HomeMy WebLinkAbout219 CAMELLIA LN - Building PermitsA��PESSOFBUIIqNG: L17 (:HMC:LLIH
avxexsruMeiF�o�aam:GLOVER, COURTNE
�oor�ss:219 CAMELL'IA LN
COSTA MESA,CA
APPL. YNIlNO /�WNESS:
MCHRECT OH FHILIEfA:
APCX.OIIFNG.'S ADOHESS:
UNT:
92627
uc xo.:
UNT:
cor'm�crarswu� D P PLUMBING AND INSTALLA ( 714 ) 991-9477
cwm�,cToaswuuxc 1588 S ANAHEIM BL �
moeess:ANAHEIM 92805 CA ���: 56M733
LJCENSED CONTPRCTONS DECLANITION: 1 MreEy efl�m imEs penelly d pe�ury Ilul I em fceneed urker prariebns ot Cheplx e
(mmmancinp wnh Secivn 1000) d Diviaion 3 d IM Busi�wea eM PMeasbna Code, enE my liceme ie in full bm end eHeq.
cm No.:050672 uc.cuss:C 36 uc.No.:563793 EXP: 09/97
� B: CiOM1b1IX: �
WN BIIILDEP DECL/�HATION: I hereby elfirm urder penepy d perlury Ihel I em evamp fmm tM CaMredon Licenee Law la Ma
reeaon l�� ]�1.5 &roiiees uM Proleaebna COAe: r1nY ciY a�nty which rpuiren e permn to mmwn. elir. impove.
dsh, a reper any avucwre, prbr b 0.v 6eueze, ebo requirm �he appliranl la euch peimX lo fib e ag'wE sletemant tliet ha a ehe
ro IicerimE W9�e^� �� �� P���+ d Ihe Conlredon License lew �Chepler 9(mmmerurip xilh Sedion ]OW) d Divebn 3 d Ihe
Buainess vd Prdesaiau COAaj or ihel ha a eha is exemq thaehan viE Ihe Detia lor ihe albpeE memqion. My viola�ion of Sedion
�wi.s M eny moii�u i« e ve.mn s+4�+ �ne eaWcam �o e a�rii oa+eM d �a m«e me� r e n��d�d edien [ssooll.
� I.esomierdlMproperlYormymmPbY�a�hwepeaeaiha'rademmpeneation.willdo�hev.wk.vM�heNnwlurewMintended
or oflmed br seb �Seclion )OGC, Buei�wse eM Pmlessiona CaEe: The Conlrerlan limnee lew doae m� epplylo en ormerd poperty
wtp buida or inpewae t�emon, erd who does eveh xwk IvmaeN w henetl a Nraph he a hm own employwe, pwideE ihet eueh
impovamenb ara m� imeMed a ollemd lor sale. X, however, iha buiMinp or vnprovement o eak wilhin me yaar d comqMbn, the
owrrerbuiltla will heve iha buNen d poviip M a she EiE na build a impro-n /w tM puryosa d aeb�.
� I, m o�mer d tha papeM. � ezduaiveM ���Pq �h 4wnaed wnvaciwn �o mu��ud the pqad (Seaon )OId. Buainsa erd
Prdassom Cah: TM Conlredas L'cema law doea iwt epply io en owrcr d popany who builds w impovea �I�neon eM who
mntrena 1« wch pqed+ wnh e oonlraclorta) liceneed punuent io Iha Conlrepore Lioeme law).
� I em exempt uMer Sectim: B. 8 P C.. br Iho raemn:
i do nerebr oenM mm i� e....a d�e u�wersie�a ine �ea���<ms a ce�e«nie H.enn ene smnr coes seaims zssos, usas. ene
25530, eM ihet I a erry fulure EuiWirp ocapent vnll / wYl na (arcb ar) nead io compty Mh said aws codm vM �M reQuirememe br
e pmnn lamnet�uctian w modifiutionhom IheAi�ue tiy�%nepement Dist�ip. Reakenliel const�ud'on eppiuliomme memq tmm iheee
a�,�.
o�s: nvaic�n:
WOPKEF'S COMPENS�TION DECL�R�TION: I Mretr/ elfirtn uMer panely W peijury me M Iha blbxi�p Eetlarelbna: .
