HomeMy WebLinkAbout1869 NEW JERSEY ST - Building Permits •
- Applicant to fill in all spaces except those within heavyborder lines and sign all appropriateaeplaratlpns• • - ' - -- '' - -
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•A MESA 'CONSTRUCTION PERMIT PERMIT NO. TRACT NO. LOT NO. 'UNIT NO: -
Pro)ec +ddress /s16�T N w Mari ss�, - - Imo- 23 349 �`Q��(�-!(Tn}' (dry - - I
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AppIic ht's Mailing Address ',nil-e •' _ . ' TYPE OF CONSTRUCTION KNEW !J ADD ALTERATION U REPAIR • •' -
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�/((� .7 El CONVERSION. El DEMOLISH ❑ OTHER' - 'A".# ^� 3/� '- , - Zone /�
Owner's Name vrl Phone/���5��7 _ ,., 1�9 �L.b�• ��7 L Z1 �-
• 5AmE ' DES�RI T NOF�LOgL</US,OF BLDG. - - '
Address '[-.aciAL/z YA{7 0 Co t'Se, ., S Main Building: -Accessorya e���_
Arch/Eng.' •,41 ' • License Na - - TYPE OF PERMIT ❑ GRADING ❑:FOU NDATIOfJ STRVCTU RAL•
Address - p • •' ' '❑ TENANT El ELECTRICAL ❑ PLUMBING :❑ MECHANICAL • B Rear - - - - //�pp// -
�y Nl�jL. - . • ❑ OTHER ' - • .A / -
'C Contractor's Nam. 7 - I
LJ I✓ _ Phone • "R OJECT,DESCRIPTION 5tpp].,FT ��a��_��_��_""""""''''''""""""�����_yy1,5 ww OCCUPANCY
/O. -I C Right _ N
Address(mailing) Sgr�.E - . . X CONSTRUCTION TYPE/ M/ 'sAMCALUATION$ . - S , - . R
City License No. ZONE •- GRADING CU.V,DS. ACRES •• _
LICENSED CONTRACTOR DECLARATION - I , - ' - r I'IOg. Re .# . Parking Req./Provided, . E
1 hereby affirm that.l am licensed under provisions of Charter 9:(commencing : Remarks: .p 7i �/j e/ / (/'' f . Tanning Notes:e ^ /�j- Uo Des K �/y( • Q
With section 7000)-of:Division 3 of the Business and Professions Code, and , //11 /A'f •dl �si�'' DI C� �g�d• ��•/^/.��1���e.1 L� g �(/ �/'G�'.Cy///yi.511'I�I WVN QN ��/��/ ' M'
my license is in full force and effect. l '�sl�G„/ GOI/LQ {� C• `2��] -c �'( 6BM/ )/ -" /O 5) • '��•"• room. $
License C15is ' License No: 'e ✓ V l /-, PLAu i'Sr✓ ,./_ C
bate ' - Signature - : ' l PLUMBING; ' 'FEE , ,rr / / t p!'1l '/)Q 6 ith cOVf -
WORKERS'COMPENSATION DECLARATION Bar Sink ' Showers Y'." I✓
I hereby affirm that I have a certificate of consent to self-Insure or a certificate ' - l ELECTRICAL I , • FEES
'of,Workers'.-Compensation ,Insurance,r-or a certified copy thereof (Section' - Backflow Preventer Service Sink , l
3800, Lab. C.) I Automatic Washer, • Transformer 0 15.50-KW • ,
Policy No. Company : Backflow Irrigation Sewer Cap Construction Po le Sub. •• l ❑ 50.+'KW
Certified copy Is hereby furnished. 6 , _, '
R
certified copy I5 filed with the city Building Siyision. Bathtubs Sewer Connection Cooking Unit Meter ❑up to 100 amps
Date Applicant - /' ' . - - '
. EXEMPTION-FROM WORKERS'.COMPENSATION DECLARATION• - ' Clarifiers. . l .- - Solar Collectors -s - • - •- - 'Dishwasher- - - • - .- Meter Clover:100amps'-- -.- - -- '
(This section need not be completed if the permit-is for one hundred ($100)or - .
less). t Dishwasher Solar Piping Dryers ❑Gas ❑Electric SubPanel ' 7 . '
I certify that,in the performance of the work fon which this permit is issued, I :
shall not employ any person In any manner so as to becom bjec to.the Drinking Fountains Solar Tank - Fan - : f
Workers' Compensation Laws of Califoc�yla. ,1 - - • 'Motors 00-1 HP -i%-8
X Date y� -�( Signature ion / should floor Drains Swimming Pool w/Spa • F.A.U.'NOT: If,after making this ati/ 'you should beco e subject to he • Inc.Solar❑9-15 HP 016-15+
Workers' Compensation provisions-of the Labor Code, you must forth th -. - ' Floor Sinks . Urinal
comply with such provisions or,,this permit shall ,be deemed revo ed: - ' - - Fixtures Microwave
CONSTRUCTION LENDING.-.AGENCY. - I : Gas Service ,Outlets Water Closet , l .
