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Home My WebLink About2330 VANGUARD WAY - Building Permits (70) • • City of Costa Mesa Development Services Department CERTIFICATE OF OCCUPANCY No. 001E10 Building Safety Division P.O.Box 1200 Costa Mesa,California The Building located at 713n tsnnrn,nA uta., M-7111 has been inspected and found to comply with-the provisions of all City of Costa Mesa Ordinances applicable thereto fora Group R-1 Occupancy. Use of Building COnldcttUS13.lIIn Legal Description 419-151-06 (See reverse side for Metes and Bounds) Building Permit No G16754 Electrical Permit No. G16754 Plumbing Permit No. G16754 Mechanical Permit No. ai F7Sd Number of apartments and/or guest rooms ISSUED TO: Building Official el' L • Newoort Tandina Limited P O Boc 10843 by Beverly Hills. CA 90213 Date , —� FY"( ` ellh This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the 1 Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White-Owner;Canary-Numerical File;Pink -Bldg.Permit File Applicant to fill in all spaces except those within heavy border lines nd sign all appropriate declarations. • OITY OF COSTA MESA '\ - PERMIT NO. TRACT O. LOT NO." BLDG.NO. 4877 1/03/85 :,75.27 , T L • COI�.�TRUCTION PERMIT U [ b1 s 4 tiVet / _ f(/—�O J - • ,Project Address ••• •• & L i C'b k b TYPE OF CONSTRUCTION NEW ADD H ALTERATION H REPAIR • • I'Applicant's Mailing Address • P.O• x IOP4?$• ba;. HILLS ❑ CONVERSION ❑ DEMOLISH-y �❑ OTHER - A,P,# IZone afa rt`� DESCRIPTION OF WORK --c/ /Q - ✓ �/� -1 �� —�� I Owner's Name MEW Ff�RT' LP MDIK �.� Phon€/ 74'"�7W S Main Building: Accessory Building: 7) 0 Z Address 1-Q• �X 1��9',,, C',EU. HIUS.,-C'R. ADA L3 TYPE OF PERMIT ❑ GRADING I1��IFOUNDATONSTRUCTURAL/O T Front T7-q Gi�.d N Arch/Eng. CLARK-HFDRiciC License No- C 5841 ❑ TENANT ZI ELECTRICAL (est PLUMBING X MECHANICAL B /� / I Address 119C�� SRN UiC nrrc �jrv� Rear ///Tn nrrrr`fs7' Sj/Y��.r- - N E-iv15� EL•, L•A -I LIJG� ❑OTHER A r Contractor's Name �� C Right L / T G R II __ PAUL: TETRIeFt • -Phone �Q'1�.7t�1 - PROJECT DESCRIPTION SQ. FT. ,r33g, "- OCCUPANCY R-i/M-I //� nz-nr^c< '`� ?rTIi, U) Address(mailing) 11a5�'a 1-A GRANGE Ai)E•/ L•A.9M.Q5 CON STRUCTION TYPE IV VALUATION 70793 g Left �b / �� nPfq/`c'S/ STV el E q p ZONE GRADING CU.YDS. ACRES Q CLI City'License No. 3�nl7 rl ))) Ping. Ref.# Z�— �y- 68 ((( Park.Fees $ �� 3�. U I LICENSED CONTRACTOR DECLARATION Remarks: CD�_ j� i - Parking Req./Provided .Z a c, i hereby affirm that I am licensed untl¢r provisions of Charter 9(commencing ,/ r R with section 7000) of Division 3 of the Business and Professions Code, and Use of Building: tea /-' • rM my license is in full .rc- and effect- _i - E 1' License Clas G.— e 0. •i • '13 PLUMBING . I FEES Planning Notes: E Date 11- 4 - Signature -0(0' i_.i el...i. t FOR N ' rO RKERS'COMP NSATION DECLARATION Bar Sink Showers . HOLD SPECIAL,I(LOUtP.0 1L± TS • T ' ereby affirm that I have a certificate of consent to self-insure or a certificate Backflow Preventer Service Sink, _ S Workers' Compensation Insurance, or a certified;-copy thereof-(Section_. . - -' - - _ _ - . ' - 3800, Lab. C.) �l � pp y' . Backflow Irrigation - Sewer dap a-^'' ' - .' - ELECTRICAL •- •; -f FEES. Policy No. ' �61 I 342,-8 Company SIAM fr COMP TktS.-B*) - - - ' _ - ® t�Certified copy is th-thehed. y . Bathtubs Sewer ConnectionI '-, ^' •�4 �- '1 Automatic Washer Transformer 0 15-50.KW- ., certified dopy I herebyfiled withthecity n v 1^ Date /1-19-75 Applicant Y Clarifiers Solar Collectors . - Construction Pole Sub. ❑ 50s KW EXEMPTION FROM WORKERS'COMPENSATION DECLARAT Dish Welsher Solar PI in q (This section need not be completed if the permit Is for one huntlr ($100) or' P g,POD6N O,04y .