HomeMy WebLinkAbout2346 ELDEN AVE - Building Permits CITY OF COSTA MESA
F, BUILDING DIVISION
f �I�gE 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us
v ° FOR INSPECTIONS CALL:(714)754-5626
4%;;WE, PERMIT NUMBER: BC11-00524
•
PERMIT TYPE: B_COMBO STATUS: ISSUED
Sub Type: RES ALT DATE ISSUED: 12/0112011
ISSUED BY: MDM
JOB ADDRESS: 2346 ELDEN AV CM Suite/Unit:
APN:' 43926121 Zoning: , ,
Virtity: Primary Occ:
Const Type: V-B SQ. FT: 0 Valuation: $60,000.00
SCOPE OF WORK: ADD 38SF FRONT ENTRY. REMOVE EXIST. DOOR IN LIVING ROOM
AND INSTALL 3 WINDOWS. REMOVE FRONT WINDOW AT DINNING RM AND INSTALL A SLIDING GLASS DOOR. REPLACE
WINDOWS IN THE BEDROOM RM MASTER BEDROOM BATHROOM AND LIVING ROOM. ENLARGE THE WALK IN CLOSETS IN
THE MASTER BEDROOM AND BEDROOM. 1 FAU <100K BTU 1 KITCHEN HOOD 2 VENT FANS
30 LIGHTS 44 OUTLETS 28 SWITCHES 3 RES. <1 HP UPGRADE SUB PANEL AND METER UP TO 120 AMP. 1 BATHTUB 1
DISHWASHER 1 SHOWER 1 KITCHEN SINK 1 WASH, BASIN 1 TOILET, 1 WATER HEATER, 1 WATER REPIPE.
OWNER: LINDA MITCHELL Address: 337 BROADWAY#C Unit:
Phone: City/State/Zip: COSTA MESA,CA :C1I-00524
APPLICANT: TOM WALKER Address: Unit: :
Phone: 949-922.4324 City/State/zZip:
CONTRACTOR: WALKER CONSTRUCTION SERVICES License No. 467137
- Phone: (949)922.4324 Address: 128 E WILSONUnit:
Cell: City/State: COSTA MESA,CA ZipCode 92627
ARCHITECT: License No. PHONE: •
ENGINEER: RAMON WONG II License No.52345 PHONE:714-335-2800
COMBINATION PERMIT FEE SUMMARY
Building Plan Check: $463.94
Building Fees: $713.75 If`R. REPLACE
Electrical Fees: $209.66 , I:;IN CLOSETS IN
Mechanical Fees: $63.65
Plumbing Fees: $101.90 F% i E'i'JB 1
SMIP Residential: $6.00
SMIP Commercial: $0.00
Bldg Std Admin Fund $3.00 ,n:
TOTAL FEES: $1,561.90 'l -00E24
'•Refer to fee receipts for all fees paid for project
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. : '5-26;;=
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.
CODES. INSPECPON TYPE DATE 'APPALS CODEC INSPECTION TYPE 'DATE •,..t,-1.'A.IMUn
'1616 Fixed System Final Fire Prevention 206 Final Mechanical )t 3—I1:f.`I
1266 Pool Spa Final 208 Final Plumbing x 3-19--la- Mir
�T
200 Final Re-Roof 210 Final Electrical 3I-ab-1/2rnp
261 Final Block/Retaining Wall 212 Final Fire Prevention _
202 Final Factory Fire Place 220 Final Planning Approval •
•f..
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy ..fes 3^�0'-t.a. LT'-"-",
1
i noiitl:rr:.
WORKERS'COMPENSATION DECLARATION: Owner ID verified by dabrive ❑Yes 0 No
I hereby affirm under penalty of perjury one of the following declarations: • Driver's License No. Expires:
❑ I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document.i.e.-property lax 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.
O I have and will maintain workers'compensation insurance,as required by,
section 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 ❑ 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
by this permit,and that no building structure,scaffolding.falsework,or demolition
Carrier: or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2.Grp
(This section need not be completed(I the penms valued al one hundred&Oars WOO Or less) 2,AO 2Sec.341,Etre B,Califomia Administrative Code).