I hereby affirm that there is a construction lending agency for the performance ; _ Device Boxes ' t Pole Light
of the 'work for,,µy�' mh this permit is issued (Section 3097 Civ. C) Interce tors -" - - Water Heater 'r
J`• Lender's Name- ry,Q • - - p _ - . . - Outlets Range • •
Lender's Address =NUJ)' Kitchen Sink Water Service �'. Switches.
- Sign '
OWNER BUILDER DECLARATION • . .' , •
I hereby affirm that I am exempt from the Contractor's License Law for the , Lavatories. . •Auto-Wash t'
following reason (Section 7031.5 Business and Professional Code: Any city or - .r Garbage Disposal Standing`$ections ,
county which requires a permit to construct,alter;improve,demolish or repair P-Trap - Laundry Trays n_ ;� Generator ❑0-5 KW❑5-15 KW .Trash Compactor '
•any structure, prior twits issuance, also requires the applicant for such permit - - P
to file a signed statement that he/she is licensed.pursuant to;the provisions of ' Roof Drains - - '
•the Contractor's License Caw (Chapter 9(commencing with Section 7000)of - , - I .
Division 3 of the Business and Professions Code) or that he/she is exempt - . - - '
therefrom and the basis for-the alleged exemption. Any violation_of Section • - . _ • •
7031.5 'by' ny-applicant for a permit subjects the applicant to•a civil - ' - ' - '
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.a4riesty of not more than five hundred dollars($500). ' r:, -
r I, as owner of the property or my employees with wages as their sole . Reinspection'Fee I $15 Issue Fee $ 3 '"
compensation, will do the work, and the'structure is.not intended or offered '
for sale (Section 7044, Business and Professional Code: The Contractor's , - 'MECHANICAL FEES Reinspection Fee I $15 'Issue Fee I $ 3
License Law does not apply to an owner of a property who builds or improves K' -" � " •
thereon; and who does such work himself/herself or.through his or her own I �P DEVELOPMENT SERVICES REQUIREMENTS' � �6� 1 /�/8/_
employees, provided that such'improvements are notintentletl or offered for Boiler Hood Or Type I ❑ : (O
sale. If, however, the building or improvement is sold within one year of corn- - Canopy Type II 0 ' Zoning Approved By - e
prove the owner will have the burden of proving he/she did not build or Im- ��Duct-Under Ground I
Building Approved By Dat '
prove for the purpose of sale). ' ' �f.--
❑ 1, as owner of the property, am exclusively contracting with licensed con- i Duct-Structural ' Refrigeration System ; Application Issued By Dat •
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 =- . - - •00-.100,000 BTU-0100,000 BTU - - • -SU MARY OF FEES
builds or improves thereon, and who contracts for such protects with a con- _ _
tractor(s) license pursuant to the Contractor's License Law). I am aware that - -- _ .D8L'BUILDING PERMIT $ .32'Bel SMIP ' $ O•SO
EV f of their Worker's Compensation insurance should be Exhaust System 0 Multiple 0 System Repair/Alteration
p p provided to,me. PLAN CHECK , $ 70r PERMIT
.Irl am exempt under Section c. : P.C.for this reason •( Firepl/Fact.Blt. ICBG# Fire Dampers ISSUANCE $ -
PLUMBING , $
_
1( Date 9i4� Owner - - '— Heating System & Ducting • Registers PLAN CHECK 25%( $ • ENERGY'P.C. ' $
I hereby certify that -have read-this application and state hat the above 00-100,000 BTU 0100,00067E . I ELECTRICAL $ I GRADING $ I '
Information is correct. I agree to comply with all city and-go my ordinances ' - . I '
and state laws relating-to buildin construction, and here. .uthorize repre- • , - MICROFILM $ '
sentatives of this'city to .enter o e above-mentioned pro erty for , I PLAN CHECK '50%I $ ,{�
inspection plyposes. , ` PC - MECHANICAL , ' $ - TOTAL FEE ; $ '�7•qo
X Signature //k���� C date .
