HomeMy WebLinkAbout127 CABRILLO ST - Building Permits j
CITY OF COSTA MESA
y' -`, BUILDING DIVISION PERMIT NUMBER
Fr . '"r
DEVELOPMENT SERVICES DEPARTMENT
PERMIT
I' 649-00841
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 128 CABRILLO ST Status: ISSUED
Suite: Applied: 06/09/1999
Vicinity: EAST&WEST PROP.LINES Issued: 06/09/1999
Parcel Nunmber: 42544203 Zoning:
ISSUED BY:
Applicant: SOUTHERLAND, ALAN E
Address: 1115 NORIA ST
Phone:
LAGUNA BEACH,CA Zip: 92651
Owner SOUTHERLAND, ALAN E
Address 1115 NORIA ST
Phone:
LAGUNA BEACH,CA Zip: 92651
Contractor:
Address: -
Phone:
Zip: License:
Arch :. Eng: •
Address: Address:
Phone: Phone: •
Zip License: Zip: License:
SCOPE OF PERMIT
33 LINEAL FEET OF 6 FT HIGH BLOCK WALL ON RIGHT SIDE PROPERTY LINE AND 10 LINEAL FEET OF 2 FT.6
INCH BLOCK WALL BEGINNING AT FRONT PROPERTY LINE ON RIGHT SIDE OF PROPERTY LINE.45 LINEAL FEET ON
LEFT SIDE PROPERTY LINE.
FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $3,000.00
Permit: $74.75 Claim Valuation: $3,000.00
SMIP Res: $0.50
SMIP Corn: $0.00
Other $0.00
Inspection: $0.00
Total: $75.25 •
• 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)754-5628
r il.' I
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 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 permit Is issued.
My workers'compensation Insurance Carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed I/the permit Is valued et one hundred dollars($100)or less)
❑ I certify that In the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these provisions.
Applicant Signature: Date:
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE(5100,000),IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commenting with Section 7000)of Division 3 of the Business and Professions Code,and my license Is In full
force and effect.Lie.# Class#
Contractor's Signature: Date:
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
su acts the applicant to a civil penalty of not more than five hundred dollars(5500).):
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 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 properly who builds or improves thereon,and who contracts for such project with a contractor(s)
license.ursuant ttoo�th ntractors Li .se Laws.).
SCo_ayl�%//fit;4 ?te Business and Professions Code for this reason:
�t,...�. .ate:
• ner ID verified by driver's license. Ja44. 0 No ajar No. . Ex Nes:11-21-2:756
Verification of Ownership by(type of document,i.e.-property tax bill or dee. .
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 Cade).
O 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: Date:
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 0 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 t0 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).
...__._..00_l.. .........(RskManagemen ...
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? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application apermit 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 0 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? 0 yes 0 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 COMPLIANC • D AUTHORIZATI• 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 camp st: : laws antlrdinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described .[ y•r inspec•• pulp.`V:free nate occupy or allow occupancy of any building authori3ed by this permit un fln�)nspection.
. /ee...�a�__ /
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Signa ii Of 1. malfaeners) Date
And/Or Authorised Applicant Date
CODE I INSPECTIONTYPE PATE RMALS CODE. INSPECTION TYPE gAIE 'BMW
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof // 210 Final Electrical
(9
201 Final Block/Retaining Wall Z1_ Lq"!p 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
244646
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TYPICAL 611 CONCRETE BLOCK FENCE
Cement Coping
With
l56 MI --- -II j_1 GENERAL- NOTES
Channel Block With 1.3/8
Horizontal Top of all e! ---- -
Fences H ,—��MN �. MORTAR: One Part Plastic Cement, and
H Three-Parts Sand
For Fences 5'or Less is GROUT; One Port Cement Three and
Si1e �I'. One Half Parts Stand
Ven.Bars 3/8"Ø at 4' .0"O.C. ill o COPING:
a i - - One Port Cement, Three •
u. Parts Sand
For Fences Higher Than 5' I,y a •.ii 'I -, S. CONCRETE: Well Mixed 1:2-1/2: 3-1/2
Veil. Ban 3/8"0 at 32" O.C. )- w - -- -- - - - -
i a Max of 7-1/2 Gallons of
Fill Cells Solid With Grout )�f > z " Ii-I Water Per Sack of Cement
Where Steel Occurs It r -
Reinforcing Steel Shall 1.■I 1' `P �- GROUT MAY BE POURED FROM THE TOP
�Ill�efe ilii _ _ OF THE FENCE IN CELLS WHERE STEEL
Conform to Sec.A-15-39 ' w o OCCURS.
