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HomeMy WebLinkAbout1961 MEYER PL - Building Permits Applica nt,to fill in all spaces except those within heavy border lines and sign all appropriate declarations. -- - - - - - - -- - -— -- - - - • CITY OF COSTA MESA, r CONSTRUCTION PERMIT ' - ' P IT NO. I TRACT•NO. LOT NU. 'UNIT NU.- 23,79 • Project Address / 6 i M Ja ye-A" .PLS �r- 7• - - `7�/-�- - - 't Applicant's Mailing Address TYPE OF CONSTRUCTION :❑ NEW-'U ADD' U ALTERATION yx REPAIR ' Grid i l'/ I I. me el Owner's Name F'C'ffA✓X C/9M f' r❑ CONVERSION ❑ DEMOLISH ' ❑ OTH • - - • - • t Phor�y -/jC9 - : A.P. - ( Zone S�/4H-G _ DESCRIPTION OF WORK/USE OF BLDG.' S t /,Q t' p _ Address - 1 ;r _ ��/ S Main Building: • • ' °- I `- _ ' 'Accessory Building,' , Arch/Eng: ' 7 ' - ' ' - •P License No. - TYPE OF PERMIT ❑ GRADING1 U FOUNDATION U STRUCTURAL. - E Front . >- - - • _ • - U. Address /)- ^ ' - 1 - ' ' '❑ TENANT ❑ 'ELECTRICAL „�]I.PLUMBING ❑ MECHANICAL •• B - - - %�/Jr 6� �IL71'7�/ - �30-�.a P.L2I --❑ BOTHER - - A Rear' N: ' Contractor's Name pn . ' Address mailing) .2/ C0 S• it/C ti?• i✓J9htty ,PROJECT DESCRIPTION SQ. FT. ' OCCUPANCY ' ,3 C Right • _ - • ,- N ^s G 2 Z Z '347 G6� CONSTRUCTION TYPE .Jf VALUATION$ s Left - , • I R: City Licenie No. T ` ZONE GRADING CU.YDS. ACRES • • ' I - i C •- LICENSED CONTRACTOR DECLARATION . - -- . • P.Ipg. Ref. # ! 1 I Parking Req./Provided' E Q I hereby affirm I am licensed under provisions of Charter 9 (commencing Remarks: - Planning Notes: - M with section 7000)00) of•Division 3 of the Business and Professions Code,and ' my license is in f' force and effect. . , - .. T License Class, L. 4- - License No Ag-3° ' - - ' S Date '/ ignature 44:---•-_ :$_•r r • , PLUMBING ' .FEES - , WORKERS'COMPENSATION DECLARATION' /. Bar Sink • ' Showers ' I hereby affirm that I have a certificate of consent to self-insure or a ce ifieate . ELECTRICAL •. - FEES • of-Workers' Compensation Insurance; or a•certified copy thereof (Section -- - '- •- ..- -' - -.. . - . - - - --. '-- Backflow Preventer Service Sink 0 15-50 KW 3800, Lab. C.) Automatic Washer Transformer Policy No. - Company Backflow Irrigation Sewer Ca - 0 50+ KW • ® Certified copy Is hereby furnished. P _ COoS[fuctiOn Pole Sub. • I'Certified copy is filed with the city Building Division. • Bathtubs Sewer Connection Cooking Unit Meter Dula to 100 amps ' • Date Applicant ' _EXEMPTION FROM WORKERS'COMPENSATION DECLARATION -- - - Clarif iers...L_ - - .Solar Collectors.' - - - - • - - - -Dishwasher- - - • - - Meter Dover 100 amps - '- (This section need not be completed if the permit is for one hundred (,$1 )00 or ' less). • Dishwasher . Solar Piping Dryers ❑Gas ❑Electric Sub Panel I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any r sp 5 come subject o,the , • Drinking Fountains• Solar Tank Fan . Motors❑0-1 HP ❑1%-8 Workers' Compynsa�tip