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I <br /> Y <br /> Submitted by: 0 <br /> Andrew Ridley Q <br /> Accepted in Duplicate Z <br /> CUSTOMER OTIS ELEVATOR COMPANY <br /> A <br /> Xl <br /> pproved by Authori -. Rep sentative Approved by Authorized Representative D <br /> Date: ►s Date: --4�i O <br /> ■Signed: X , ,.,L \ Signed: (. ^ ,- - - ---- <br /> Print Nile' �e L' `r��� Print Name: le = - KOUtereba <br /> (4 .._ Ge:al Manager <br /> Title: & TIVIAMIA, Title: m <br /> E-mail: f 0 <br /> Name of Company: £h r I C <br /> ❑ Principal,Owner or <br /> Authorized Representative of Principal or Owner <br /> ❑ Agent <br /> (Name of Principal or Owner) <br /> C <br /> O OTIS ELEVATOR COMPANY,1995 All Rights Reserved Impact Form MNT-ADD(12/01) Contract#TA09479 Page 2 of 2 <br /> .q <br /> , <br /> %a <br />