A.S.T.M. ; Z CELLS AND AREAS OF HORIZONTAL REIN
'�I w n ' SHALL BE CLEAR.
DEBRIS.ETC.CLEAN
FREE OF ALL
All Steel to be Lapped ee
24"or to Code
!Bp I I1.11 �-
NATURAL GRADEv�/41Iiffv
mi
,,w„ . fl '
':?g \ 'N 'VMO b
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TWO 7/!"d BARS Iisi t✓0
CONTINUOUS TOP
6 BOTTOM I-A--WIDTH IIII TO 56 0 C MAX ill
SEE CHART
HOQ.ZST EEL MUST BE TIED IN BELOW - DEPTH Cr EARTHTCOTH
PLACE AT TIME OF TRENCH • 1/5 THE HEIGTH OF FENCE
INSPECTION. -BT-LOW BOTTOM OF FOOTING
ID" -1 2" SCALE: 1/2" L. I'
FOOTING REQUIREMENTS CHART
WALL HEIGHT 6' .5f-r-4 3. 1
WIDTH • . . . . 14" . . . 141 . . . . 12". . 12"
THICKNESS . . .10" .10" 8" 8 "
DEPTH OF EARTHTOOTH 24" . 20" 16" . 12"
SPACING OF EARTHTOOTH. 12' . . 14' . 16' 16'
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BUILDING DIVISION
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•THIS SKETCH IS FOR INFORMATIONAL PURPOSES •SOLID WALLS/FENCES BETWEEN 21-6'&6'IN HEIGHT SHALL
ONLY. APPLICANT IS RESPONSIBLE FOR PROVIDING BE SETBACK AT LEAST 10' FROM FRONT PROPERTY LINE.
AN ACCURATE REPRESENTATION OF THEIR PROPERTY
IN CASE THE SHAPE AND SIZE DO NOT CORRESPOND •SOLID WALLS/FENCES SHALL NOT EXCEED 2'6•IN HEIGHT
WITH THE INFORMATION PROVIDED ON THIS SHEET. WI7HIN 10'OF THE FRONT PROPERTY LINE(NOT CURB LINE).
•VERIFY DISTANCE FROM CURB TO PROPERTY UNE
AND SHOW ON PLAN. VERIFICATION FROM THE CITY'S
ENGINEERING DIVISION IS REQUIRED. CALL(714)754-5343
o FOR INFORMATION.
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STREET _
BLOCK WALL LAYOUT FOR BUILDING PERMIT
PLANNING DIVISION
1
s J�_ll�-,
.41
' 17164 FEE RECEIVED
COSTA MESA BUILDING-SAFETY DEPARTMENT MAY 2 8 1957
P. 0. BOX 917 COSTA MESA. CALIFORNIA
FINANCE DEPT. b
For Applicant to Fill In Completely CIT*PBEIcZ IIQI EQL PERMIT
TYPE OR PRINT
BUILDING 429-10-/.3 7— BUILDING
ADDRESS *ter C AsR/j. A o St•
/J COSTA MESA. CALIFORNIA For Office Use Only
/'�
OWNER O V ,v/n4A'/` / S I RECEIPT NO. I PERMIT''��////..// NO.
MAIL /j ��//' rr p �7 RECEIVED BY DATERECEIVED !ATE�jIED
ADDRESS ,L s'i? C�--�18,,4 • /t .-.I .S 72-.176 6 4. 6O /I,-`CO-_a.
CITY GCJSTfI !'/GC/ �- NO.TEL. BUILDING p ('��K�F""� -
// - / / ADDRESS / �-Q - /3 o -/3 .2 •
ARCHITECT ENG NEERA/i R/C KAM/V Nom/V•1/ 7 COSTA MESA. CALIFORNIA
X30 G // FIRE G
ADDRESS `/ I ,�/ ZONE � TYPE U GROUP i �y
CONTRACTOR / I N A 0 - A BYPROV D DATE t//-6 C.
ADDRESS /92 W EL,CA.t /CL - ZONING //��
CITY O74 �'-/
ZONE R.2.4„..„..N.: IVUILDING
OP NEW C a.�,�„K•
LEGALLC.NO.ATE Ae. TNO. Q"O / ESCRIPTION (r • /)/` NM /, v
SIZE / y /6 NO. OF BLDGe. I r�11�+ '] I- kc-
CENTER ,.