n Laws of Cal' o Date / D� Signature Floor Drains SwimmingPool w/S a' I • 'NOTICE: If,after making this declaration,you should become 5 ct to the - - - - ' I _ p F.A.U. • Inc.solar'❑9-15 HP 016-15+ • Workers' Compensation provisions'of the Labor Code, you m t forthwith ' '"'- Floor Sinks• . J - - - . - Urinal r Fixtures' ' comply with such provisions or this-permit shall be. deemed revoked. - - - - Microwave CONSTRUCTION LENDING AGENCY I - - . I - - / Gas'Service .Outlets Water Closet 1` pQ — Device Boxes ' • I hereby affirm that there is a construction lending agency for the performance Pole light I I of the work for which this permit„is issued (Section '3097' Civ. C.) . - - Interceptors - ,Water Heater Outlets Lender's Name' - ��(( ))/�T�� �)� _ - 1 Range . 'Lender's Address Address - - [ - `-q - _ - - _Kitchen Sink '� Water Service Switched ` ' OWNER BUILDER DECLARATION - • r-• - ' - - ! Sign I hereby affirm that I am.exempt from the Contractor's License Law for the Lavatories Auto-Wash - _ Garbage Disposal •' following reason (Section 7031.5 Business and Professional Code: Any city or - 9 PI Standing Sections county which requires a permit to construct,alter;improve,demolish Or repair' P-Trap . ' Laundry Trays; ' • Generator ❑o-5 KW ❑5-15 KW any structure, prior to its issuance, also requires the applicant for such permit Trash Compactor to file a s gned'state hat-he/she is licensed pursuant to the provisions of . Roof Drains ' 'the Contractor's License Law (Chapter g with Section 7000) of - ' - , • - 1 Division 3 of the Business and Professions Code) or that he/she is exempt - - therefrom and the basis for the alleged ion. Any violation of Section - ' 7031.5 by any applicant for a permit subjects the applicant to a civil . -' � , chatty of not more than five hundred employe 0). I $ 3 LJ I, as owner of the property or my'employees.with wages as their sole ' Reinspection"Fee ' ! ' $15 Issue Fee' compensation, win do the work, and the structure is not intended or offered - Reinspection Fee .I $15 ' Issue Fee $ 3 for sale (Section 7044, to ss-and Professional Code: The Contractor's ' - . • , -. MECHANICAL FEES -• - - - - ,, , - License Law doeonot apply to an ownerof a property who builds or improves ' __ I - I , thereon; and who does such work.himself/herself or through his or her own - - DEVELOPMENT SERVICES REQUIREMENTS: employees, provided that such improvements are not intended or offered for ' Boiler • Hood or Type I I ❑ Zonin A roved B sale. If, however, the building or Improvement is sold within one year of com- - Canopy Type II ❑ g pp y • Date pletion, the owner will,have the burden of proving he/she did not build or im- Duct- Under Ground . - ' BuildingA roved prove for the purpose the oe). I { PI By - Date—E'•-F+.