� I lwe eid wil meimein e cenilcme d mneant to aeX�inwre irc wakers canpaw�ion, n praided lu by Senion 3)00 d �ha LeEu
� coa.. i« me ron«�e a ub wwk i« �n m�s v�n u��sa.
x❑ i n.� e�a we m�m� .wmm� mm�enmi�n ��.enn. m �ea��a M sa� s�ao w m. iem, caea. r« me wn«menc. n me
wak la wnich Ihia parme is uaued. My wn���. �,,,�a od�v ��mn„ �a: E X P I RE S
c,m,�:
Pdiry Number 0 2/ 01 / 9 7
�Thie aepion neM nw be mmplmeE [ tM penn<is lor one hunpred dolbrs /.StOpl w bv.)
� I cenLy thet in �he pufmnenca d tM wak tor whch �hn paimn u ivuad, I ahell �wl employ any peiam in any mennx ao n to
�e. ana wbjad lo IM xwkere' campanee�ion lews d Celilanie. eiM epree tM il 1 ahwM bacome wEl� b IM worken'
//—oo� �o�ro� o�so�. a sm� a�oo m ma �e« cros. i.n�i �enn..nn w�dv �mn ma. w��.
f�de: �wd�v:
jV eminp: F�llun ro ucuro woMrera'romps�uetlon cwsreps l� unlewNl, �ntl �IWI iub/ecf en rrplryx ro ulMml pmeMu eM
•ll fl� �,p b aro hwrtlrstl thous�N EW/an (5100,WJ). In e�Gltlon b fM rnsf ol eomps�ustbM1 damspu a! provltleJ br In
Ttlrn 9]OS ol tlro Le4or Coes, Intxs�t, entl eRomsY�s /su.
CONSTflUCTION LENOING AOENCY: I Mreby elfirm uMx penely W per'ryry Iliel iMn is e conalruUion bnEi'p egeM.y ia ihe
parformerKe d tM waM M whidi ihu pemii e ewaE (�� �. C'v. C).
LENDEN'S NRME:
LRIUEN'S AUDNESS:
1 cMiry ihat I heve read thia epplicetion aM Mde ihe� tlro ebove infmnelion b mrtea. I eprea to compy wilh el1 tlry eM oounry adir�enme
eM siete lawa ralelip lo buiWip cansl��Mion end hereEy euthorae repremme�ivm d thu dry to enter upon tha ebow-menliw�ed pmpnry
o�a: �
Whne-BuiWnp 85+fery: GraeMFb; Genery-ApPFrani; Rnk-Ravenue; Ooldenmd-Rsamn
CITY OF COSTA MESA — BUILDING PERMIT
PERMIT NO: P 081]60 PLAN CHECK NO: N
CONSTRUCTION TYPE:
JOH DESCRIPTION .
CLAIM VALUE:
V—N PERMIT TYPE: PLU
REPALCE WATER SOFTNER
CALC—VALUE:
PERM NO: P 081360
GOVT: N SUPP: N
PURPOSE: OTH
SQ FT;
GROUP OCC: R-3 /
COMMENTS: WA'1'k:tt �Ut'1'N�:H
u��r�r�r*�r�r��e�r*�r��r*x**�r*�r*x*�r�r�e�r�r�r��r�r*�*�� �r�r***�r****�r�e*�*�****�ra��r+r****+r�******�*��*
Z O N I N G R E Q U I R E M E N T S
S E T H A C K S'
—'----------- MAIN BUILDING ---------- --------- ACCESSORY BUILDING ---------
FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN
LEFT: FT IN RGHT; FT IN LEFT: FT IN RGHT: FT IN
PARKING REp • PROV: PARCEL: 42614305 ZNE: REF NO;
PLANNING NZSTES>
� . i
iEiEfklElEiElEiEitlFiFiFiFlElfiFiEiEiFlEiFiElfiFiElFfE1E kiEiFiEifillEiFiFlEiEiFfEiFlEifiE3Eif16ff1F1f�fiklFiEiEiFiE1E41EiEfE3EfEiE1EiE1EIEfE1EfEiFfFlE�EfE1F
D E V E L O P M E N T S E R V Z C E S�'�R E Q U I R E M E N T S
ZONING APPROVED BY . ' DATE:
BUILDING APPROVED BY :
APPLICATION ISSUED BY: /%A��• '
�r �r �r �r �r * *+r � *+� * * * * * * � * � � �������������s�������� �F
LEGALIZATION:N F E E S U M M A R Y
BLDG PMT PLUMHING ELECTRIC MECHANIC
IT 825t
DATE:
STRUCTURI�L� SEGMENT: N
FIRE SMIP/RES GRADING
SMIP/NON—RES
PLAN <!