OF LOT J00 /(J I NOW ON LOT -' A p NO /� �PC `../ i !�
USE OF �O q , I��s. : 1?•S EVES / \\
EXISTING BLD / f� ___ , -PROVED ALLO ; D_ I
SETBACK LINE FROM N , �I (CENTER LINE ET.) �i Tall
OF STREET / / REAR YARD I FRONT // FT. •� ! �
SIDE YARD I LEFT /4 I RIGHT 9 / R.SIDE 9 FT. // IN. VI
DESCRIPTION OF WORKL.SIDE 0 FT. N. lZ
NEW I ' 0 ALTERATION I D ADDITION 17
REAR toFT. IN, A)
REPAIR I PPROVE. �' C
II MOVING II DEMOLISH I ;�. ,�' 4.31-II-I5
BUILDING -. / " NO. OF I< x •p'' �� . a
SIZE I L ROOMS 2 STORIES / �, �-Y,( -� m j a
COVERINGEXTERIOR WALL.
C.c.,- COVERING JAS IJ P R I0/T I/ i Al E D��` \ `I
USE OF BUILDING AND WORK TO BE PERFORMED �� - I4 _
6 A A -Si ItC
.- 2 .�eC / 'Cl
CO iAi/LW r ; Z 49U/G0//VG I I 11=
I, vRal� ° - `��.aP aovra_ /9 6 _' I n
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I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICAIION THE AMOUNT SHOWN UNDER VALUATION IS FOR L
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- PURPOSE OF ESTABLISHING A PERMIT FEE ONLY " le
PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING 1111yyyy
BUILDING CONSTRU/CATION. �J �/j VALUATION ,/ 14.
SIGNATURE OF ///- 4 / Y9 ���'//.T,.>- i .PERMIT FEE $ a 7
PERMITTEF ///111...CCCiirrrJJJ-t✓l/( '-• V $ / 3`tO� 6. PLAN CHECK s /07 '-
/ P
c Z
AUTHORIZED AGENT 6 U
TOTAL FEE 4
y1,1 ���- cc i� Y' (cam t-1( Lf
I
17184 FEE RECEIVED
COSTA MESA BUILDING-SAFETY DEPARTMENT Mpy311962
P. O. BOX 817 COSTA MESA. CALIFORNIA FINANCE DEPT. 6 L,LC
For Applicant to Fill In Completely 1,41.1c9kMATRI8PiRmIT
TYPE OR PRINT
BUILDINGM�T �J ,o w BUILDING
ADDRESS/AF Jia-./1•71 C 4,/P/L J .F7
D O/
COSTA MESA. CALIFORNIA For Office Use Only
OWNER /lO/ - / • ',P/TC�oN I RECEIPT NO. I PERM M/NO y
MAIL pp r p /� RECEIVED/pFYI DATTILREC IVED DATE ISSUED
ADDRESS �ON /,G u/43' //.� !//C^ p .1,--'%/4-4� ./7 c�,, /6J�Z
TEL.
CITY c p).cr 4 /P7A.54 NO. ADDRESS ( pl p ��3Q - /5Y l< y�� 'L(-�(.'
OR ENGINE p / /I�/ iv TELA^ "97 COSTA MESA. CALIFORNIA
OR ENGINEER R/c�l / /� NO///�-'
ADDRESS /a;;C7 r" / /^�.S/-j FIRE ,
ZONE TYPE Y GROUP
.06:11?N
CONTRACTOR DON
�' BY DATE
DATE b / /./67-..
ADDRESS / 9) 11/161.•1-"-5- /CZ . ZONING
..../t)7__ O.OF
CIY C o ZAMc /// / Q'Oo(g/ (/ I BUUSDONNM
LIQ70./65 2 Q / E . LEGAL
,TSIZE / / DESCRIPTION
OF LOTS/V 6 6 I NO. OF LOT
J /� NOW ON LOT A.P.NO. // 7 - /9z -12 ..-
USE
USE OFVARDS EVES
EXISTING BLDG.GAd;AG6 .5 I APPROVED ALLOWED
SETBACK LINE FROM // (CENTER LINE ST.)
/
CENTER OF STREET �/ REAR YARD FRONT FT. Alle IN.
SIDE YARD I LEFT // I RIGHT / R.SIDE / IN.