--Lar • 0 I,'as owner of the property,am exclusively contracting with licensed con- Duct-Structural Refrigeration System Application Issued By - • Dat I tractors to construct the project (Section 7044,Business and Professions Code: • - • The Contractor's 'License Law does not apply to an owner of property who _ Duct-Ventilating - 4- ❑0-100,000.BTU 0100,000 BTU - - SUMMARY OF FEES buildssor improves thereon, and'who contracts for such projects with a con- - tractor(s) license pursuant'to the Contractor's License Law). I am aware thatI I BUILDING PERMIT $ SMIP. $ _ proof of their Worker's Compensation insurance should be provided to me.' Exhaust System 0 Multiple❑ System Repair/Alteration , • PLAN CHECK $ ' PERMIT 0 I am'exempt under Section B.& P.C.for this reason , Firepl/Fact.Blt. ICBG# , Fire Dampers • PLUMBING $ S.�Q ISSUANCE $ • Date Owner • Heating System& Ducting . Registers ENERGY P.C. $ _ PLAN CHECK 25% $ •�• 63 I hereby certify that I hake'read this application and state_that the above t 00.100,000 BTU 0100,000 BTL I GRADING $ ' information is correct. I agree to comply with all city and county ordinances ' ELECTRICAL , $ • - and state laws nglto building construction, and hereby authorize repre- r - PLAN CHECK 50% $ MICROFILM $ ' sentatives of this,city enter u n the above-mentioned proper( f r i Signature i pr nrpo s p/ _454-, _ MECHANICAL $ TOTAL FEE $ G. /3 Signature p/ ! Reinspection Fee $15 Issue Fee $ 3 PLAN CHECK 25% $ I • It CMF 0865-46,rev.10/84 white - Building; Canary - Applicant; pink - Accounting; Goldenrod - Assessor CONSTRUCTION AND PLANNING POOL & SPA APPROVALS Permit# . Date Inspector APPROVALS Permit# Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. j 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 UFER 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 „.1 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. POOL/SPA 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 0 Gas 0 Oil 23. Gas Pipe-Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 0 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-8i Siding 77. FIXED SYSTEM FINAL • 29. Insulation 78. FIRE PREV. FINAL • 30. Drywall Nailing HEALTH DEPT. REQUIREMENT • 31. Plaster Brown Coat • 79. FINAL INSPECTION 32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED • 33. Final Electric Notes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe-Test .//c/peee'• 36. Hood or Canopy • ✓/�� 37. Final Factory Fireplace • 38. Final Plumbing • 39. Water Service-Final - 40. Gas Service-Final 41. Solar Domestic-Final - 42. Backflow Preventer • 43. Backflow Irrigation 44. Landscape Irrigation System - • • 45. Sound Attenuation 46. Handicap Regulations •47. FINAL STRUCTURE & BUILDING 48. Special Requirements Completed 49. Electric Release to Edison - , 50. Gas Release to Southern,California Gas Co 51. CERTIFICATE OF OCCUPANCY. ' _ - No. Date Qi--J '`2,;52c `i- 2� A Cis HILLIARD & BRICKEN 77/768 John Hilliard ❑ Consulting Acoustical Engineers ❑ Gordon Bricken November 4, 1977 Mr, Harold Sproul 716 Marigold -Corona del Mar, -California Subject: Plumbing Inspection at 1961 Anaheim Street in the City of Costa Mesa. Dear Mr. Sproul: We have inspected the plumbing installation at 1961 Anaheim Street; in the City of Costa Mesa and find that the plumbing is in a condition where it does not degrade the party wall rating as required by the City of Costa Mesa. Sincere . R004ESSIONqi 4" 1,. HILL/4p �tig /v / r y / / ^ , re No. 384 ohn illiard, 'f .c. Presider Jj. E<E'CTF\gy /111Mb ASFC,F CPU‘ 1.(ECEI VEID NOV )4 ISI 1971 East Fourth Street,Suite 18 0 Santa Ana,California 92705 0 (714) 835-3728 / 9648 rEE RECEDED . ip COSTA MESA BUILDING-SAFETY DEPARTMENT - / ii LA. R 0.BOX 317 COSTA MESA. CALIFORNIA FINANCE DEPT. CMESA FOR APPLICANT TO FILL IN COMPLETELY APP ICATIONTA FOR PERMIT TYPE OR PRINT BUILDING BUILDING /QZ / A..W e& F-- ADDRESS COSTA MEESA ALIFORNIA FOR OFFICE USE ONLY N RECEIPT NO. /-�p,EYAryT/Np. OWNER e, ebtixt /, I� �146i• I DATE ISSUED MAIL (J ✓L �I RECEIVED BY /DATE RECEIVED_ DATE ISSUED ADDRESS / / � ni.7PT pig,e., /(� c'—/)-s✓C//I � / TEL. BUILDING CITY C 177 NO. • ADDRESS ARCHITECT OR ENGINEER LaOar,V� � /kl///I/J G. COSTA MESA. CALIFORNIA (�' FIRE ADDRESS ZONE �) STATE APPROVED CONTRACTOR /'4r; LIC.NO. BY DATE ADDRESS 6 ZONING LEGAL LOT / /� /�)(/ ZONE INO.OF IUSEOFNEW • I DESCRIPTION I NO. r 0 I BLOCK I TRACT//rJ[T ` PLANS BUILDING l�i l� A.P.NO. //S A'JG . - id By DATE //!/T l/'-/ I SIZE JI 1/// l (NO.OF SLOGS. / . YARDS ���[[[///��� EVES Cs OF LOT a �1 G/ NOW ON LOT REQUIRED ALLOWED USE OF .(� (CENTER LINE ST.) EXISTING BLDG. / 1 Q S I C✓//C/I_- FRONT %;} FT. IN. SETBACK LINE FROM I�^/ CENTER OF STREET X/--S REAR YARD e- R.SIDE /0 FT. IN. SIDE YARD I LEFT `�TtI RIGHT 440 T L.SIDE le . FT. IN. DESCRIPTION OF WORK `� REAR ""69 , FT. IN. NEW IX I ALTERATION I II ADDITION I REPAIR I II MOVING I II DEMOLISH I �F. BUILDING. g�iY/.Z NO.OF SIZE -7 ROOMS STORIES EXTERIOR WALL ROOF /lJ CC✓,, J1 COVERING COVERING ^241 =2f } U USE OF BUILDING AND WORK TO BE PERFORMED �'_ n . /�cmc'-41.._ V I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING BUILDING CONSTRUCTION. / VALUATION SIGNATURE OF "Ma its/ `/}r e.. }n, PERMIT FEE $ PERMITTEE Gey (( //L • $ 6001 PLAN CHECK $ AUTHORIZED AGENT �- [ TOTAL FEE $ �L D'AMATO AMERICO APR 8 1960 OWNER � DATE 6-17-59 JOB ADDRESS 1961 Meyer Pl. BUILDING PERMIT NO. . . 96448 GENERAL CONTRACTOR Owner Builder _ VALUE $ 600.00 - AP. No. 1154163&8 LOT TRACT FIRE ZONE DESCRIPTION OF WORK Patio Rc 1 oof INSPECTIONS DATE I GROUP TYPE ZONE R 41 Underground Soil U.G. Water PERMITS ISSUED __ Underground Gas SUBCONTRACTOR DATE NUMBER Overhead Water and Gas Rough Heating Rough Plumbing Miscellaneous Prop. Swr. Line House Con. St. Swr. Sprinkling System Heating, Final Plumbing Fixtures Final Gas Test Construction Pole Underground Power Rough Wiring 1 Trenches Forms Steel Floor System Steel Reinforce Chimney Re-Rod Bond Beam 1 Sheathing Frame and Flashing fa idk 1=23--:----go / Lathing, In Out Plaster, brown coat _ - Plumbing Fixtures, Final Electric Fixtures,Final _ -_:---- - OCCUPANCY Form 210-3M-4-39 - ..- - 96148 OWNER HARBOR E STATES DATE 6_29-55 g; t JOB ADDRESS 1961 Meyer Pl. \\ BUILDING PERMIT NO. 11-54 GENERAL CONTRACTORDike & Colegrave VALUE $ 8,000,00 Singlemilt' residence & garage LOT 6o BLOCK TRACT 1986 Plan 13 GROUP I TYPE V ZONEM FIRE DISTRICT 11172 PERMITS ISSUED INSPECTIONS DATE SUBCONTRACTOR DATE NUMBER Footing Trench Z--6--e 7/f 33' Foundation Forms and Grade to Garage �24L111,.....- Plumbing, _X( Rough Framing p ie 8 11,E Plumbing, RougB to Sier ,4, c� y +y .. Plumbing,Rough Complete."- 4, n...✓ 6/1 3-c—It ,,.0 a- cA-7--3-14/ -2-2-4-1-1 Temporary Pole iii/�J ] 1 sS, tit',- - - -- /- -d-_4/0r� /./O/{, Wiring, Rough oP.& &7. - .r--,-..r ) Jl-/S-Sr /33/ Heating, Rough j?G4 /6—/��j[r Qp�� Heating, Final a-s--1a—j'Y.S7 -c$• PJ-L- `,-a3 fir 2ga'l Sewer, House / Sewer, St. -Vqy, /,I yj_ei/L) '-1I--5C c24,17 7 Septic Tank or Cesspool ``,, Lathing, In O4t� C d"J4- Plastering S"*''1�t f.2a'.LS/, Plumbing,Final,Fixtures Complete7W4,11)_/4 j 1 Plumbing,Final Gas Test if )'-e,6 -Sf Wiring,Final r. I.1 /Oy---5S— Occupancy jt'Occupancy 5s-✓/jam /0_1,-1< t Form 210 G-T-1 1500 1-55 . Costa Mesa Building Department ✓, APra,lCATION FOR PERMIT----_ 111 EAST 20th STREET 1472 BUILDING 1 - - •.COSTA MESA, CALIFORNIA ;. :. FOR OFFICE USE ONLY FOR APPLICANT TO FILL IN Receipt,No._ .- Permit No. - Building Q4/419 I /44 �� Address 1961 Meyer Place Aix Costa Mesa, California Receird by. Date Rgec'd. Date Issued I Nearest 19th Street t 6 - a-�`•-Sr --,-29�r Cross St. Building I Address •• Owner Harbor Estates Costa Mesa, California 1 Mail • Address 1119 East st 17th Street Nearest Tel Cross St. . City Costa Mesa No.LI 8-1159 Zone `�// No.of Type I Group Architect or -Lic. K �Y I Plans V Engineer Carlson & Middlebrook -- Approved by • Date Address Garden Grove CORRECTIONS Cit Contractor Dike & Colegrove No. Lim 1301 Address Lig E. 37th Street LegalLot 1 Description I No.60 I Block I Tract1986 i (Attach Metes and Bounds) • . • ldg Size of Lot 60 x 110 No.Now of onBLots. none 0 Use of I No.of I No.of -' .. - - - 70 Existing Bldg. none Families Rooms - - 5 Setback Line from Rear Yard 261511 Center of Street 501 Side Yard 201 5 -___ . - - - - DZ' DESCRIPTION OF WORK _ r New IX I Alteration I I Addition Repair I I Moving I Demolish I Building No.of Size • s.. ft. Rooms Stories 1 Exterior Wa I I Roof Covering stucco Covering comp APPROVALS UseofNew Foundation Location 2 Inspector Date Building Plan 13BR p Forms,Materials, - SinBle family residence and garage Under-Pinning v Frame: Fire Stops, t:n Bracing,Bolts in c Lath. Int. ,n