Drivers' License or 55 ,• Reinspection Fee ' $15 ' Issue Fee $ 3 PLAN CHECK 25%' $ . - • I l
CMF 0865-46,rev. 10/84 white - Building; Canary -Applicant; Pink -Accounting; Goldenrod - Assessor
111NSTRUCTION AND PLANNING POOL&SPA
PROVALS Permit# Date Inspector APPROVALS Permit# Date Inspector
emporary Electrical Service or Pole 52. Pool & Equipment Location .
oil 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 UF 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 t .67. Fencing & Access Approval ,
17. ,Rough Wiring Sign 68. APPROVED FOR PLASTERING .
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
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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
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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. FINAL
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30. Drywall NailingHEALTH DEPT. REQUIREMENT .
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31. Plaster Brown Coat , 1 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 >f
-
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- y/7 to i /�
48. Special Requirements Completed -: !/!�Y (O! _
49. Electric Release to Edison 'c) •
50. Gas Release to Southern California Gas Co . , -- -•
51. CERTIFICATE OF OCCUPANCY _ . -
No. Date
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33655AFP za 7, ; II
769:f -4-L.**9-1.53
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
For Applicant to Fill in Completely • APPLICATION FOR BUILDING PERMIT
��/ RECEIVED BY DATE RECEIVED D • E I S EDS//
.BUILDING / e 9 z /EW T i?SGC/ ST. 9 e-741--9/ ��A/J i' /
ADDRESS O t� / ��/ 1.12:,9
� f/ ?p / '
OWNER /?LL& t /,92D A.P. NO. I39 — 103—3z PE 13n 6
BUILDING/ ` e ADDRESS /!YG / .Ugcl/ 1T ccs Sr,
MAIL / �// 9 ,{/C� `JCK.7L Sr. l
ZLuLii ADDRESS O(� 'V �TEL �/ �J �j /
•
c o CITY Cos' MESA NO.3S -37SO 'TRACT3(�SGr I LOT/Or BLOCK
I- Z
Z < CONSTRUCTION NEW ADD ALTER REPAIR MOVING DEMO!ISH
NC0 ` 6-
O- N LENDER 'V )(
a m /C
_JD BRANCH / '/
J(11 - OWNER /.46-6 /4%-2-/J
03 J ADDRESS ,/�,r 'n VALUE OQ
m Q ARCHITECT TEL. USE F/f-rr/ /LY b 0/�'/ $
OR ENGINEER NO.
UQ
w CL ADDRESS FIRE /,//•
Z ZONE TYPE 7 GROUP
APPROVED /.744, DATE ��
0_ W /
J O CONTRACTOR /'O/zG/E.e l'c.n/ST,, Co. BY
03 7�
W W /J ADDRESS /O SO /„��'trn C_ Sr, ZONE NO.OF USE OF NEW rA/i1GY
0r TEL., Q-1 (PANS Z BUILDING
Z� CITY Sr4N'T/} j-/,/�¢ NO.SW-99/d/ rL _ Rvan+ Aoplra l/
—o STATE /J (/ CITY YARDS APPROVED YARDS APPROVED
111
cn CL LIC. NO. .�( 70 �O LIC. NO: MAIN BUILDING •CCESSORY BUILDINe
J0 SIZE NO.OF BLDGS. (FROM T {/��[)
OF LOT 70 x, 7
0 0 INOW ON LOT /
FRONT T. W-11-111.- FT.
USE OFEXISTING BLDG. SF/L- 6.4e--16-6---
R.SIDE IV FT. F
F- SIZE OF 704 i• NO. OF / / AV
Z NEW BLDG. cY 7- ROOMS STORIES L.SIDE rV FT.
< EXTERIOR
0. COVERING ALL$T(�CD COVVERING ROOF ���✓C n REAR I } FT. f /AI FT.
-
J USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. — BE'.MAIN&
1 MAIN BLOCS. Are ESS. BLOCS.
0
Q ^ VAR.# •ATE
0 f/4 /� 40047 C.U.P.# �,D APPROVED
~ RY LA/ [Nf! _DATE_2 Q SLAP 7/
I35)
���lll
Z
0
U I hereby acknowledge that I have read this application and state
0 that the above information is correct and agree to comply with
•
all laws regulating building construction, and I shall not employ
CC
1- any person in violation of the workmen's compensation laws of
N the State of California. m
ZSCS SQ. FT. o
I hereby certify that I am properly licensed as a contractor under
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR 5
Chapter 9, and that such licenses are in full force and effect,or 1 THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: o
am exempt from the provisions of the State of California Business M.
and Professions Code, Division 3,Chapter 9. VALUATION rrc'-& 03
PERMIT FEE $/// �) w
' Signature of m
Permittee $ 733 £' PLAN CHECK $ // E
Authorized Ag t -/J/f / 4 L w u.