� Cooking Unit ' ' _ \ Meter ip to 100 amps - rJ less). I o thatm In performance in of the work for aswhich othis permit ect to t �I- Drinking Fountains .. $OlarrTank ' . f ) / Dishwasher ,Meter Dover 100 amps, shall not employ any person in any manner so'as to become subject to the, Workers' Compensation Laws of California. I I Floor Drains' • Swimming Pool w/Spa 1 r 1 Dryers gGas, ❑Electric ? Sub Panel l Date Signature ' s — - 0� NOTICE: If,after making this declaration, you should become subject to the ' Floor Sinks • Urinal • _ Motors_❑C-1 HP ❑1'/a-8 v Workers' Compensation provisions of the Labor Code, you must forthwith - - - - - - Fan •_ -_ _ (,f comply with such provisions. or this permit shall be deemed revoked. Gas Service Outlets CONSTRUCTION- LENDING AGENCY - / Water Closet 0L f F.A.U. • Inc.Solar 09-15 HP 016-15-1- 1 (C` I hereby affirm that there is a construction lending agency for the performance Interceptors ' / Water Heater Z 00 Fixtures 'Microwave of the work fo is ttppl5,eermit is issue 399 �y C.) - - �3 , Z (p(1 Lender's Name W el<M HE t)SEfl MOf•ZLRAGR :n. Kitchen Sink Water ServicePole Light E UI1�Ptf�E D(J 4 00 Device Boxes Lender's Address' q LIN M. Iii, Sip, col - �+ g _ (J �f•C ; OWNER BUILDER DECLARATION SAC. ��-9 JOa - l - / , In L' Outlets Range SCO I hereby affirm that I am exempt from the Contractor's License law for the Lavatories J • - following reason (Section 7031.5.Buslness and Professional Code: Any city or P �� Switches Sign county which requires a permit to construct,alter,improve,demolish or repair any structure, prior to Its issuance, also requires the applicant for such permit RoofDrains - • - - - i A ` Garbage Disposal ' Standing Sections to file a signed statement that he/she is licensed pursuant to the provisions of - "'e Contractor's License Law(Chapter 9(commencing with Section 7000)of - - • . - 'ision 3'of the Business and Professions Code) or that he/she is exempt Generator 00.5 KW 05-15 KW ' Trash Compactor .refrom and the basis for the alleged exemption. Any violation of Section - ..131.5 by any applicant for a permit subjects the applicant to a civil - ' - t penalty of not more than five hundred dollars ($500). Reinspection Fee I $25 Issue Fee $ 3 .Z t'r�7T� KT'�-� • 2, �� LJ I, as owner of the property or my employees with wages as their sole , Reinspection Fee $25 Issue Fee ' $ 3 compensation, will do the work,and the structure'is not intended or offered MECHANICAL • FEES for sale (Section 7044, Business and Professional Code, The Contractor's --- - - - -' --' L PUBLIC SERVICES REQUIREMENTS: License Law does not apply to an owner of a property who builds or improves Boiler Hood or Type I 0 - 7� II 11 11 thereon, and who does such work himself/herself or through his or her own - ZoningApproved By Ord W /3�� employees, provided that such improvements are not intended or offered for ' Canopy Type 11 0 PP Date sale- If, however, the building or improvement Is sold within one year of com- Duct- Under Ground Application Approved By - Date iZ Z 8 pletion, the owner will have the burden of proving he/she did not build or im- p ove for the purpose of sale). Duct-Structural Refrigeration System Application Issued By v q1S�:) Dat I Z 7 ' LI I,as owner of the property, am exclusively contracting with licensed con- - tractors to construct the project (Section 7044,Business and Professions Code: 'LDuct-Ventilating ❑0.100,000 BTU 0100,000 BTU 4 - SUMMARY OF FEES .5". 