I hereby acknowledge that I have read this Application N and state that the above is correct and agree to comply Lath.Ext. `2I.e with all City Ordinances and State Laws regulating building construction. ui Signature of Plaster, Int a Permittee Dike & Colegrove Plaster,Ext. r. Authorized Agt. Masonry Reinforced x?' Valuation Permit Fee $ ,20, O v v 1 8 DOS. - Plan Check $ j. o o Bond Beam W $ Total o Fee $ -Psi- c J FINAL cnc,J one. n+H 2M 5-54 .l OWNER D'AMATO, Americo DATE 7-16-57 JOB ADDRESS 1961 Meyer Place BUILDING PERMIT NO. 5452 iftEltL.0 AONTRACTOR Owner-Builder VALUE $ smeno P. Si. 11tt55 LOT 60 TRACT 1986 FIRE ZONE DESCRIPTION OF WORK Fireplace in Dwelling _GROUP J TYPE III ZONE PLAN NO. 5185 INSPECTIONS DATE SUBCONTRACTOR PERMITS ISSUED _ _ DATE NUMBER Trenches' Forms Steell f '/ FloorSyStem A f Steel Reinforce-5Chimney Re-Rod COS- 17//7/5/ Bond Beam Frame and Flashing Lathing, In Out Plaster, brown coat Underground soil _ W/G Pipe Test Top Out Furnace Gas Vents • Rough Plumbing Cesspool Septic Tank Prop. Swr. Line House Con. St. Swr. Sprinkling System Heating Final Plumbing Fixtures, Final Final Gas Test Construction Pole _ Underground Power Rough Wiring • Fixtures, Final• 7, a ,OCCUPANCY O(4f2- 744'7 Form 210-5M-1-57 _(f • 5452 Ifs '� 5485 FEE Ecky D ,LI COSTA MESA BUILDING DEPARTMENT - /� /P��/ ? P.O.BOX 317 COSTA MESA. CALIFORNIA FI ANCE DEPT PEX�r CCM MESA FOR APPLICANT TO FILL IN APPL O FOR PERMIT ADILDING „ .;_lie_ ,,., /y�/ � BUILDING ADDRESS COSTA MESA. CALIFORNIA FOR OFFICE USE ONLY �J RECEIPT NO. [PERMIT NO. f..I OWNER rta. 7� e„6 ) ant a .�O V 4,14'02. MAIL // ��� ��. ) pq RECEIVED BY //pJATE RECEIVED DATE ISSUED ADDRESS /9CO #%crC/©{? '/L / /b •-,S tE -S7 i - /,�' f S TEL 1JI_ __ _ BUILDING / CITY `Y- '4L 7 ••,[,a€C/ NO. lists, ADDRESS - ARCHITECT , LIC. O OR ENGINEER /� thO i� NO. COSTA MESA. CALIFORNIA FIRE ADDRESS � ZONE JJ Pe / an c, . ZONE NO.OF TYPE GROUP/ CONTRACTOR 0,4(,,FL'/✓1��., ( r�NO.- PLw NS / [ / ADDRESS ].r,-L_t Cf'/'.Ol E. TEL. APPROVED, �•j• NO. BY DATE LEGAL LOT JJ/`t''..^�� _ A6 ` CORRECTIONS DESCRIPTION NO. [1..Y cii BLOCK ' TRACT /j.r�e A.P.NO. �'/S-' /S3 -- 1 p • ,, J SIZE NO.OF BLOCS. / • OF LOT / ///,, NOW ON LOT USE OF ILJC.. //2 it (et.t.I//_ { EXISTING BLDG. L SETBACK LINE FROM / CENTER OF STREET E REAR YARD X • SIDE YARD RIGHT FA, LEFT L X. < /r • DESCRIPTION OF WORK . • NEW ALTERATION d ADDITION . REPAIR MOVING DEMOLISH BUILDING NO.OF SIZE ROOMS STORIES , EXTERIOR WALL ROOF COVERING COVERING i USE OF NEW U� � �/' y BUILDINGl� �e. ,yyV ,/ .� �' ���//// / I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY WITH ALL CITY ORDINANCES ANO STATE LAWS REGULATING BUILDING CONSTRUC- norv. /' / VALUATION SIGNATURE OF '�/GiJ/ /J '��e,^s, 0 21.z...- PERM i- PERMIT FEE S ��/ PERMITTEE LVJ K- L _ I L O 0 ,_ PLAN CHECK S -” • 'I $ J AUTHORIZED AGENT TOTAL FEE S 44 vein