\ TOTAL FEE $ >�6!
4 OWNER WARD, PaulDATE 9-24-71
JOB ADDRESS 1869 New Jersey Street BUILDING PERMIT NO. 33655
GENERAL CONTRACTOR Forcier Const. Co. DESCRIPTION of WORK Add Family Room
'AP No. 139-103-32 LOT TRACT FIRE ZONE VALUE $2,733.00
INSPECTIONS
Gas Signature Date GROUP I TYPE V
SUBCONTRACTOR ZONE R-1
� soL PERMITS ISSUED
Date Number Signature
WATER Plumbing
ROUGH PLUMBING
PROP. SWR. LINED HOUSE CON. n
SPRINKLING SYSTEM
MISCELLANEOUS ,
ROUGH HEATING AND AIR CONDITIONING
TEMPORARY SERVICE OR POLE
UNDERGROUND n POWER n
ROUGH WIRING La'/ypQ 7/�
[ / t Heating and Vent.
TRENCHES ORMS STEEL REINF. �-/O � ,
FLOOR SYSTEM
BOND BEAM n STEEL REINFORCE n
rii%
SHEATHING FRAME AND FLASHING -7/
LATHING - IN T itPLASTER, BROWN COAT //
STRUCTURAL, FINAL _ ( 1 tEl El-. ric
HEATING, VENT., REFRIG. AND A.C., FINAL > F/f/r .rAA ,Cd" /O-i2- 4,7 Al
PLUMBING, FINAL AND GAS TEST n //yvJ
ELECTRIC, FINAL e3 /7.�C?7
BUILDING, FINAL i� N, 61,7
—vPFr' A REOIIIREMENTS
12373 FEE RECEIVED
COSTA MESA BUILDING-SAFETY DEPARTMENT FINANCE lE3T.
P. O. BOX 917 COSTA MESA. CALIFORNIA CITY OF COSTA MESA
F ,
For Applicant to Fill In Completely APPLICATION FOR PERMIT
TYPE OR PRINT BUILDING
BUILDING 1869 New jersey St.
COSTA MESA. CALIFORNIA For Office Use Only
RECEIPT NO. PERMIT NO.
OWNER Vermont Avenue Land Co., Inc. I (/7,373
MAIL RECEIVED BY DATE RECEIVED DATE ISSUED
ADDRESS 419 E. 17th St• �` / ,2.D-6o p)po1 14LYt
TEL. BUILDING
CITY Costa Mesa NO. Li81159 ADDRESS
ARCHITECT Carlson & TEL. COSTA MESA. CALIFORNIA
OR ENGINEER Middlebrook NO. ////''TTII
/� FIRE ,/ `A4�
ADDRESS Garden Grove - ZONE TYPE / GROUP "f
CONTRACTOR Dike & Col egrnve Inc. BYPROVED -'J
, BY ZONING e' DATE /I 41/
ADDRESS 4119 E. 17th St. ZONING A,� hll/j{/J
Z NO.OF USE OF NEW/y4
CITY Costa Fesa /( I PLANS BUILDING
0.
LIC NO. 16729 TNo. Li. 8-11 9 LEGAL it
DESCRIPTION Lot 100, Tr. 36/.RSIZE NO. OF If/'
OF LOT 70 X 100 I NOW ON LOT- nom A.P.NO. 11A>
USE OF YARDS ( . EVES
EXISTING BLDG. ? APPROVED ALLOWED
SETBACK LINE FROM ,, (CENTER LINE ST.) ii,��
CENTER OF STREET 501 REAR YARD 1 FRONT JFT. IN.
SIDE YARD I LEFT 121 I RIGHT SI R.SIDE FT. IN.
DESCRIPTION OF WORK /SIDE / IFT. IN.
NEW I X IH ALTERATION I II ADDITION 1 REAR 3 / FT. IN.
'`�IN.
REPAIR a I MOVING I DEMOLISH APPROVED lA�1�II 1 DATE n gra/I—��
NO. OF
SBZE DING 15/0 scl.ft.ROOMS 7 STORIES 1 /J
EXTERIOR WALLU
COVERING • COVERI ROOFING C•II• & .• • - L7`
USE OF BUILDING AND WORK TO BE PERFORMED
°'
11�.0 r.