ISSUE FEE 22,00
BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE
TOTALS----> 8.75 22.00 � 0.00 30,75 30.75 .00
REVENUE DIVISION TOTALS--> COLliECTED: 30.75 OVER/SHORT: ,00
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK
30.75 .;�
1E 1E'IElE �E'Ik 1E 1E 1E 1E iE ik 1E 1E 1E �E fF iE 1F iE i! 1E 1E �E iE 1E 1E iE iE iE aE'Ih 1f 1E iF,1E ik 1E 1E 1E 1f 1E iE IE 1E 3E 1k 1E 1E k 1E ik iElE ib if f(� iF iE 1E i! ik iE 1E �E 1E 3ElE iE iE 1f ik iI� if iF 1E 1E iE iF
I N D I V I D U A L; F E E B R E A K D O W N
TYPE QTY D E S C R I P T I O`,N UNIT COST TOTAL COST
PLU 1 WATER SOFTENER 8,75 8.75
END OF FEES
ez-ea-i�v�iei:e� vnisae.�s
PEKMITPT08136fd
CONSTRUCTION AND PLANN�NG. . . POOI & SPA � � _ � � j'
Date Inspectoc- � ' � . Date I,nspector
APPROVALS Permit # APPROVALS Permit # , ,
i. TemDorory Electrlcal Serviceor Pole' , 52: Pool & Eq�ipment Location ' � ��
2. Soil P(pe•Undrgrnd. " �- , - 53. Steel Reinforcemenf " - ;� � �
��73.:.Electrical Conduit'Utility-Undrgrnii. � � �54. Forms � . +' . �
'4.`Electrical ConduiixUtSdrgmd. � , � 55. Electrical Bonding � - _ �� 3.�'„ ;
�fi::5teel Reinforcement' � , 56. Rough P�umbing & Pressure Test
. 6.,,Electrical UFER'Grnd. ' � _ 57., APPROVAI TO COVER�GUNITE : -�-
: -1 . r
.:,Z„Footings '-� � � - 58.. Electiical ConduU-Undrgrnd. �
;8: Poundation �:��, � '� � � � 59. Gas Pi�pe, i7�U�drg'rnd„ Test . � �
�9. Water Pipe•Und�g�d.� � ` _ � 60. Backwash Lines; Q;Trep, L� Undrgrnd. �� ��-
10. Structural Ploor:System ' � _ . 61. APPROVALTQbECK ' -
1 t. property Sewer�Line�& House`Connection -� 62: Backwash & Receptor�Finai ' � -
�z.-SeWe� Cap - � ' ,63. Heater & Vent-final '
r
13. Roof Drains .... � 64. Plumbing System - Final � �
14. flough Plumbirtg � ' 65. Electrical-Final '' .
15. Rouqh Electrir,��l•Conduit ': � 66. Solar System��tnal . , ��
76. Rough ElectricSiViriqg_ � � - � - 67. Fencing & Access'Approval � '
17. Rough Wiring Sign _' ..- 68. APPROVED FZ1R PLASTERING �.
18. flough Electrical-T Bar Ceiling . ' � 69. POOUSPA SYSTEMS FINAL . � � �
l9. Rough Heati�g & A4� Conditioning _ - �; � �, ,_, E.tREArE,PT\REQUI[2EMENT'�, � ' ' '
� �c _ - - • v �_ r . _ _ ' <' C CJ "r; � -�
20.�Rough Factqr`y Fireplace �;-• _ � t. .� APP,$O�k(:�:- Permit # -- - .