Policy Number:
0 As owner-builder, I will not employ anyone to do work which would
RI 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 Applicant's Signature Date •
te Labor Code.I shall rthwlth comply with these provisions.
t ` jR. /r /f ( Division of Industrial Safety Permit Number:
Applicants Signature Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL 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? ❑Yes 0 No
($100,000), 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. '2 a registration form for acutely hazardous materials? ❑Yes 0 No
Lic.# 6 ('7 7 Class# '/ (Section 25533 of the California Health and Safety Code, with some
exceptions, requires registration with the Costa Mesa Fire Department by
`/J/ I 7-jt /( each business which at any one time has on hand a quantity of acutely
Contractor's Signature Date 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
CONSTRUCTION LENDING AGENCY: temperature and pressure).
❑ 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 fa 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 ❑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 Date
4. If an RMPP is presently required, has Section 25534 of the California
OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? ❑Yes ❑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 ❑No
issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California Government 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 Cole) 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 ❑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($500).): 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? ❑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: I
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 I 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
. .rize. b .ermit u final inspection. -
i
Signature of Legal Owner(s) Oaie Dale
Signature Date
3057-46(3107) Andlor Authorized Applicant Date
bPROJECT ADDRESS: 2346 ELDEN AV UNIT: CITY OF COSTA MESA - BUILDING PERMIT IJi.nM Nu; a UD71 .39
:OWNER'S NAME: BOSS HAROLD OLIVER TR
ADDRESS: P 0 §OX 7902 PERMIT NO: B 059134 PLAN CHECK NO: N tau v1 ; N aurr; N
NEWPORT BEACH,CA 92660
CONSTRUCTION TYPE: V-N PERMIT TYPE: STR PURPOSE: ALT
640-2384
ARCH/ENGINEER: REG.NO.: JOB DESCRIPTION : T/OFF REROOF W/FIBERGLASS SHINGLES SQ FT; 1 , 420
ADDRESS: UNIT:
CLAIM VALUE: 1 , 420 . 00 CALC-VALUE: 1 , 420 . 00 GROUP OCC: R-3 /
PERMITTEE: MESA PACIFIC ROOFING ( 714 ) 645-7552
ADDRESS: 1127 BAKER ST ******3TriSE*�r*+Mr****D********OR ****+IER*D***�E********�E**�E -**�t*x-***TE***�r�E •*i<�E***********
COSTA MESA CA 92626
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section Z ONING REQUIREMENTS
70001 of Division 3 of the Business and Professions Code.and my license is in tuff force and effect. SETBACKS
CITY LIC.: 03 72 STATE LIC.:4 3 0 745 ,...... cuss: C 3/
'Date: Signature: L—rry-e- --� MAIN BUILDING ACCESSORY BUILDING
FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN •
WORXE COMP USATIONDECLARATION: Ihereby.flirmthat lhave.certificate ii onsent to sell-insure or a certificate of Workers' LEFT; FT IN RGHT: FT IN LEFT; FT IN RGHT: FT IN
Compensation sera a e e0 copy thereof(Section 3800.Lab.
insurance. �J, 7/01 /93
POLICY NO.: EXP.DATE:
coMPAxr: STATE FUND PARKING REQ: PROV: PARCEL: 43926121 ZNE: REF NO;
1-] Cenified copy i hereby furnished. th Gender]copy is Bled '- old Building r PLANNING N(5T ES>
1 //, ************* ****************************************************** (**********
ale: _ Applicant: _..__. C:7-1, DEVLOPMENTSERVICESREQUIRS
EXEMPTIO ROM 'RXERS'COMPENSATION DECLARATION: This section •:'not be cmnplet• ' the penal is for one hundred($100)or less).
