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1590 Cor/*vat,- or: (08+A MESA CA `1262.6
Qop proper}y DErek DAMS
ENclesure wall ail be ON }tie R15h - Sipe or Proeet*y
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p • •Fs9 CITY OF COSTA MESA
4 BUILDING DIVISION
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4r-s-1.
,,'�„�„ 411. DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
PERMIT
0-01620
•
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us
PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING ,
Job Address: 1540 CORIANDER DR Status: ISSUED
Suite: Applied: 10/09/2000
Vicinity: Issued: 10/09/2000
Parcel Number: 13950201 Zoning: R3 R3 let .. .."-...Applicant: GOODMAN, JACK
ISSUED BY:
Address:
Phone: 714-847-1773
Zip:
Owner VAUTHRIN, GLEN ,
Address 2912.PEMBA DR ,
Phone: ,
COSTA MESA, CA Zip: 92626
Contractor SIERRA ROOFING CO ,
Address: 16631 KETTLER LN
• Phone: 714-847-1773 -• .
HUNINGTON BEACH,CA
Zip: 92647 License: 511172 •
• Arch Eng:
Address: Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT . .. '
TEAR OFF EXISTING ROOF, INSTALL TIMBERLINE 30 YR. COMP. NO NEW SHEATHING PROPOSED. - •
' FEE SUMMARY
Plan Check: $0.00 .. Calc Valuation: $7,800.00
- Permit: • $153.25 - - - 'Claim Valuation: '' • $7;800.00
SMIP Res: $0.78 ,
SMIP Com: $0.00 -
Other: $0.00 -
Inspection: $0.00 -
Total: $154.03
' PLANNING & ZONING -' '
SETBACKS`
MAIN STRUCTURE,Front 0-0 Rear' 0-0 Left 0-0 . Right -0-0 / /'
ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 '
PARKING Existing: 0 Required: 0 Proposed: 0 '
NOTES:
•
•
•
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: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
- for a period of 180 days.
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.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(6/00) .
DECLARATIONS I ) fl
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700rof the Labor Code,for the performance of the
work for which this permit is issued.
❑ I have and will maintain workers'compensa •n insurance,as required by section 3700 of the Labor Code,for the performance of the work for which his permit is issued.
My workers'compensation surance ca ,er.i•policy number are:
Carrier: n G Policy Number:
(This section need not be completed if fhe. if is valued at one hundred dollars($100)or less.)
❑ I certify that in the performance of i-=work for which this ermit is issued,I shall not employ any person in any manner so as to beco subject to the workers'
compensation laws of California,and agr e at if I sh become subject to the workers'compensation provisions of Section 3700 f the Labor Code,I shall forthwith
comply with the • .rovision/ /0 9/�
_App IcanLSi9nnLSlgneture it • X172—Q Date:
WARNING:FAILUR/SECURE WORKERS'COMPENSATI VERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PEN TIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLA- ($100,000),IN ADDITION TO THE COST COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION: /
I hereby affirm that I am licensed under prr Lsipns of Chapt: (cy encing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.Lic..fl ((I���_��to�J Class II
_Contractor's'SIgnalur:. .i4rYr!1r'�i t Date: 0 n1�.'
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or 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
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors 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 the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. 0 Yes 0 No Driver's License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a 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 or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
C As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Dale:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes ❑No
(Section 25505 of the California Health and Safety Code requires,with some exceptions, that a Business Plan be filed with the Costa Mesa Fire 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 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely 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 temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑yes ❑No -
(Section 25534 of the California Health and Safety Code provides that the 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.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application ap_ermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes D No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No
(If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑No
8 (If'yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of 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.
iAja Legal )
r LSAn�Or:Authorized At_N� /' /(1 79/rep
Date
CODE L ThISPECTION TYPE PAIS R)DI1965 CODE! INSPECTION TYPE PATE 1NTMAL$
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof (127 a Gam" 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
204 Final Demolition 250 Final Building/Occupancy
City of Costa Mesa i
Building Safety Department CERTIFICATE OF OCCUPANCY N°2211 C
P. O. Box 317
Costa Mesa, California
The Building located at 3,5bO_Conenter ® 9
has been inspected.and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto
for a Group K:a'3 Occupancy.
