPA 58.01.25). Failure to complete this survey or falsifying information reported on the survey is "an offense punishable by enforcement action, which includes termination of treatment services and/or civil and criminal penalties". For purposes of notification, all industrial users (i.e., non-domestic users) are required to notify the Wastewater Treatment Facility of hazardous wastes in accordance with 40 CFR 403.12 located online at https://www.gpo.gov/. Company Name: Facility Address: Mailing Address: Contact Person: Title: Phone: Email: Does the facility perform processes in any of the industrial categories or business activities listed below? 8 Airport Deicing 8 Leather Tanning and Finishing 8 Aluminum Forming 8 Meat and Poultry Products I 8 Asbestos Manufacturing 8 Metal Finishing I Battery Manufacturing Metal Molding and Casting Canned and Preserved Fruits and Vegetables Metal Products and Machinery []Canned and Preserved Seafood Mineral Mining and Processing 8 Carbon Black Manufacturing 8 Nonferrous Metals Forming and Metal Powders 8 Cement Manufacturing 8 Nonferrous Metals Manufacturing I 8 Centralized Waste Treatment 8 Oil and Gas Extraction []Coal Mining Ore Mining and Dressing Coil Coating Organic Chemicals, Plastics, and Synthetic Fibers (OCPSF) Concentrated Animal Feed Operations (CAFO) 8 Paint Formulating 61T v Jacobs JACOBS 350 CANYON SPRINGS ROAD PO BOX 5158 �+ TWIN FALLS, ID 83301 h!1/1H` Concentrated Aquatic Animal Production Paving and Roofing Materials (Tars and (CAAP) Asphalt) Construction and Development Pesticide Chemicals Copper Forming Petroleum Refining Dairy Products Processing Pharmaceutical Manufacturing Electrical and Electronic Components Phosphate Manufacturing Electroplating Photographic Processing Explosives Manufacturing Porcelain Enameling Ferroalloy Manufacturing Pulp, Paper, and Paperboard Fertilizer Manufacturing Rubber Manufacturing Glass Manufacturing Soap and Detergent Manufacturing []Grain Mills Steam Electric Power Generating Gum and Wood Chemicals Manufacturing Sugar Processing Hospitals []Textile Mills Ink Formulating []Timber Products Processing Inorganic Chemicals Manufacturing []Transportation Equipment Cleaning Iron and Steel Manufacturing Waste Combustors 8 Landfills Indicate the types of waste generated by this facility: 8 Domestic Waste Noncontact Cooling Boiler/Tower 8 Contact Cooling Blowdown Water 8 Process Washdown []Air Pollution Storm Water Runoff Control Indicate where waste is discharge: Sanitary Sewer Storm Sewer Surface Water Ground Water 8 Waste Hauler 8 Evaporation List pollutants discharge by this facility: CITY r TWIA 1.:11.1.