� ���. �
27.�fluCts,in�Structu�B". ' "" - - .4 � ,; �;" 70;_Undergroupd Hydro r
22. Ducts, Ventil' ti�� e � `' =; c'.' < � -' � � ' `
_ � 9f �- .. + �7 � . � 77. Product;Piping C:Gas ❑ OiI
23. Gas Pipe=flough & Test n� .T7S �K [-: G --+' `� 7y, Underground Fivsh a` _
24. Ro6f Fiamin . .`': ._,- �.''�. . ;, `� =^ , _ -, _, :_.. � '�� .
9 r �-::`• t3. Undergrnd.StorageTankOGas �Oil
25. Roof Sheathing �" �� ' T � m rJ x^ 7q, pverhead Hydr�_ x
. �� ��: � • r� „ � ��
26. T-Ba� Cei)ing (Structurall &'tNoriocoat .`; , ;iv: 7S. Dry Chemicai��, i: y i
27. .Frame and Flashin9�� ' � �' " >' = �T 76. Dry Staodpipe" � � ` ^ `-'
_' - :.� n r' -. t' r T
" 28. Latfiin �&Sidin �� ' � ;-' - �` � • � � � u� ,
_ 9�. 9-.. . _ - �. , "•; 7-7,. FIXED-SYSTEN7�F_INAL- :a
_ 29. Insulation " r - -:• (� 7B._FIRE"PREV. F�IttfAL ;�'� � T
x �� �}� ��-�n .�,,: ,-^.,
30. Drywall,Naifing _ . r { � �, �_c.�t� l;;;HEALIr-H DERT�REQUIREMENT
31. Plaster Brown;CoaY� �� . '� ! � �'' �° 79. FINAL�(�SPECTION � ,., '�
32.. Electrical Power Meiei�F,inal `` ' +°., `�' 8(7. FOOD CERTIF,tCAT,E'�5$UED
"� 33._Final Electric � _" � '� � t�fotes: _2; �� x � '��
�; ,. r. � _ _ • _ �� tiE.r1Z_^>
34:yFinai Ne`ating:& Air`.Con`aitioning' _ * � i � . . ' - �,,, ; � - "
35."Final Gas Pipe-Testr _` :. i �. �s � �� x= C- i� K'
t I^.
`: 36,_Hood or CanoPY . ' '� - a � � ' * �. �. _ n T
, - ,., j ha m , _ -� T
- 37. Finai FaMory FirePiace^ . • .r � � i � ' �r � � � ..
38. Final Plum6ing � . .'. r ' � : r. _ _ �-----
� �,.o F' ' �,
l
i
39. Watei Service-Pina��� � � V r 1 i !a ; � ' ."
� r r.
" 40. GasService-Finat -' • �"' ` - � ' �'� -"f' '
t ` - - . _ . ...• : a. .
i
47. Solar pomestic�Final'' �� . z� �, ,-� . -
� - -
42.~Backtiow Preventer.: , �" � F ' -
e'i - a. - t': J �n" T
• - _ ' a 1- "
43. Backflow Irri.gation� -- - t ` . !: `� f •
r._ � ' .. ', r; - r_. ic �:, :' '.. ,�. f ^ C.' .
44..Landscape IrFigation System`�- �, - ,:� J L z - ,` S _ - �
-45.�Sound Atterivatio� - • < -' - , - - • �-o '
Y,
�46. Handicap Regvlatio�s '_ � ` ^ ^ - - � , "
^ 4 t'�
_47.-FINAL STRUCTURE & BUILDING _ I � r � -' 7 � - ' '
48.=FINAL PLANNING' - � ` "� ' �'�• - `r ` E •
F ': n .k r, -
�',49.�.Ele 2ric Release to Edison ;: I� � - ' -
_ �
. ; at _ '. _ ' - .
50.`Ga;�Release to Southern Calif6Ln; Gas Cv ^ � y - '
57. CERT�FICATE OF OCGUPANCY - ' ' ' " ` "
NO Date
. ,.. _. ._.. .._ „; � . .
OWNER DIKE & COLFX'iROVE � DATE i2-z-55
JOBADDRESS 219 �amellia 1'8ri0 BUILDINGPERMITNO. 2119
GENERALCONTRACTOR Dike & Cole�rove VALUE $ 8�5QQ.nQ
LOT j� BLOCK TRACT 2562 Residence & paraee
GROUP I& J TYPE V
INSPECTIONS DATE
Footing Trench � "—�
Foundation Formsand Gradeto Gara e
Rough Framing � ��
Plumbing, Rough o a � � /GG.�
/�'r :S
Plum6ing, Rough Complete � �
Temporary Pole
Wiring, Rough �' / — s
Heating, Rough
Heating, Fin�l 2 „
Sewer. / Sewer, St.
. Lathing, In
� Plastering
Plumbing,
Plumbing,
Wiring, Final
Occupancy
Fmm210(
Fixtures
ZONE
SUBCONTRACTOR
FIREDISTRICT Q]J�Q
PERMITS ISSUED
DATE I NUM61
�i�
� .C�y's_ta Mesa Building DeparLment
� ��,,� � 1N EAST 20th STREET
.y" � COSTA MESA, CALIFORNIA
' �'OR APPLICANT TO �'ILL IN
Building
Address �9 ��],I.j.B T,3II8
Costa 1VIesa, California
Owner
Bui
Nearest
g�ll9 Cross st.
5 zone i
nronnecc or uc.
Engineer Carlson R� Middle b�mk
Address G2Y'dP,II GI'6V8
City Lic.
Contractor D1kH & COle�Y`aVe No. 2`T�
nddress lt].9 E. 17ti1 Si'.., CostB MeBa
(Attach Metes and
Sizeof Lot82_5�
Centeroi
New
SiZe 11'
Exterlor Wall
No. of Bldga
� Now on Lot none
INo.of 1 No.of �
Families Rooms
Rear Vard 7 �
g I I Demolish I
No. of 1
Reoms � 3to�iee
'LECATION FOR PERiVYET �
BUILD,dNG '
OIt O&'&'ICE USE ONI.Y �
._ _ ___Receipt.No. _ __ Permit No. ;
� �. �
`. :: �-/�/ i �
by- Date Rec'd. Date Issued ;
;_ . � - :
/�?- /- s � �,�_ ,? �<a", i
-- �
- t
bosta biesa, California
IPlans I TYPe �/ I SN .�r
_ --,
---, 1 tJ.%i� � ��
. (i�i �`-
.1.+{.�• ._.
. - — ••.� -IYIL.)H
t^J'.i 9r.'.':.i ❑.: n0' bpJ� .�?::
..�•.i'itlyd n. v:��; : „�•a:; ths�tc i
:OLnP� APPRUVALS
& gyI`g�8 Foundatton Loeation Inspeeto
Forms, Materials,
Under-Pinning
Frame: Fire Stops,
I hereby acknowledge that I have read this Application "`��' ��
and state that the above is correct and agree to comply Lath. E
with all City Ordinances and State Laws regulating
building construction.
Signature of Plasten
Permittee 012 Z'O
(Q . Plasten
AuthorizedAgt. G C��-
Mawnr
Valu,ation Permit Fee $ Re •
Plan Check $ , Bond B
$ � ��
5 � Total n �}.n
Fee $ IXtS��V FINAL
F�RM �O4 G-H 2M 5-54
��
OWNER GLOVEft, C.
JOB ADpRE55 219 Camel7
GENERAL CONTRACTOR L. .
�AP No. �$_�_15 LOT 1
INSPECTIONS
SOIL
� GAS
� WRTER
�OUGN PLUMBING
PfiOP. SWR. LINE Q HOUSE CON. �
� �SPRINKLING SYSTEM
� MISCELLANEOUS
ROUGH HEqTING RN� AIR CONOITIONIW
�TEMP00.Apy SERVICE OR POLE
UNOERGftQUNO � POWER �
ROU6H WIRING
TRENCME$ FORMS STEEL R
FLOOR SYSTEM
BON� BEAM �J STEEL REINFORCE
SHEATHIN�
FRRME Fryp F�ASNING
�ATNING — IN r] OUT �]
PLASTER. BROWN COAT
STRUCTUWAL. FINAL
MEATING. VENT., REFRIG. ANO A.C.. F
PLUM91N6, F�NIL AN� GAS TEST ❑
' ELECTRIC. FiHnl
TRACT 2562 FIRE
DATE
SUBCOHTRACTOR
-17-7'
PERMIT
i
�,� 1�
r, =,983 r.� �av „-,�PA�°oo �ss,� �,�*�
COSTA MESA BUILDING-SAFETY DEPART NT
�� �M�F 20.00
P.O. BOX 1200� COSTA MESA, CALIFORNIA 9 26 , .