I certify that in the performance of the work for which this permit is issued,I shah not employ any person in any manner so as to become
subject to the ers'Compensation Laws of California. ZONING APPROVED' BY DATE: i
•Date: Signature: BUILDING APPROV1ED BY : IP-- DATE:
'4
NOTICE:II.alter making this declaration,you should become subject to the Workers'Compensation provisions of the Labor /M ' ,i
Code.Uyou must
DING G I heth such provisions
this pa construction
agency o. APPLICATION ISSUED BY: j/l . DATE• —�� -c L.--
which
LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for it iiiEEE 7e
which this permit is issued(Section 3097.Civ.C). *****N'********;•*******le**** * *** X. * ****** '***************** x'*'*
LENDER: **************/****************IF**iE******* ************Ik*********** 4**********
ADDRESS: LEGALIZATION: N F E E SUMMARY STRUCTURAL SEGMENT:Y
OWNER BUILDER DECLARATION: I hereby affirm that l am exempt from the Contractors'State License Law for the following reason BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES/ GRADING
(Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct,alter,improve,demolish,or PERMIT 35 , 00 5 0,,
repair any structure.prior to its issuance,also requires the applicant for such permit to tile a signed statement that he/she is licensed SM I P/NONT-RES
pursuant to the provisions al the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business p LAN
and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.My violation of Section 7031.5 by ISSUE FEE 15
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).
BUILDING-DIV-> PERMIT ISSUE PLAN-CHECK TOTAL PAID DUE
I. as owner of the property or my employees with wages as their sole compensation. will do the work, and the TOTALS----> 35 . 50 50 0 . 00 0 . 00 00 35 , 50 35 . 50'50 . 00
❑ structure is not intended or offered for sale(Section 7044.Business and Professional Code: The Contractors'State License Law r'
does not apply to an owner of a property who builds or improves thereon,and who does such work himseimerselt or through
his or her own employees.provided that such improvements are not intended or offered for sale.IL however the building or REVENUE DIVISION TOTALS--> COLLECTED • 35 . 50 OVER/SHORT: 00
improvement of sale).
sold within one year of completion,the owner wall have the burden of proving he/she did not build or improve
for thehe purposeBLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SM I P/TOT GRADING , LAN-CHECK
35 . 00 . 50 I{
I.as owner of the properly,am exclusively contracting with licensed contractors to fruct the project(Section 7044,Business
❑ and Professions Code: The projecciors'State License Law does not apply to an owner of property who builds Law).
thereon *********.************************************************************1tie********
and who contracts for Such projects with a contractor(s)licence pursuant to the Contractors State License Law).I am aware
that pmol of their Wooer's Compensation insurance should be provided to me. INDIVIDUAL F E E BREAKDOWN /
❑ I am exempt under Section: B.8 P.C.
for this reason: TYPE QTY DESCRIPTIO N UNIT COST (TOTAL COST
Date: Owner: SFR 1420 REROOF BY VALUE RESIDENTIAL NOZONE 1 .00 A 1 , 420. 00
I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505.25533.and END OF FEES
25534 and that I or any future building occupant willhvil not(circle one)need to comply with said state modes and the requirements for a
permit for construction or modification from theAtm Management District.Residential construction applications are exempt from
these provisions. 771.
Date: Applicant:
I hereby certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ;
ordinances and state laws relating to building construction and hereby a t ' representatives of this city to enter upon the above-mentioned • 1/,'
property lot ins,• lion p ,' e5.
4/0 .000
��' I] 70 4__:-t 2.: ,3 TC' J I` ,S('.