DESCRIPTION OF WORK L.SIDE FT. N.
NEW I V ALTERATION I V ADDITION I REAR (/�) FT. �.//_) IN
REPAIR I II MOVING I V DEMOLISH I X APPROVED 4 j DATE Jl�� (�!/
BUILDING/2 y Lei NO. OF /
SIZE /I 6 ROOMS STORIES
EXTERIOR WAJJ�. ROOF
COVERING }`/�APIP I COVERINGI5FYJ' &Lfs,
USE OF BUILDING AND WORK TO BE PERFORMED
DI /WV_ is,- AT
G4ifa ire-
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./ "q �j /Q/9 VALUATION A —_
SIGNATURE OF �I eS /' P—Ar U�IJ IX PERMIT FEE $ %J{ N
PERMITTEE ///,/ r�
$ /`�/ PLAN CHECK $ 41.
AUTHORIZED AGENT u
_
MMINF TOTAL FEE $ ..
1/4
fr CITY OF COSTA MESA \ I , ) ,,./ 17794 FEE RECEIVED
Building Safety Department Il I ti
' r SEP 17 1962
Application for permit for the fabrication and erection �i I /I\ FINANCE DEPT.
of awnings, advertising signs or devices. i -/ 444 y
FOR OFFICPjUSE0ONCOSTA MESA
' LOCATION
Building Site Address Date Issued / /�^ V�� Permit No. /�/ t
�/ r •--- � / _3 S�/' Fire Zone 3 Type Group
Name of Lease � J C/ Phone (O !9_G
- // � / Ste' Approved by �i Date y—
Contractor `Sttaatte, License No. Li .,, ZO NG
address L i --r 7 City �� ,�'�r��p Phone / /0 n/ Zone �/r Use of Bldgs. i���= —��a.
Architect or A. P. No. /I/ 7- Q 7 L-
EngineerState License No. 3
Bldg. Site Address
' address' ' City Phone
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DESCRIPTION Legal Owner ,t %y
Description of awning, advertising sign, or device: , , 2 r
Address
Awnings canvas ❑ metal LI Width: ft. in. Length: ft. in.
City 'wJ� 1676 Phone
Ground Sign ❑ Projection Sign ❑ Roof Sign 0 Wall Sign n Metal Letter Sign Yards Approved. 5 'C
Banner 0 Canvas Sign n Gas Tube Electric Sign (Sub-section 1.44, Ordinance 313) ❑ Large Sign in excess of 8 sq. ft. Setback from center line
Combination Sign n Special Device (other) 0 Explain: of street to front Prpyerty lin in.
•
From grope y 1/me Imoo a ge of sign ft. in.
Two copies of plans and specifications shall be submitted with application for permit for each sign. Plot on Side Yard Setbacks:
plan sheets proposed location of sign and locations of all other signs at site. Minimum size sheets must be 18" ��//��
•y 24" and non-erasable. Left Side o ✓/� ft. in.
�,f within the 10-foot area of front property line, owner is to sign written agreement with the City. Right Side c---12141- in.
/
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Size of Sign — Thickness ft. in. Heigh v` ft. " in. Length ft. in. Building Line Setback from
center line of street �ft. in.
Weight lbs.- ' Height above grade ft. O in. Projection ft. in. Area of Sign I eft. in.
The undersigned hereby agrees to fabricate and erect awning or advertising structure within the intent and �/'
meaning and in strict accordance with the provisions of Ordinance 95, Ordinance 313 (Electrical Ordinance of Height above Grade Q t5. in.
the City of Costa Mesa), and all amendments thereto.
Projection ft. in.
ALL APPLICATIONS MUST BE FILLED OUT BY THE APPLICANT. ALL FOOTING, FRAMING AND ELECTRICAL IN-
SPECTIONS SHALL BE CALLED.
/
Length ft. in.
Signaturi. . •� /, The amount shown under Valuation is for the purpose of Awning Height above Grade - ft. in.
Permitee ai �� /�!.W - 4` P P
establishing a permit fee only. Projection ft. in.
Authorized Ag 84,yr r VALUATION Permit Fee $ -.2 -
Location and size /', J
//,�. �� 1 $ =_ Plan Check $ -sem approved by (�1,`/ • ,0.�-'C // ��,
it�d. by ✓� Date �-�7 Total Fee $ / Date — / • f R/ 4-1----
Form 21.1-1M-11-60—S-B P