APPLICATION FOR STRUCTURAL PERMIT
/ For Applicant to Fill in Completely — Use Ink Only REceiyeo e� DATE FECEIVED DATE'ISSUED
BUIIDING �•� `��a ` ".:� 1':.�'._ � ':�.k.i. ..
ADDRESS�/ ` �/` / �
"` � ` O�(! '�// �' R IT NO.
OWNER�.J\ .\G..D ,� "":.; `^a�+�......i`t^. A.P.NO.c . �'"' ".'1 .
MAIL p BUILDING " 'a . 'C � `� �• � p��
1`ADDRE55 ,'�`y`• „+,-. - ADDRESS
�'CITV ._ �C7�.� � •:. i'NE ^�G�._jyO� `` `TRACT /CJ (s s LOT t / .' ..OLOCK~
CAN5TflUCTION � . -- ' ... . • NEWr'ADD: AL7E �R P
LENDER
BRANCH . /' �• .• � ' 't s� . .
. .— . . .OWNER .C�i � .
ADORESS '% �� .`� i . c;; o'.[ �?.'�`\`�,�.:a., � _ ; • ` �
- ��.`'� �i � .: �VALVE'' Ur
� ARCHITECT � ' TEL. USE � U i .. O $/S
� -� •OPoENGINEER+ N
.. - ._ , . "•.. .. . ..-. . . �yFIRE�-'Li.,', .;;, .'J.'l'_ � �'____.i/1';'
t " = a�` ; �'�`;�: �t"i �q_`. C.�
- ADDflESS��..�� %��:, �� .'.�, bG' . -�- . ���.
.�TE ZONEQ NO.OF USE OF NEW�� Q
�� �:�.' �CITV�' � /�%�� �.' .i . NO � � , i�'. t�� � . PLANS .'•� �BUILDING �OV�
H STATE � � %\ _ r• GT.V �''. �AROSAPPROVED, �., ��yqRDSAPP,ROV.EDp
� IIC.NO�.. � .b>"'LIC:-NO.� `�w� �:=>'MA'W�BUILDING�':'.ACCESSORV"BUIIDING,
{�' .SRE ���.� , �. NO:OF�BCDCaS. ' ��FROMGLST=EET) .
G.: :OF`LOT '�1�':\��_: 1'.-.�. `=: /'/ 'O-. (
+:i +'.`i� NOWON�LOT'�. �FflONT 7 .CJT �FT.
¢ �USEOF
•�" ZEXISTING BL� �.a �'G C :`�- . i C .q>S -,/ :`,. ::i �, ' _ ]
n.i � S � FT
� . . � .. ♦ . � _
F� r, �� - Separate permits a�e��iequired for =�.'::,� �_'�` ,j C151DE" 7"FT.�'-`�-� ;�� �� FT. '� �'�
Q electric, plumbing and heating work. � REAR � 3�'FT. FT. '
W USE OF BUILDING AND WOflK TO BE PERFOFiMED
F. DISTANCE BET. BET. MAIN & �
Q � MAIN BLDGS. ACCESS. BLDGS.
� � VAR.aW DATE '
a�JG C.U.P.q� ' APPROVED
' �4�,� G/l GCN�� �IiNP/ APPROVEDiy,io tJ _ �J � /
_._i�., l.—� f/� !
- ,' ' ` . `" . _ ,� � '
� `
W
� I hereby acknowledge thet I have reatl this application and stata �
y� thet the ebove Informatlon is correct and agree to comply with �m �
p+ all laws reBuleting builtling consttuctlon, end I shall not employ .�
�Z any parson in violatlon of the workman's compensation laws.of . � �
� the Stata of Celifornla. � ' . � m
3 I hereby cerNfy that I am properly IicanseA as a contractor under Q. FT. n
the Stata of California Business and Profassions Code, Divislon 3, THE AMOUNT SHOWN UNDER VALUATION IS fOR m
, Chapter 9, entl that such licensas are In full force and eftect, or I THE PUFPOSE OF ESTABLISHING A PERMIT F N V: �
am exempt from the pr sions of tha State of Calitor� Ia�Businass VALUATION PERMIT FEE S a
antl ProfeSsionS e ision 3, I�epter 9. -J - m
�r�� ANCHECK� $ � ^�
Slpnature of - /�j� �n -r-y �
Permittee o � $ �� �/1 TAX E � u
4J C/
Autho ed Agant ' . . TOTAL PAID §
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