17 ' The Contractor's License Law does not apply to an owner of property who- �c?, builds or improves thereon, and who contracts for such projects with a con- Exhaust System 0 Multiple 0 System Repair/Alteration • BUILDING PERMIT $ • �•CO SMIP $ tractor(s) license pursuant to the Contractor's License Law), PLAN CHECK $ 2.3°•, PERMIT 0 I am exempt under Section • B.& P.C.for this reason I Fire I/Fact.Bit. ICBG# .30.00 P 23D( '¢ •� PLUMBING $ Sr,•C('') • ISSUANCE $ Date owner Heating System&Ducting I - C{cC/, PLAN CHECK 6.75" $ .4y 4E3 ENERGY P.C. ' $ I hereby certify that I have read this application and state that the above / J o-i00000 BTU ❑100,000 BTtJ A C GRADING information is correct. I agree to comply with all city and county ordinances '-- -' - ELECTRICAL $ Y $ and state laws rel g to building construction,'and hereby authorize repre- - MICROFILM G 97. 7 ✓ sentatives of • ity to e er upo• the above-mentioned property for PLAN CHECK $ �� inspection pu s. R,./ ' Signature . ��. Date //�/7ri7 MECHANICAL/Sp0$ TOTAL FEE/ $-Y17`$'r11L / Drivers' License or SS it > . - =..reReinspection Fee .$25 Issue Fee $ 3 PLAN CHECK 3,r,9$ - D7 :3 CMF 0865-46 rev. 7/83 'White-Building;Canary-Applicant; Pink-Accounting;Goldenrod-Assessor - - - - - - _ POC SPA • CONSTRUCTION AND PLANNING ~• • DateInspector Date Inspector ' 4APPROVALS Permit# _ APPROVALS Permit# 1 • 1. Temporary Electrical Service or Pole- 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. • 53. Steel Reinforcement i 3. Electrical Conduit Utility-Undrgrnd. _ • 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement, *Sr . Vc� 56. Rough Plumbing & Pressure Test 6. -Electric& UFER Gmd'. 57. APP-ROVAL TO COVER-GUNITE ' 7. Footings Dr Uv 58. Electrical Conduit-Undrgrnd. , 8. Foundation ; ' - 59.-Gas Pipe, 0 Undrgrnd.,Test !' ' 9. Water Pipe-Undrgrnd. - 60. Backwash Lines, P-Trap, 0 Undrgrnd. • 10. Structural Floor System . 61. APPROVAL TO DECK 11. Property'Sewer Line & House Connection ,' 62. Backwash & Receptor-Final . 12. Sewer Cap 63. Heater & Vent-Final 13. Roof Drains ' ' _ • I. ' ' 64. Plumbing System - Final • 14..Rough Plumbing - ‘7zq/fr-'i er 65. Electrical-Final • 15.-Rough Electrical-Conduit moi/ 66. Solar System-Final 16. Rough Electric Wiring 460m if �G^ 67.. Fencing & Access Approval 17. Rough Wiring Sign ' 68. APPROVED FOR PLASTERING 18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT 20. Rough Factory Fireplace Wein- C€49 APPROVALS Permit# 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating , , 71. Product Piping 0 Gas 0 Oil 23. Gas Pipe-Rough & Test 72. Underground Flush 24. Roof Framing / I 73. Undergrnd.Storage Tank 0 Gas 0 Oil 25. Roof Sheathing ' fj/3/cccc L/C, 74. Overhead Hydro 26. T-Bar,Ceiling (Structural) & Monocoat 1 (( 75. Dry Chemical 27. Frame a id Flashing fe (w 76. Dry Standpipe 28. Lathing',&Siding • 77. FIXED SYSTEM FINAL 29. Insulation ,/q"(��'j�/b/Y!,'1k 78. FIRE PREV. FINAL 30. Drywall Nailing `/( ✓c--/ HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter-Final iyio 80. FOOD CERTIFICATE ISSUED ,-1 33: Final'Electric Notes: f'/r�y�� i d- O- ,-7.,„,r, _ et 34. Final Heating & Air Conditioning 44Oc /. , ,t , - J,/, o-�' tips � 35. Final Gas Pipe-Test /'7/2 /�y✓(//9,/?C vviw!• 36. Hood or Canopy '/ C 37. Final Factory Fireplace /ZJ1g/.