Single family residence with
attached •ara•e. Plan 20AR
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE
AND STATE THAT THE AROSE IS CORRECT AND AGREE TO COM- PURPOSE OF ESTABLISHING A PERMIT FEE ONLY.
PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING
BUILDING CONBTRUCTION- VALUATION
SIGNAITU E OFC......-1,6
PERMIT FEE $ 96• •
PERMIn
$ ]-6,101. PLAN CHECK $ 18. '•
AUTHORIZED AGENT Dike & Col grove, Inc. _ E
.
o , . TOTAL FEE 5 5G. y
OWNER Vernnnt Ave. Land Co. , Inc. DATE 6/21/60
JOB ADDRESS 1869 New-Jersey, St. BUILDING PERMIT NO. 12373
GENERAL CONTRACTOR Dike Colegrove, Inc. VALUE $ 16 101
AP.No. LOT 109 TRACT 3648 FIRE ZONE DESCRIPTION OF WORK Res..w/att.Gar.
INSPECTIONS A < DATE I GROUP I & J TYPE V ZONE R-1
Underground Soil -r i$.G. Water,773 ,i---2,0'at
SUBCONTRACTOR PERMITS ISSUED
Underground Gas N/�J DATE _ NUMBER
Overhead Water and Gas ll
Rough Heating /l'NS X'70-(en `I: /U r0 k-9-G u � 6/>,- ---
Rough Plumbing ,j4, Z.-2.9P-6t7i ../...- 'w-/ i 7- 7-/6,19 _pS,Oh---
Miscellaneous ^ ��/`D
Prop. Sw — Ho}It Con. St. Swr. f/g,y//lil !1'=f=4....� c'�-.�? WI feed `1 4 j rig, S II
SprinklingSystem /�
HeatibF Final IL t �I''_ 7�'� l
Plumbing Fixtures �r�/_�(j�
Final Gas Test 6- ( �s (e' /
Construction Pole
Underground Power
Rough Wiring -� 7-," -6=19 K.52X3.-7
Trenches L-Forms V Steel 2-J-/-64 •
Floor System
Steel Reinforce Chimney Re-Rod
Bond Beam
Sheathing F- f� s- a 4. 4.n
Frame and Flashing /3, J e— 7q 7 : ,0
Lathing, In Out 4', "7,7 / '— /73—6 0
Plaster, brown coat . 7' 7- '- /b — $ -C a
Plumbing Fixtures, Final er / f'r
40
Electric Fixtures, Final j/-7-•-(o
Building, Final tri-
/ y ,P
OCCUPANCY Lao:`e-e �`1
Form 210-5M-11.59 S-B P
SEP 24-711-M00 770F3e9****
25., 0
CITY OF COSTA MESA PLANNING DEPARTMENT
A. P. No. 110 10422
Bldg. Permit o.
ti
PARK AND RECREATIONAL FEES - Apartment Developments
Fee Payment Receipt
Project Address IR69 NFU LFRSFY STREET. COSTA MESA. CALIFORNIA
Owner's Name PAUL WARD
Bachelor or 1 - Bedroom Units I @ $25.00 = $25.80
2 - Bedroom Units @ $40.00 =
3 - Bedroom Units @ $55.00 =
4 Bedroom Units @ $70.00 =
5 - or more Units @ $75.00 =
Total Fee $25.00
Total number of Dwelling Units 1
Planning Department Approval Date 9-24-71 Park Area No. 1
W.L.D. ah
By Applicant's Signature • 4,7
CITY OF COSTA MESA PLANNING DEPARTMENTcrrr ,
Sfd' 'L''I �-71U00 770 u':,`..A �.u.�.n
L
A. P. No. 139-10.1-27 /
Bldg. Permit No. _.=�� G,76—
PARK AND RECREATIONAL FEES - Apartment Developments
Fee Payment Receipt
Project Address 1801 NFW JERSEY STREET, COSTA MESA, CALIFORNIA
Owner's Name p4111 WARD
Bachelor or 1 - Bedroom Units 1 @ $25.00 = $25.90
2 - Bedroom Units @ $40.00 =
3 - Bedroom Units @ $55.00 =
4 - Bedroom Units @ $70.00 =
5 - or more Units @ $75.00 =
Total Fee $25.00
Total number of Dwelling Units 1
Planning Department Approval Date 9-24-71 Park Area No. 1
ByW.L.D. ah Applicant's Signature, a�
cc