� ® ��e�. Jacobs JACOBS w 350 CANYON SPRINGS ROAD �` � � PO BOX 5158 TWIN FALLS, ID 83301 Describe any existing pretreatment technology: Indicate whether any of the following chemicals are used in your facility: LEGEND: Leave blank if Status is Absent Mark"S"if Status is Suspected Absent Mark"P"if Status is Present Mark"M"if Status is Suspected Present Chemical Compound Status 0 Chemical Compound Status ACENAPHTHENE 0 ACENAPHTHYLENE ACROLEIN 0 ACRYLONITRILE ALDRIN 0 ALPHA-ENDOSULFAN ALPHA-LINDANE 0 ANTHRACENE ANTIMONY 0 AROCLOR 1016 AROCLOR 1221 0 AROCLOR 1232 AROCLOR 1242 0 AROCLOR 1248 AROCLOR 1254 0 AROCLOR 1260 ARSENIC 0 ASBESTOS (FRIABLE) BENZ(A)ANTHRACENE 0 BENZENE BENZIDINE 0 BENZO(A)PYRENE BENZO(B)FLUORANTHENE 0 BENZO(GHI)PERYLENE BENZO(k)FLUORANTHENE 0 BENZYL BUTYL PHTHALATE BERYLLIUM 0 BETA-ENDOSULFAN BETA-LINDANE BIS(2-CHLORO-I-METHYLETHYL) ETHER BIS(2- ❑ BIS(2-CHLOROETHYL) ETHER CH LO RO ETH OXY)M ETHANE BIS(2- ❑ BIS(2-ETHYLHEXYL)PHTHALATE CHLOROISOPROPYL)ETHER BIS(CHLOROMETHYL) ETHER ❑ 4-BROMOPHENYL PHENYL ETHER CADMIUM 0 CAMPHECHLOR CARBON TETRACHLORIDE 0 4-CHLOR-M-CRESOL CHLORDANE 0 CHLOROBENZENE CHLORODIBROMOMETHANE 0 CHLOROETHANE 2-CHLOROETHYL VINYLETHER 0 CHLOROFORM CHOLOROMETHANE 0 2-CHLORONAPHTHALENE CI'ry c,o- �N 1�,►I.1,� Jacobs 350 CANYON SPRINGS ROAD JACOBS � � PO BOX 5158 0 + TWIN FALLS, ID 83301 �N1N . 2-CHLOROPHENOL 4-CHLOROPHENYL PHENYL EHTER CHROMIUM 0 CHRYSENE COPPER 0 CYANIDE DDD 0 DDE DDT 0 DELTA-LINDANE DI-N-OCTYL PHTHALATE 0 DI-N-PROPYLNITROSAMINE DIBENZ(A,H)ANTHRACENE 0 1,2-DIBROMOETHANE DIBUTYL PHTHALATE 0 1,4-DICHLOROBENZENE 1,2-DICHLOROBENZENE 0 1,3-DICHLOROBENZENE 0 3,3'-DICHLOROBENZIDINE 0 DICHLOROBROMOMETHANE 1,2-DICHLOROETHANE 0 1,1-DICHLOROETHANE 1,1-DICHLOROETHYLENE 0 DICHLOROMETHANE 2,4-DICHLOROPHENOL 0 1,2-DICHLOROPROPANE 1,3-DICHLOROPROPENE ❑ DIELDRIN (MIXED ISOMERS) DIETHYL PHTHALATE 0 DIMETHYL PHTHALATE 2,4-DIMETHYLPHENOL 0 4,6-DINITRO-O-CRESOL 2,4-DINITROPHENOL 0 2,4-DINITROTOLUENE 2,6-DINITROTOLUENE 0 1,2-DIPHENYLHYDRAZINE ENDOSULFAN SULFATE 0 ENDRIN ENDRIN ALDEHYDE 0 ETHYLBENZENE FLUORANTHENE 0 FLUORENE GAMMA-LINDANE 0 HEPTACHLOR HEPTACHLOR EPDXIDE 0 HEXACHLORO-I,3-BUTADIENE HEXACHLOROBENZENE 0 HEXACHLOROCYCLOPENTADI ENE HEXACHLOROETHANE 0 INDENO(1,2,3-CD)PYRENE ISOPHORONE 0 LEAD MERCURY METHANAMINE, N-METHYL-N- NITROSO METHYL BROMIDE 0 N-NITROSODIPHENYLAMINE NAPTHALENE 0 NICKEL NITROBENZENE 0 4-NITROPHENOL 2-NITROPHENOL 0 PENTACHLOROPHENOL PHENANTHRENE 0 PHENOL PYRENE 0 SELENIUM SILVER 2,3,7,8-TETRACHLORODIBENZO- P-DIOXIN (TCDD) 1,1,2,2-TETRACHLOROETHANE 0 TETRACHLOROETHYLENE 2,3,4,6-TETRACHLOROPHENOL 0 THALLIUM TOLUENE 0 1,2-TRANS-DICHLOROETHYLENE TRIBROMOMETHANE 0 1,2,4-TRICHLOROBENZENE T% 4sc", Jacobs 350 CANYON SPRINGS ROAD JACOBS � PO BOX 5158 TWIN FALLS, ID 83301 1,1,2-TRICHOLOROETHANE 0 1,1,1,-TRICHLOROETHANE TRICHLOROETHYLENE 0 2,4,6-TRICHLOROPHENOL VINYL CHLORIDE 0 ZINC In accordance with Title 40 of the Code of Federal Regulations Part 403 Section 403.14, information provided in this questionnaire will be available to the public without restriction. Requests for confidential treatment of other information shall be governed by procedures specified in 40 CFR 2. "I have personally examined and am familiar with the information submitted in this document. Based upon my inquiry of those individuals immediately responsible for obtaining the information reported herein, I believe that the submitted information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and/or imprisonment." Name (print): Signature: Title: Date: