HomeMy WebLinkAbout3238 WASHINGTON AVE - Building Permits�oonEssaem�owo: 32 3g WpSHIN GTON pV
�%S�E�F�FALCONER MARCIA H
�oonEss:323g WAS{iINGTON AVE
COSTA MESA,CA 92626
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caamncrararw�GORNEA ROOFING (714)d98-6988
cam.croxs�uu�o12733 WESTERN AV
aoox�ss:G . G. CA uc xo.: 4 9 4 8 0 6
92841 uxr:
LICEN9ED COMFRCTOHS OECLARR�ION: I hereby eflFm uMer penelly d pe�ury Ilat I em licaneod urMm poviums ol Chepter 9
(mmmendrq wi�h Senion ]000) d Owuion 3 d Ne Buvinen erd Vmlmvma Coda, aM my liunu u in lull lwca vd aHea.
c uc.No.042964 uc.cuss:C39 uc.r+o.: 9q806 EXP: il/97
ome: � conveao.: �
OW BUILDER p LRR�tION: I hereby e/fiim wEx penell rjury ihet I em emmp Irom IM Conlreaae l'xenee lew lor the
� � 0 raeaon (Setlbn )0]I.5 &»'vima dd P�dMevion+ Cade: AM c1Y rt muM' whidi nVuree a DermY to wmWd. Mm, im>oue.
d'e�, a rapai erry auucw�e. p�v b ia uuwice. e6o'epw'm tM epplimnt tu wch penm to fib e epneE nmemeru thet M a eM
e fiumeE W� to Ne pv+ivma d Cr Caureem lioeroe law IChaqer 9(mrvnenenp rmh Swion nIW) d Oiieion 3 d Re
Bvm�m W PrWxibre Cdel a �hat M a kro u uanq �hseM1vm uM IM baw la ihe e�epeE ezmmqion. MY vuW un W SeCian
)W 1.5 by e�ry epW'rav Itt e perm, auhjade �M eppfraa �o e tlW pmMy d nq mas Nen Ir�e hwd�ed ddlen �SaOpp.
� I.mowrorW�hepWMYarmYandWewwihwWe!uiAeitlewmDaivsYYion.willdotlnwwk.udlM�vWunend'vqeMed
w dlxeE �« eeb (seaion )a.. euvnes, ena r�aaa.on.code: rne comreaw.limue laweoee na eopv�o en own«d piapeM�
wM WiEa n inpwea Ihereon. end Mp doas � h xdk IimrM a henM a Waph he a hm own amG�WM�. pa'�deC IM wch
impmwneMe va m� uuaded a dlaed la eeb. tl, lawaver, tM Ewtlinp a inpwanM w wld wqhin pw yw d complMun, tM
wror-0uitlw �ti0 hew Ihe dndan W pwi�q M a eM GE nal buGd a'unpove la tM WR� W eeb).
� I. m owner d tM pWMY. em na�iAn+N oonirm�q �mA lioeroed contreclas W wnarW tha pNb (Sed'on IOM. &niime vd
Pmleeviwu Coda: The Contredas Licanae lew doee na epply io en awrer W popeny x1a Wike a Imqwa �Mrson vd v.fio
comrecu lor such proleCa wnh e wnlreGor(e) Icenaetl punuenl lo ihe CanVedon Licenee Lew�.
❑ I am e�empt uMer Seclion: B. 8 P.C., br I�ie roemn:
DNe: ��:
I Eo IwoW canM Nm 1 em ewere W enE u�deislud tlw nVuimmoM W Cel/aw 4MMh W Sele1Y CoEe Setliom 25.505.255�3. anE
255]�. eM thet I a a^Y Mum buildiiq o�pem wiil / wil Mn (d�cb an) need �o cwnPN wY� mN mta ooAr ud �M nWimmama br
apemiillacanewnianormoEifralionhomiM�r iu�ly uupamsmDinriC.ResidenlidmM�upioneypkel'vuene»mqimmihaee
a�.
Dma: Appliraa:
WOPKER'S COYVENSATION OEC Wi�TON: I hereb� Nkm udr pr�Wy d{wjry pw d ths bCowinp dodeeatba:
❑ in�..m.u�m.:�a�na�.a�.emw.en:�,w.ro..Ana:�o,,,ro�.mo�...nw�a.ei«Msem�arooam.�e,.
Code. ia lM perlwmence oi Ne wk Iw w1icA thu pem�n u ivued.
�� 1 Mn eM W mmmen xoM1en' mm0a�ion IrauraM.e, u nw'ved M Seaian �100 d qe Lebar Code. br ihe M�amenoe d �ha
work Iw whid� Nu pemN e eeued. MY ��' � � imurence raner ud pdiry wmMr ua:
• c�.: ST1�T�E FUND EXPIRES
ad� N�mna — O 1/ O 1/ 9 7
(lhis eMiwr neeL na be romWs�ed I tM pemid ie lar ars hvndiad ddlera (ffOpl w bes.1
I wrlN �� in ihe peAormence d iM wark In whch ihie peimil n iauad, I Mdl � mmpby ury paiem in any manns m u �o
cana wbjetl to IM wwkae' campsiuelion �ar.e d CelilaNa. uM pree thel 4 I ehouk become abjetl to IM xorken'
c Mmmion P�iom W Seqion 3100 d iM lebor Code. I WY lal� ' mW wuh Nma pmtims.
rDme: / �Vp�eiM:
r�p: F.uun ro s.c won.n• mmo«u.uon cw.r.p. �s I, �iM �IWI sWflel �n w�nplqw ro ulMn/ pw�Wtlu urtl
nvn nn.. �q ro aa now.w mouaw ewwn (Sia4oaoA � �wn ro m. �o.r or �o�..�wn a�.... n.oNe.e ro. ��
S�ctlon �l(M ol Ns L�6or COJs. /rrtwss4 �� ���^�Y�s I�x.
CONSi11UCIlON LENqNO AGENC�: I hereb/ etfirm iWar prutly d perj.vy �hm �hve u e ovw�uCion Widvq epriry tor tlr
oaiormd,a a me woni �« M�h me o�+� n ea»a (s«aion �ow. cw. cl.
LENDEN'S NNIE:
LRlUEF'S ADOHES4:
� cenM �nm � neve rem �nia ecd�m ene ame �nai ine mwe Int«mmia, e carea. � ea�a. io camdr wnn v� mr ene coumv aa'viezen
erd eW e kwe reW np lo WiW'vq cvWrWnn vd hmeEy eulharrse �ernlatives d Ihb tily lo enler upon tM ebove�memorwd popetty
�«1ropBtl�O�`D°'°'JAMES BRANCH
�_ /
Oete: � f
(5151-IB.WP) WINe-BuJdM8Se1MY:arwmWe:CenW-�DGF �:Rnk-Rawve:(bldenrob-Nemw
CITY OF CQSTP. MESA — BUILDING PERMIT PERM NO: B OII092'7
PERMIT NO: B 080927 PLAN CHECK NO: N GOVT; N SUPP: N
CONSTRUCTION TYPE: PERMIT TYPE: STR PURPOSE: OTI�
JOB DESCRIPTION : T/OFF & REROOF W/COMP SHINGLES SQ FT; 4,400
CLAIM C�ALUE; 4,439.00 CALC—VALUE: 4,400.00 GROUP OCC: R-3 /
COMMENTS: REROOF 2900SF RESIDENCE W/COMP
*+�***+�*�***et�-it*it�t�t�e*�*�t*�*x�*�*�tie�*�t�+t�it�t***at�****x�***�t****+t*�-*�t*��t*x�***���**��*�
Z O N I N G R E Q U I R E M E N T S
S E T B A C K S
------------- MAIN HUILDING ---------- --------- ACCESSORY HUILDING ---------
FRNT: FT ZN REAR: FT ZN FANT: FT IN REAR: FT' IN
LEFT; P"f IN RGAT: FT IN LEFT; FT IN RGHT: FT ID1
PARKING REQ: PROV: PARCEL: 42427201 ZNE: REF NO:
PLANNING NOTES>
i
iF 1E if iE If IE iE 1E iE iE 9E iF if iE iE iE 1ElE 3E iE if 1f if iE iE IE If �E IE iE fE aE iE if if af iF iE iF iE iE If If iF aE if iE iF 3E if 3f if �f 3E iE IE jE jf If iF fE IE iE fE �E 1E 3F jE if iF 3F if fE aE iE �E iE 3E iF
D E V E L O P M E N T S E R V I C E S R E Q U Z R E M E N�T S
ZONING APPROVED BY .
ILDING APPROVED BY :
PPLICATION ISSUED BY:
iE 1E iE iE 1E 1P 1E IElE 1E iF ik IE 1f iE 1E iE iE iE iE ik
EGALIZATION:N F E E S U
BLDG PMT PLUMHING ELECTRI'C
ERMIT 99.75
C
M A R Y
MECHANZC
_ DATE:
DATE;
DATE; *�-�11"'�F��l�1 ` G
��IEiElElfiFiFiE�EiEiE IE
STRUCTURAL SEGMENT:Y
FIRE SMIP/RES GRADING
.SO
SMIP/NON—RES
SSUE FEE
UILDING—DIV—> PERMIT ISSUE PLAN-CHECK TOTAL PAID DUE
OTALS----> 100.25 0,00 . 0.00 100.25 100.25 ,00
EVENUE DIVISION TOTALS--> COLLECTED': 100.25 OVER/SHORT: .00
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK
99.75 � .50
iE iE IE IE 1F iE 1E IF 1E iE 1F iE 1f 1F iE 1E iF 16 iE iF IE 1E if 1E 1E 1E IF 1E �E fE 1F IE iE iE 3E IE 1E 1E 1E 1E if ik ik iE iE iF 1k iEfE if 1f iE 1E ik iE 1E if iF iE iF fE ff� af iE 1E 1E 1E iE 1E 1E IE if 1k 1E iE IE IE iE
I N D I V I D U A L F E E H R E A K D O W N
YPE QTY D E S C R I P T I O N UNIT COST TOTAL COST
FR
4400 REROOF BY VALUE RESIDENTIAL NOZONE
END OF FEES
1.00 4,400.00
01 002212E6-002212E7 T�J T 10t1.?5
DR'fE� 1:/]9I9.`� TIPfE� 14=a2
� CONSTRUCTION AND PLANNING . � P00� ,PA -
r APPROVAIS Permit # Date Inspector pppROVALS Permit # � Date inspector
t, Temporary ElecVical Service or Pole � 52. Pool & Equipment Location
2. Soil Pipe�Undrgrnd. 53. Steel Reinforcement '
3. Electrical Conduit UtilitY•Undrgmd. 54. Forms �' �
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding �
5. Steei Reinforcement 56. Rough Plumbing & Pressure Test � -
6. Electrical UFER Grnd. 57. APPROVALTO COVER•GUNITE
7. Footings 58. Electrical Conduit-Undrgrnd.
8. Foundation 59. Gas Pipe, 0 Undrgrnd., Test ,
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, � U�drqrnd. �
10. Structural Floor Svstem ' 61. APPROVAI. TO DECK �
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final I I
12. Sewer Cap ' 63. Heater & Vent�Finai
13. Roof Drains � 64. Plumbing System - Final
74. Rough Plumbing 65. Electrical-Final
15. Rough Electrica6Conduit � 66. Solar SVstem-Final
16. Rough Electric Wiring 67. Fencing & Access ApProval
17. Rough Wiring Sign 68. APPROVED fOR PIASTER�NG
18. Rough Electrical�T Bar Ceiiing 69. POOL/SPA SYSTENIS FINAL
79. Rough HeaUng & Air Conditioning FIRE DEPT. REQVIREMENT
20. Rough Factory Fireplace APPROVALS Permit #
21. Ducts, i� Structure 70. Underground Hydro
22. Docts, Ventilating 77. Product Piping �Gas OOiI
23. Gas Pipe-Rough & Test 72. Underground Flush
24. iioof Framing 73. Undergrnd. Storage Tank O Gas ❑ Oil
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing 76. Dry Standpipe
28. Lathing & Siding 77. FIXED SYSTEM FINAL
29. Insulation 78. FIRE PREV. FINRL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION
32. Electrical Power Meter�Final B0. FOOD CERTIFICATE ISSUED
33. Final Electric Notes:
34. Final Heating & Air Conditioning � ,�/� ,� `
35. Final Gas Pipe-Test � �O -G� ��� � L�
���-/f �� �'��
36. Hood or Ca�opy c/' /R � O�, �
37. Final Faaory Flreplace ,-
� � f �
38. Final Plumbing
39. Water Service�Final
40. Gas Service-Final
41. Solar pomestic-Final
42. Backflnw Prevenier
43. Backflow Irrigation
44. Landscape Irripation System
45. Sound Attenuation
46. Handicap Regulations
47. FINALSTRUCTURE&BUILDING �Z_,Z�_� �WLY'
��
48. FINAL PLANNING •
49. Electric Release to Edison _ __
50. Gas Release to Southern California Gas Ca
51. CERTIFICATE OF OCCUPANCY -
No. Date �
'1� p."4jf 45�Cne���--°y�`i.Of C,OLL�2Ei/2 �RLL�OiI2Cl1 !�i�_.
.0 _aw��»1..1,C.�.4.�:�u�Wu �
— �' ----�. —
°!� 3..^,:: �l .�i10 NFPO?i N'P.Y . LPVC^ PE•�CI-i. C1L:F. ?;;3JI . �Z17) �.16d?55 . �2;7I 636.2786 .(714j 828-6?72
�rniti � ccr,rFs: . �
iEi �i. •� • �,_Pr,r., Nu,Cn . e�e.l�c
S.,<��':� o•.y���v")�:1 F.i:'?�`.;.,, i.OBu�]�.�.'.
pl�ls.b:.. z}.._.��..,,.,,� _ .,.
���„ ,,_A � o�o &ec4, CJp, iCB01 I�U� A:l�D9�
,�, ..:_.1�:;�):�,
a., _/: �
i� �.,��
kiii�li5i 2�� �.��6
Ezaminaticn: 76-5137
GJ:ii_TF.
COMPr2E5510� TF.5T5 GPJ n,#;c;`tiC^�%c CYLIND'cRS -�
Tack Hubbard
3:L5 Octron A�:er..�e
Long 3eacls, Ga_lifcrr.ia 90805
P'tiOJ:C7 Sivl��:?.ivG YGOL - �UIRCIA �ALCO�"r.R ��O�IJ /
Af?��ESG 3?_38 bias'r,inr�.to;1, Cost;� ?Se=a, California �
SAF,ir'LE- FROAi Siial.lo:•, F,^d, D��ep Lau, bonci i,ea��
N.CNIiF.=' CONTRACTOR
�ldd.—ld 2�0015 �
ENJII:FEA Sl18iON:.QACSOR
J. :d. Reagan Enterprise Gunite Co.
SP:-CIfdEO
MIX 4.5 to 1 S7CEAtuTH 2,000
DATE CA57 8-6-i6 SiU/hP -
DATE TESTED
CYIIPiD"eR 40.
COMPR'e5516N
TOTAL LOAD, LBS.
POUNDS PER SQ. IN
8-13-76
1
7 Days
36,000
_.275
�4-13-76
2
7 D:tyc
38,000
1.345
COMPLIArVC'e 14 Day test' cemplies wit:� cp�cifications.
F1:.DE 6Y DELIVERED 6Y
CYLINDERS � Carl J,ick Hubhard �
OISiPI0Ui1CN;
Jac�; Etu�bard - 3
Costa Afes� Aiddg. Dent.
�u��.�f��� ��;����1 D��r.
�'��;'z?� �'',`
8-13-76
3
7 Daye
37,000
1.3.10
8-20-76
4
14 Days
57,000
2,015
RECFIYEO O:i
;i1-2-3 8-9-76
��4 8-16-76
.Y' , ... . . . fV v�'
,,. .s, ' UYL
.��L 11[^O�+'i .�R[ illpYliTC"J I,5 'M`_" CCN=1DCflT�w� 1'ROI`CRiY O� CIIEM1TS. AV'NORIZATIO'1 I'OR PV'JLIC.�TION OI OVR RCFOFi9, CONCLV+�ONS. OR E<�
TY�C'S �'�'OM OR f�fGI,HDIH4 t��EM IS NCSCRVLJ �`fNJIN4 nV�� M'�l'iCY �rp110V.�� TS /. M.VTV�L PPOTECTION TO CLIENTS. TME I'VOIIC .�NO OVNSElVE3.
330��2 i.'�
� z 3 �.//�q%Q.v Building
—� Address
�. �LLLGB++4il1�� Ow[ter
���ic.� �j�� Con[ractor
�� eJ26-c+y� Address
Permit Date
��� 8 �( Number � !3 %% Issued
CITY OF COSTA MESA
DEPARTfiENT
OF
BUILDING SAFETY
Registered Deputy Building Lnspeccor
Certificate of Compliance
Date of this Certificace
8/� /7G
To the Director of Building Safety:
I hereby cer[ify that the following portions of work on the buildings
at the above address which required continuous inspection and which I was
employed to inspecc, were inspected by me and comply with the provisions
of the Building Code applicable thereto.
1) Concrete 3) Welding 5)
2) Masonry � � 4) Reinforced Gypsum
Swimming Poo1 Size /d� X.3x Gunite x Hand Pack
Sacks Cement /.3 � Tons of Sand � J�
Approximate % of water in aggregate cT%p
0
Special Cases
This report covers work completed during week ending 8l�J�%�p
-�:o.Q, d � P 4��
� � ��}. � REGISTERED DEPUTY BUILDING INSPECTOR
� • � �� Name '
� Address �/ D�o�i � �i.�G�
Laboratory � , Telephone �,$S–(o�B'�
Fo rm BU 6
aOWNER FALCONER, M. H. DATE 7-15-76
�C JOB ADDRE55 3238 WashinQton Avenue BUILDING PERMIT N0. 42287
� GENERAL CONTRACTOR Madrid Custom Pools DESCRIPTIONofWORK Pvt. Swim Pool
No. 139-094-07 LOT TRACT FIREZONE VALUE$3,000.00
!ECTIONS Si norure Date GROUP J TYPE III ZONE R-1
Pool Location
�t— ' '% SUBCONTRACTOR PERMITS ISSUED
/ / Date N�mber Si nvt�re
FnrmS
Main Drain _
.Steel Reinforce
Elec. Bond _
Etectric
Appro�al to Cover �C� 3•7 K�CAc
Underground Electric '
Gas Piping Test
� Plumbing
Filtering System Lines `-�- '�-
Backwash Lines and Recep.
6Z� G � •� ��
Electrical Final R � 30'%�
Heater and Vent Final _
r System Final
Backwash and Recep. Final
Fencin9 Final
�-�-/�-/4�L4 �-�,ois�i.s./_
' � � ` 42287
FS
fG
L
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'V
GOSTA MESA BU�LDING-SAFETY DEPARTMENT
P.O. BOX 1200 COS7A MESA, CALIFORNIA 92626
tut. ts-76�,",-�QOOf614�+ �¢��36.50
APPLICATION FOR STRUCTURAL PERMIT
For Applicant to Fill in Completely — Use Ink Only
RECEI DATE RECEIVED TE I D/
BVILDING /_
ADDRESS � Z / ' � � �7
_ �I / ERMIT NO.
OWNER A.P. NO. - �
M A � � r BUI LDING
AODRESS JG�. ADDRESS � �
TEL. TRAC"r �Y /Jl LOT� BLOCK
CITY NO. � �"r
�pNSiRUCT10N J W A P
LENDER �
�
BRANCH n
N R L' � Q.C.G` .
ADORESS
VALVE ^7
ORCNGIN ER. L'U TEL. � 6` L� S ' $ J�L'�C�• �
FIRE
ADDRESS �, /L� 20NE TVPE GROUP
`�� . � • f APPROVED
CONTRACTOR I c�.y��n..__o� �,,,i BV DATE � —
ADDRESS �1-v4 C�U
ZO NO.OF USE OF NEW,
TEL. p�qN$ BUILDIN � �
CITY �l C NO. �� Ef �i>
STATE �� CITV VARDS APPROVED VARDS APPROVED
LIC. NO. 2(�C LIC. NO. MAW 9UIlDING ACCESSORV BUILDIN('i
S12k NO.OF BLDGS. (FROM C/L STqEET) //� p �
OF LOT NOW ON LOT RONT FT. FTNV
USE OF � � � 7 /�
E%IS'rING BLDG. SI T. ���-R�7'
Separate permits are required for �. s�oe FT. T.
electric, plumbing and heating work.