Use of Building 4 MI
e►..9s._
ftr t. "'.i ::=Y. .�.. !v_ -v o:: atn':M s.,: r. r�+d ax ieniss: ' —
Legal Description m5b� a
(See reverse side for Metes and Bounds)
Building Permit No. ,:259 Electrical Permit No. 23763 Plumbing-Permit Na
Floor Load Signs have been installed as Room Capacity Signs have been instated as
required under Sec. 2308 U. B. C. required under Sec. 3301 (1) U. B. C.
17050. CERTIFICATE OF OCCUPANCY. (a) No apartment house, hotel, or lodging house shall be used or occupied
until the owner or operator has been issued a valid certificate of occupancy by the enforcement agency.
(b) A new certificate of occupancy shall be obtained whenever there is a change in:
1) Occupancy classification of a building or portion thereof
2) The number of apartments or guest rooms
3) Ownership
If Group H Occupancy, number of apartments and/or guest rooms as required under Sec. 17050.1 (d), California
Administrative Code, Title 8, Chapter 9, Article 8.
Number of apartments 4 and/or guest rooms
ISSUED TO: Building Off ial
by .
Date EV.Dy 1965
This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed
\except by the Building Official of the City of Costa Mesa under Sec. 306 (e) U.B.C. Form au34-IM-11-63-.S-B P
isOWNER THISS>'?1TI, DONALD DATE 9-22-78
JOB ADDRESS 1540 Coriander Drive BUILDING PERMIT NO. 46758
GENERAL CONTRACTOR Terry Oogar DESCRIPTION of WORK pati n llaekc
AP No.1q_5n2_nl LOT 4n TRACT 5475 FIRE ZONE VALUE $ 790 on
INSPECTIONS Signature Date TYPE V GROUP J ZONE R-3
oIL PERMITS ISSUD
GAS SUBCONTRACTOR
;)p Date Number Signature
WATER _ Plumbing _ _ __
ROUGH PLUMBING
4 PROP. SWR. LINE 0 HOUSE CON. 0
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGH HEATING AND AIR CONDITIONING
TEMPORARY SERVICE OR POLE
UNDERGROUND D POWER 0 '
ROUGH WIRING 'Heating and Vent.
TRENCHES ❑ FORMS U STEEL REINF. u •
FLOOR SYSTEM
BOND BEAM n STEEL REINFORCE n
SHEATHING
FRAME AND FLASHING
LATHING — IN n OUT n
PLASTER, BROWN COAT
STRUCTURAL, FINAL Electric
HEATING, VENT., REFRIG. AND A.C., FINAL
PLUMBING, FINAL AND GAS TEST n
ELECTRIC, FINAL C �✓
BUILDING, FINAL M/b /
• I-- 4 46 ;8
.. ...iSiA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626 rr,, 77rr,, �-�ppppb� qq Be. . ...
• APP I AT N FOR4STRUCTURAL PERMIT .- . .
For Applicant to Fill in Completely — Use Ink Only
REG D DATE RECEIVED, DATE ISSUED
BUILDING n g�' ■q.�/ . -]G
ADDRESS �� lr.0 C6,E„A 4,1 Lo a _ ` 0/ERMIT NO. ♦A
OWNER a/UyA!/ reSA)jL y ([ji.S..iE// A.P. NO. /37--.5-62-o 1
• MAIL BUILDING •
ADDRESS;jiO4 /I(c/Sfi//LE r lri' y ADDRESS �a Tia/ �.tTi.e..ev►t.Ol3�+
/� y� /J TEL. o242- TRACT J 7 7S LOT SIO BLOCK
CITY daSTe /4/6c 4 NO; s,-..aget-
CONSTRUCTIONN • NEW ADD ALTER REPAIR MOVING DEMOLISH
LENDER
Y
BRANCH OWNER /(
0 / y
/ARCHESS
ARCHITECT TEL. US4�4 7 Fc��a �q � M
OR ENGINEER NO. FIRE
ADDRESS ZONE TY E yi G1--22-1--
CONTRACTOR
`3---
APPROVED/�j Y�f O CO ��+ BY DAT
ADDRESS(/ ei7 « p��qt
CITY ..[[470 The �j 7//Ai NOL ` USE OF TE . /"��,//�r��/. ZONE IPSNO. BUILDING NEWD Ce CKS
STATE - CITY YARDS APPROVED YARDS APPROVED
LIC.NO. LIC.NO. MAIN BUILDING I ACCESSORY BUILDING
SIZE NO.OF BLDGS. (FROM C/L STS ,BEET)
itel
O. OF LOT NOW ON LOT / FROM 47 7 FT FT
hUSE OF
ceeEXISTING BLDG. j9 T4 11—SIDE /3 FT. FT.
