HomeMy WebLinkAbout2785 SAN JUAN LN - Building Permits - —
PIOJEC.ADDRESS: 2785 SAN JUAN LN - UNIT: CITY OF COSTA MESA - BUILDING .PERMIT ' PERM NO: B �J5510U:
DWNER'SNAME: ENGDAHL, ROGER P
r ADDRESS: 2785 SAN JUAN LN , PERMIT NO: B 052005 PLAN CHECK NO: N GOVT: N •SUPF1 N
COSTA MESA,CA 92626
CONSTRUCTION TYPE: •V-N • PERMIT TYPE: STR PURPOSE; ALT
641-5849
•
ARCH/ENGINEER: REG.NO.: JOB DESCRIPTION : T/OFF RESHT REROOF W/ COMP - . -SQ FT:. 3,200
•ADDRESS: • UNIT: -
PEamITTEE: RAY'S ROOFING ( 714 ) 559-9369 CLAIM VALUE: 3, 200 . 00 CALC-VALUE: 3, 200•. 00 GROUP OCC:' R-3> /
ADDRESS: 14571 HIGHCREST 'CI• COMMENTS: T/OFF• ' RESHT REROOF W/ COMP' '
. IRVINE CA 92714 DE+F+FBF*�F**4AF�H****�F�FRH�E***�ERH***�F�r:EAF*�F+E*�F+F***RHE*** **�E **�E*�F+E*********>F***>E*****IEAE* *
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section Z O N I N G R E Q U I R E M E N T S , .
7000)of Division 3 of the Business and Professions Code.and my license is in full torte and effect. • S E T B A C K S •
CITY UC.: 019427 STATE LID.;361042 CLASS C39
p �!/� y3 f MAINBUILDING - ACCESSORY BUILDING --
.--- Date: 5' /'- �� Signature:_ ���/ FRNT; FT IN REAR: FT IN FRNT: FT IN REAR: FT --
IN.
WORKERS'COMPENSATION DECLARATION: I hereby affirm that I haKa certificate of consent to self-insure or a certificate of Workers' LEFT: FT IN RGHT: FT IN LEFT: - FT IN RGHT: FT IN
Compensation Insurance..or a certified copy thereof(Section 3800.Lab.C).
,POLICY NO.: EXP.DATE: '
COMPANY: PARKING REQ: PROV: . PARCEL: 14164301 ZNE: ' 1 REF NO:
J Certified copy is hereby furnished. El Certified copy is filed with the city Building Division. . PLANNING NOTES>
Date: Applicant: •
DEVELOPMENT SERVICESREQUIREMENTS
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (This section need not be completed if the permit is for one hundred(5100)or less).•
I certify that in the performance of the work for which this permit •sued.I shall not employ any person in any manner so as to become
subject to the Workers'Compensation Laws of California. ZONING APPROVED BY DATE:
Date: •57-67- signawre' BUILDING APPROVED BY -
DATE; '
NOTICE:II.after making this declaration.you shout becom to the Workers'Compensation provisions of the Labor
Code.you must foNG coIwith such provisions this pa shi bedeemed revoked. APPLICATION ISSUED BY: >.� DATE• O
CONSTRUCTION LENDING AGENCY: hereby Cfirm that there is a construction lending agency for the performance of the work for _ �!-- _ _ '
which this permit is issued(Section 3097.Civ.C).
LENDER: ************************************ ********************************,*********
ADDRESS: - LEGALIZATION:N - - - FEE S U M M A R• Y, • STRUCTURAL .SEGMENT:Y
OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors'State License Law for the following reason BLDG PMT PLUMBING _EL-CTRIC MECHANIC FIRE SMIP/.RES GRADING '
(Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct,alter,improve,demolish,or PERMIT 63 ;00 ' . ' 50
repair.any structure.prior to its issuance,also requires the applicant for such permit to file a signed statement that he/she is licensed SMIP/NON-R E$
pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of-the Business PLAN
and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by ISSUE FEE • •
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500).
• BUILDING-DIV-> • PERMIT ISSUE PLAN-CHECK TOTAL PAID. DUE
I. as owner of the property or my employees with wages as their sole compensation, will do the work, and the TOTALS----> 63 . 50 0 . 00 0 .00 63. 50, ' 63-. 50 . . 00
❑ structure is not intended or offered for sale(Section 7044,Business and Professional Code: The Contractors'Slate License Law
does not apply to an owner of a property who builds or improves thereon,and who does such work himself/herself or through - •
his or her own employees, provided that such improvements are not intended or offered for sale.If, however the building or REVENUE DIVISION TOTALS--> COLLECTED: 63 . 50 OVER/SHORT:" . 00
improvement is sold within one year of completion.the owner will have the burden of proving he/she did not build or improve . ' BLDG PMMTT PLUMBING ELECTRIC MECHANIC FIRE ' SMIP/TOTT GRAD_I NG PLAN-CHECK
for the purpose of sale).