�t A/C 38. Final Plumbing /11//7[3}' , 7'f' - , 39. Water Service-Final - - t 40. Gas Service-Final ' 41. Solar Domestic-Final •- . , 42. Backflow Preventer 1 43. Backf low Irrigation ""i ) . • 44. Landscape Irrigation System - • 45. Sound Attenuation - 46. Handicap Regulations - 47. FINAL STRUCTURE & BUILDING �3�G1 (/� 48. Special Requirements Completed 1 /lnrl2 r 49. Electric Release to Edison �11L. - , J , 50. Gas Release to Southern California Gas Co • ; ' 51. CERTIFICATE OF OCCUP N •YL Z� ,/t'` _ t ' . i U No. 6 D Date /f" /1 • c - CITY OF COSTA MESA a051"lit BUILDING DIVISION gtst F;77 FAIR DRIVE.COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca:us _ _ - '3 1I FOR INSPECTIONS CALL: (714)754-5626 1 PERMIT NUMBER: BX11-00349=-- - ---' PERMIT TYPE B_MISC STATUS: ISSUED APN: 93865209 DATE ISSUED: 11/03/2011 Zoning: , ISSUED BY: JOB ADDRESS: 2330 N201 VANGUARD WY CM Suite/Unit: N201 Vicinity: Primary Occ: Const Type :?? SQ. FT: 0 Valuation: $4,216.00 SCOPE OF WORK: REMOVE AND REPLACE WATER PROOFING AT REAR BALCONY DECK. REMOVE AND REPLACE PLYWOOD SUB FLOOR. REMOVE AND REPLACE DECK TO WALL SHEET METAL AND PERIMETER DRIP EDGE AS NEEDED. REPLACE SIDING AS NEEDED FOR SHEET METAL REPLACEMENTS.WORK IS LIKE FOR LIKE. NO STRUCTURAL CHANGES AUTHORIZED BY THIS PERMIT. , OWNER: NEWPORT LANDING/TOTAL PROPERTY MANAGEMENT Address:: 2 CORPORATE PARK,#2 Unit City/State: IRVINE, CA Zip Code: 92606 Phone: 949-261-8282 I nr APPLICANT: EHLERS,JACK Address: '. Unit: City/State: Zip Code: Phone: 949-635-6767 CONTRACTOR: PROFESSIONAL SERVICES CONSTRUCTION INC License No. 590919 Address: 23146 ARROYO VISTA Unit: City/State: RANCHO SANTA MARGARITA, CA Zip Code: 92688 Phone 949-635-6767 Cell: ARCHITECT: License No. I ,.I_P. Phone - i ENGINEER: License No. „ 1-OR Phone - FEE SUMMARY 1'"r Building Plan Check: $0.00 ., Building Permit: $111.25 Electrical Permit: $0.00 _ SMIP Residential $0.50 - SMIP Commercial $0.00 Bldg Std Admin Fund $1.00 , TOTAL FEES $112.75 HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010-PER CMMC Sec. 13-279 Monday thru Friday-7:00 am thru 7:00 pm. Saturdays-9:00 am thru 6:00 pm. Prohibited all hours-Sundays and the following Federal Holidays: New Years Day,Memorial Day, Independence Day, Labor Day,Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No.92-28, § 1. 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes,and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE C. INSPECTION TYPE DATE INIITIALS CODE t INSPECTION TYPE GATE f r INIfALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Root 210 Final Electrical -- - 201 Final Block/Retaining Wall 212 Final Fire Prevention " 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site �/ - . / 7_/-nom 204 Final Demolition 250 Final Building/Occupancy X / a T. 1 - •r pie WORKERS'COMPENSATION DECLARATION: Owner ID verified by drive. .,license. ❑Yes ❑No I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires: O I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-property tax bill or deed): compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. sI have and will maintain workers'compensation insurance,as required by ection 3700 of the Labor Code,for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: permit is issued. My workers' compensation Insurance carrier and policy 0 I hereby certify that no excavation five(5)or more feet in depth into which a number are: person is required to descend,will be made in connection with work authorized �7 / , by this permit,and that no building structure,scaffolding,falsework,or demolition Carrier: /" S ��- r/� or dismantling thereof,will be more than thirty-six(36)feet high. (Chap.3.2,Grp (This sectonn rpt be competed 4 the()em/uryvalued al one hundred dollars(S100)of Mss.) 2,M2 Sec.341,Title 8,California Administrative Code). Policy Number: 33aoo '"C oar -/// 0 As owner-builder, I will not employ anyone to do work which would ❑ I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division. to the workers' compensation laws of California. and agree that if I should become subject to the workers'compensation provisions of Section 3700 of Applicants Signature Date the abor Code,I shall rthwith co r ply with these provisions. J / N3/D> Division of Industrial Safety Permit Number: L! /a. Applicant's ignawre ate HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: INC: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE I. Will the applicant or present or future building occupant need to file and IS NLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 Yes 0 No (5100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST. AND exceptions, that a Business Plan be filed with the Costa Mesa Fire ATTORNEY'S FEES. Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of LICENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons,or 200 cubic feet of compressed gas I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure). with Section 7000)of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file my license is in full force and effect. a registration form for acutely hazardous materials? 0 Yes 0 No t / Class# (Section 25533 of the California Health and Safety Code, with some p / exceptions, requires registration with the Costa Mesa Fire Department by �ff. �IAreach business which at any one time has on hand a quantity of acutely Contractor's S.gnDale hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard UCTION LENDING AGENCY: temperature and pressure). O I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely Lender's Name: hazardous materials)? 0 Yes 0 No (Section 25534 of the California Health and Safety Code provides that the Lender's Address: Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. Signature Dale 4. If an RMPP is presently required, has Section 25534 of the California OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? 0 Yes 0 No I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? 0 Yes 0 No issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California Govemment Code requires that the requested that he or she is licensed pursuant to the provisions of the Contractors information be furnished on applications for non-residential building permits). License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and 6. Will any part of the facility to be constructed under this permit be within the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑Yes 0 No applicant for a permit subjects the applicant to a civil penalty of not more than (If"yes", the facility must meet the requirement of Sections 25534 and 42303 five hundred dollars(5500).): of the California Health and Safety Code). ❑ I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other compensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the offered for sale(Sec.7044,Business and Professions Code:The Contractors subject of this application,have all of the disclosures prescribed by California License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes 0 No thereon,and who does such work himself or herself or through his or her own 8. (If"yes",attach certificate of compliance from the appropriate air pollution employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of control officer). completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH 'city ordinances regarding Hazardous Materials and Emissions. LICENSED CONTRACTORS to construct the project(Sec.7044, Business and Professions Code:The contractors License Law does not apply to an owner of Signature Date property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that 0 am exempt under sec. the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of Business and Professions Code for this reason: the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 1/ S9 pure IAS //�3/ Signature Date U/lE al /(/ ,J 0 3057-46(3le7) And/or Authorized Applicant Dale