F Separate permits are required for L.SIDE n.Zt C.liFT.
G electric,plumbing and heating work. REAR �1 0
a / FT. FT.
i4 US iLDING AND WORK TO BE PERFORMED
F DISTANCE BET. BET. MAIN&
QQ 40 r / • ` _MAIN BLDGS. ACCESS. BLOCS. •
•
T C c US /0
x /J� / _ ")' / _ VAR.. DATE
Q d� IC (/ // / C.U.P.ak APPROVED / /
APPROVED/st`� DATE 9!2.8 L YQ
R l '
W
AL C I hereby acknowledge that I have read this application and state re
gP that the above information is correct and agree to comply with m
.' all laws regulating building construction, and I shall not employ
Z any person in violation of the workman's compensation laws of _ o
Sthe State of California. /G co
I hereby certify that I am properly licensed as a contractor under a SO. FT. a
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR ro
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:
co
am exempt from the provisions of the State of California Business VALUATION PERMIT FEE T
and Professions Code, Division 3,Chapter 9. !! $ 8 m
I �� I"�J PLAN CHECK $ no
Signature oept �� U.
Permittee �� $ D TAX $ L1) 2
err
S U
Authorized Agent TOTAL PAID $
•
• FEL RECEIVED
232591 1y+,EEC 1964
CQtA MESA BUILDING-SAFETY DEPARTMENT FINANCE DEPT. .
II - P.O.BOX 917 COSTA MESA,CALIFORNIA
• CITY OF COSTA MESA
For Applicant to Fill In Completely APPLICATION FOR PERMIT
TYPE OR PRINTBUILDING
BUILDING /� /l / CC -
For Office Use Only
ADDRESS / -r q0 (reiet/T' ,/>L`/2�
RECEIPT NO. PERMW bica,
/COSTA MESS{A, 'C`ALIFORNI/A-. J //DA][ C// Oli .ti�/7
OWNER IY/t (- -Sot// !l btVC"4. (. //z/ ,
RECEIVE Y kVAi///�IVED ;�U`L* ± 196' .
MAIL ADDRESS /b 41U isOQ/ a1/fE�
ADDRfiBS I'`/Y L '.S �`L'G L t / Tom_
• FIRE
CITY /Sri 6L(`/a ?"-r A-) NO./7/o-tJ) ZONE TYPE �/ GROUP
APPROVED
ARCHITECT TEL. • BY • DATE .
OR ENGINEER NO.
ZONING
ADDRESS
ZO',`�E_�/ NO.OF USE OF NEW
q -� ,,II ,{ `�
PLANS�I BUILDING
CONTRACTOR (ILL/IICA _/ A/-f C./C✓L �/L-.1 VVV
/ LEGAL i
ADDRESS /94' Z •S. / u L 4 / DESCRIPTION '�"� i -r--k ✓ v
CITY to/l/- /e- /t)
NOTE: NO EAVE OVERHANG SHALL BE LESS THAN
STATE p /t LC L// NEO. 4'7/IZL .1� SO'TO SIDE BREAR P.L.
SIC.IC.NNO. /J
/ OW EAVES
F
OLOT /t? //Y X /'7r. L'0 I NONLOTS/ ALLOWED (U.B.C.REQUIREMENT)
YARDS APPROVED YARDS APPROVED
USE OF MAIN BUILDING ACCESSORY BUILDING
EXISTING BLDG. . •
-- -- - - - - - (FROM'C/L STREET)
SETBACK NE FROM ,r�
CENTER OFLISTREET .S REAR YARD
lc FRONT FT. FT.
•
SIDE YARD LEFT / /2 I RIGHT- I/ ' '7 ` R.SIDE tO FT. Ff.
DESCRIPTION OF WORK L.SIDE /Q FT.• FT.
NEW / ALTERATION _ ADDITION REAR / LJ FT.
ESFf.
DISTANCE BET. BET.MAIN Q
REPAIR MOVING DEMOLISH MAIN BLDGS. ACCESS.BLDGS.
BUILDING ` /' NO.OF r-- VAR. DATE
SIZE �vV 71 ROOMS -rROOF5C.U.P.# APPROVED
EXTERIOR COVERING WA��L9KU COVERING J/ BYAPPROV ED I Z t
Ltiti6 DATE ( I�',�- r
USE OF BUILDING AND WORK TO BE PERFORMED
fit- - id/ .s— o (Jae{
\dr%``C't. •
J `I`j^.!(JY\.e • sO.FT.