/
��.Date: Signature:
DATES c.t;y.:y92 '_'i'L: '54
1641-46 While—Buildino:Green—Code Enforcement:Canary—Aoolicant:Pink—Revenue:Goldenrod—Assessor
rant
CONSTRUCTION AND PLANNING POOL PA
APPROVALS Permit # Date Inspector APPROVALS Permit # Date Inspector
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. - 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test
6. Electrical OF ER Grnd. 57. APPROVAL TO 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, 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 64. Plumbing System - Final
14. Rough Plumbing 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final
16. Rough Electric Wiring 67. Fencing & Access Approval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOLJSPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit#
21. Ducts,in Structure 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping 0Gas 0Oil
23. Gas Pipe-Rough&Ten 72. Underground Flush
24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 0 Oil
25. Roof Sheathing 4.-1f-qy 6.441- 74. Overhead Hydro26. T-Bar Ceiling (Structural) & Monocoat ` 75. Dry Chemical
27. Frame and Flashing 76. Dry Standpipe
28. Lathing & Siding � .• 77. FIXED SYSTEM FINAL
29. Insulation I . 78. FIRE PREY. FINAL
30. Drywall Nailing I I HEALTH DEPT. REOUIREMENT
31. Plaster Brown Coat I 79. FINAL INSPECTION
32. Electrical Power Meter-Final •
t 80. FOOD CERTIFICATE ISSUED
33. Final Electric I t Notes:
34. Final Heating & Air Conditioning I
35. Final Gas Pipe-Test I
i
36. Hood or Canopy
37. Final Factory Fireplace •
38. Final Plumbing
39. Water Service-Final
40. Gas Service-Final I
41. Solar Domestic-Final
42. Backflow Preventer I I I
43. Backflow Irrigation
44. Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations A / A
47. FINAL STRUCTURE & BUILDING Tru..G�Z _.- 5 ' ,0 _. cal,6
48. FINAL PLANNING ! �'^��"[ �I"
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co I I
51. CERTIFICATE OF OCCUPANCY
No. Date
4840 FEE RECEIVED,RECEIVED
COSTA MESA BUILDING DEPARTMENT `�Y1"""� � � ''� '
P.O.BOX 317 INANCE DEPT'
COSTA MESA, CALIFORNIA • CITY OF COSTA MESA
FOR APPLICANT TO FILL IN APPLICATION FOR PERMIT
ADDRIS �¢l trinrr,cI (��,•-e- . BUILDING
COSTA MESA. CALIFORNIA FOR OFFICE USE ONLY
RECEIPT NO. 1 yon ,
OWNER itzadln Al?SDN-.t O�///7!
MAIL /� , • RE IV Y DATE RCEIVED DATE !SLUED_�
ADDRESS ice Mb/,SJ IC'S---,5-7 S
/?^�.1 /MLA
l TE Lj,a�63 BUILDIN CW /" /!_'A NL ADDRESS
ARCHITECT LIC.
OR EM NEER NO. COSTA MESA. CALIFORNIA
FIRE
ADDRESS ZONE
/ ',',I' J� ZONE NO.OF TYPE GROUP
CONTRACTOR QAC /1TADA, CITY NOC_ I .
�1(: / (�. PLANS i / 4�
ADDRESS /9cY'�F/-/" ,v I'/ TNEO..0/L,JA i? 1--801/ BV PR•!`. _ .� - - DATE) •
i ,o
LEGAL LOT •/ry�` l i•'AM1 �Rj� I
DESCRIPTION NO. / J J BLOCK TRAC •+ Y,J
/� ,,.SOV ce
A.P. NO. /�f - {/ S �„ - 2 CITY OF COSTA MESA
slzE 'I
PIANNINIi Uti I.
OF LOT f•{ V JS No.or Blocs.NOW ON LOT / SUBJECT T BLDG, DEPT. REG.
USE OF
EXISTING BLDG. yL,J/ ///
SETBACK LINE FROM / n ______A. DATL! /-.....
CENTER OF STREET a 0 REAR YARD •2 f BY PLAN TECH.
SIDE YARD RIGHT /0 it" LEFT O &- -- .-'--,__.__-. . .3
�,^,__. .r.�_•a-•. --
DESCRIPTION OF WORK
NE ALTERATION ADDITION
REPAIR MOVING DEMOLISH
BUILDING o / NO.OF )
SIZE �!v ROOMS STORIES /
EXTERIOR WALL ROOF
COVERING _ � A,
iL_ f� COVERING
--
USE OF NEW 4�� U �� 'S p r�
BUILDINGN /� ffri 6ZjC_A-6k 0 �f
4S PE. /4.rs £. 3.G aso
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND
STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL
CITY ORDINANCES AND S AWS REGULATING BUILDING CONSTRUC-
TION. ` VALUATION
C
/ PERMIT FEE $ 0
SIGNATURE •Feg4n
PER MITTEF (/< ��^�
, fJrJ 1 &&r...-&r...-PLAN CHECK $ /V V
7
AUTHORIZED AGENT TOTAL FEE S do /
A