REAP FT. �
� 5 BUILDING AND WOfi TO BE PERFOflMED DISTANCE BET. BET. MAIN &
� � � � MAIN BLIX'a5. ACCESS. BLIX'i$.
� VAF.�d+ OA7E
C.U.P.9y+ APPROVED
APPROVED � � /
/ ' lU
I hafeby acknowleApe [hoi 1 have raatl this eppllcallon end ttate '^
n
that Sho above informetion Is corract antl a9�ee to comply with �
all Inws reB��atlnB buildinB conrtrvctfon, antl 1 ahotl noi amploy
nny person in vlolatlon of iha workman's eompenaation lowf of a
tha Staie of Celifornle.
I ho/aby certlty ffiet I nm prope�ly Iieensed as a conttector under SQ. FT, a
tho 5tete of Callfornio Bualnesa antl Professione Cotle, Dlvi�lon 3, THE AMOUNT SHpWN UNDER VALUATION I FOR m
Chnpter 9, antl Met such Iiconws ora in tull torca ond eftact, or 1 TME PURPOSE OF ESTABLISHING A PERMIT FE NLV: �
om ezempt from the Orovlsions of t�e Staie of Callfornia euclnass Q
VALUATION PERMIT FEE E
ontl Proiasslons Cotle, Divl�lon 3, Chap2er 9. ♦ m
� PLAN CHECK E o
$Ipnp[wa of •
Parm�ttoe � �� ` Z'^"'��' _ $ �O TAX E � �
pvf% • V
Authorized ABent TOTAL P.4�D E �
� ;' = = i �.�� ��_
COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O• BOX 917 COBTA ME6A. C/LLIRORNIA
For dpplicanf fo Fill In Complefely
TYPE OR PRINT
BUILDING 323g Washington Ave ,
ADDRH89
COSTA MESA. CALIFORNIA
OWNER Tz'ojan Land Co.
MAIL �533 Baker Sti•
A��RFRG
TEL.
Garden Grove
roa Dike & Colegrove� Inc.
1533 Baker St.
Costa Mesa, Calif.
107293 No: KI 9-1151
60 x 100 � w�w��u ;-D6Bnone
BETBACK LIN$ PROM
CENTeR oP 8'�eeT Q� REAR YARD 311
SIDE YARD I LEFT >� I RIGHT 7�
DESCRIPTION OF WORK
.._... I x II -.-----._:. I II .--.-.--. I
1SW S(� f't NO. OF '7 1
1� 4i(]AMG CT(IQIF�
EXTERIOR WALI� ROOF
COVERING SLllCCO COVERIt
U6E OF BUILDING AND WORK TO BE
Single family residence with i
attached garage. Pla.n 21CR
1 HEPEBY AGKNOWLEDGE THAT 1 HAVE REAO TX19 APPLJGTION
ANO BTqTE THAT THE ABOVE I6 CORRE1CT AND AppEB T M-
PLV WITM GLL QTY ORDINANC¢6 AND %y�E lAWB RCa ING
BUILDINO CON6TRO($1�1. I -/� / `
ve � i !��% n _
SIGNA7URE OF i}`� / �'"
��E RECEIVED
` � SEP 16 tngp
�INANCE DEPT.
CITY OF COSTA MESA
APPLICATION FOR PERMI7
BUILDING
For Offiee Use Only
RECEIPT NO. A «�FfMO. �
BY
COSTA MESA.
FIRE
ZONE
APPROVED
188U¢O
ZONING
ZONE NO. OF U68 OF NEW •
_ R-1 I vuNa 2 I eun.oiHo W� 8tt
LfiOAL _ . � ._ _ �n��
uHe er.�
APPROVED
THE AMOUNT BHOWN I1NDEfl VALUATION 16 FOR THH
PURP09E OP 88TABL18HING A PBRMIT FEE ONLV.
.UATION �
IPERMIT FFF A � •
` g l�)�O�♦ PLAN GHEGI( $ 1�
AUTHORIZEP AGENT pike 8t Ci0 grove, Inc• CI.• 0
TOTAL FEE $ 74 