I HE EIiY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE S
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM. PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. C
PLY WITH ALL CITY ORDINANCES AND STATE LAWS EGULATING VALUATION
-
qBUILDING CONSTRUCTI PERMIT FEE $ /P^ / N
SIGNATURE
, -PRMITTE -� /1/ . . ,4/9/57C. 0f A CHEC '--
AUTHORIZED AGENT I'
TOTAL FEE $ /9
•
2�? 4 CITY CFfl; STA MESA
CCIatA MESA BUILDING-SAFETY DEPARTMENT MAR 24 1965
P.O.BOX 917 COSTA MESA,CALIFORNIA
For Applicant to Fill In Completely APPL .,..•' I• , f RI;PE{tMIT.
TYPE OR PRINT //JJ p L IL�.JJ
BUILDING ) (ea 'AAAI tom,. For Office Use Only
ADDRESS /� 70 l' ,44.4,
RECEIPT NO. PESNI�M�84
.COSTA MESA, CALIFORNIA .. LJJtJ<J
A-14.-2.
� / -. - RECEIVE BY - DAT RECS$VED _ y /DATE IS/SUED,
/� 4.- . .�d U���. n�j 3�+/Z/j^/�C 7 J/ j/(2.1....---
OWNER
MAIL ADDRESS / - 4 Cart Am114=te 0'!-
ADDRESS CEJ .n_-i• ��/�
TEL.
CITY ✓c• NO. ZONE PG.�l1( GROUP
��_`P .APPROVED 4.12-..Y6)
/y
ARCHITECT TEL. BY CLl - DATEJ/ZA4
OR ENGINEER . NO. I '
- ZONING �Ji�J
ADDRESS
ZO NLA S GSE OFNEW p^/
/ �Q _ I PLANS I BUILDING �l/"� LV
CONTRACTOR �7✓/}}-`:27 Q l--�fL>-. LEGAL �I CIO
'D-/Pk �'—
ADDRESS -?( 05 �js- LC+VLvG<.S DESCRIPTION / /Y� �(-� �� I5 '? J -
/> A.P.NO.
CITY /rte Yn-<_.._...(_2L
NOTE: NO EAVE OVERHANG SHALL BE LESS THAN
LIC.NO. '94097- 'NO. JJ38.31- •
90^TO SIDEQ REAR P.L. -
EAVES
SIZE .� .I NO.OF SLOGS.-' , • ALLOWED (U.B.C.REQUIREMENT)
OF LOT NOW ON LOT
USE OF - YARDS APPROVED YARDS APPROVED
EXISTING BLDG. --- MAIN BUILDING ACCESSORY BUILDING
(FROM C/LSTREET)
SETBACK LINE FROM q •FRONT /LT . C fiI FT.
CENTER OF STREET . .S• REAR YARD' Y `Th
1
V -
SIDE YARDI LEFT r-. I RIGHT R.SIDE c�---, FT.
DESCRIPTION OF WORK • ' L.SIDE __flr FT.
•
NEW / ` ALTERATION ADDITION REAR r FT.�-"- Fr•
DISTANCE SET. BET.MAIN R
REPAIR MOVING DEMOLISH MAIN BLDGS. ACCESS.BLDGS.
•
BUILDING NO.OF VAR.* DATE
SIZE " c '-'" C.U.-P.* - APPROVED
•
EXTERIOR WALL. I COVVEFRING �- - BYAPPROVED,C ,6 a�I R `, )_-J I
COVERING l// �(/� A 10
USE OF BUILDING AND WORK TO BE PERFORMED
Dv e/&Fz/4/J�, J • 4 j/ .
01
I HEREBY A KNOWLEDGE THAT I HAVE THIS APPLICATION THE AMOUNTS OWN UNDER VALUATION IS FOR THE c
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. E
O
PLY WITH ALL CITY OR ANCES AND STATE LAWS REGULATING VALUATION ( �—
BUILDING CONSTRU
SIGNATURE OF �,Q�/�. D PERMIT FEE $ O
PERMITTEE /��^�Z����NY1'W'l. {�� m
O (J S /� O PLAN CHECK $ _
7
AUTHORIZED AGENT U.
TOTAL FEE 5
i