I.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business 1
❑ and Professions Code: The Contractors'State License Law does not apply to an owner of property who builds or improves thereon
and who contracts for such projects with a contractor(s)license pursuant to the Contractors'State License Law).I am aware
*'*'*'***'*'*'*'****'******'**'*'*'******'*'*'*'*'**'*'**'***'***'*'*'*'***'*'* '*'*'*'**'*'****'**'* ************'*
that proof of their Worker's Compensation insurance should be provided to me. I N D I V I D U' A L 'F E E B R E A K D .O W N
❑ I am exempt under Section: B.8 P.C. .
for this reason: • TYPE QTY DESCRIPTIO N UNIT COST TOTAL. COST
Date, Owner: SFR 3200 REROOF BY VALUE RESIDENINOZONE 1 .00 - 3, 200 , 00
I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505,25533,and END OF EES _
25534 and that I or any future building occupant will/will not(circle one)need to comply with said state codes and the requirements for a q. '
permit for construction or modification from the Air Ouality Management District.Residential construction applications are exempt from
these provisions. a
• EXPIRED
Date'. Applicant. 0C1 f1S
I hereby certify that I have read this application and stale that the above inlormalion is correct.I agree to comply with all city and county incomptele InSp
ordinances and state laws relating to building construction and hereb rite representatives of this city to enter upon the above-mentioned - • -
properly for inspection purposes. �ny�.�
`�' Dare:& /' S I .x �!"`" ` Gate 5 "• "
� 01 00086974-0f3086975 v-A�' 63.50
1641-46 White-Building;Green-Code Enforcement:Canary-Applicant,Pink-Revenue:Goldenrod-Assessor 'q"M1+ ^ -
--1 •
CONSTRUCTION AND PLANNING - PO. y SPA
APPROVALS Permit# Date Inspector APPROVALS Permit# Date Inspector
-
r -
1. Temporary'Electrical Ser'ice or Pole - 52. Pool & Equipment Location ,
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement .
i a it ,
-:3,,,Electrical ConduUtility=Undrgrnd. 54. Forms
.r4. Electrical Conduit--Undrgrnd. 55. Electrical Bonding
�'5.`CS`teel-Reinforcemient 56. Rough Plumbing & Pressure Test ;�
•
I "b6,-Electrical UFER4kGrnd. v - 57. APPROVAL TO COVER-GUNITE
-.:67.<4Footings �`T 58 C. . Electrical Conduit-Undrgrnd. H
8.,Foundation i'. 59. Gas Pipe, U Undrgrnd.,Test • C'
. 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
IL 4_
12. Sewer Cap of 63. Heater & Vent-Final
13. Roof Drains _ 64. Plumbing System - Final
14. Rough Plumbin_"g `r 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final
16. Rough ElectriEWiring 67. Fencing & Access Approval
17. Rough Wiring,Sign 68. APPROVED FOR PLASTERING
18. Rough Electripl-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning - - FIRE DEPT. REQUIREMENT
- • - - - - c...-•;.- Cr. o :d
20:'Roiigh;Factory Fireplace U:r <I.. C "' .r• t'APPROVAL'S-C Permit# ' -"
r. :- 0.d x - . ic, u, Cr' > X. Q
r.
21 Ducts, in Structure, i t.. .. ,r - n i' 70. •Underground Hydro *
22. Ducts, VentiIating.4 %IS 4 -.1: n: 71. Productfr Piping 0 Gas OOil
23-Gas,Pipe Rough &;Test ,.. ; •, `.y r , r 72. Underground FlusFi-c n = 14
24: Roof Framing is I t-: x > ?" " :7354 Undergrn`d.Stora eTank'D Gas ❑011
25. Roof S�eathin "` .11 '1 ^ v• '-
9,Nx a: a . J ?;r x 74: Overhead'Hydro_' �� p
26:,T-Bar Ceiling (Structural) &sMlonocoat ., -, W C w r z 751.- Dry Chemical r -- u:
27.7-Frame and Flast ing mU a7 { 'y'; •mr 76. tory Standpipe :�r ,'r c `1 ,5
28. LaihiniA Siding x, v. '�rL: G 4 n >: ••- •• t. • 77. M FIXED SYSTEFINAL !+' 1
." c•• . .. .. i h - t;c3
"29. Insulation • , g .. _ 178.. FIRE PREV. FINAL , ;� o. r `z '
.t30. DrywallrNailing _y •� ,o I `S ': - HEALTH7DEPi. REQUIREMENT '
. 31. Plaster'Brown Coal t,. ,. I,, ; .,79." FINAL INSPECTION C -T 1 ," - a
•32-Electrical Power Meter-_Final j t: t 180::FOOD CERTIFJCATE ISSUED
X33:-Final Electric b'i ¢ 4, til I I' .' t 1 Notes: �, '" -,t ,
34:•,Final Heating & Air Conditioning �; a ¢; 5 p _
-135 Final Gas Pipe-Test - - - r l • : �° ;. '� tk • . HR- r�
36. Hood orCanopy _ _ re- _ I 'h- f' -_ s n_:; rl + „ ••
, Cr
37.Final Factory Fireplace ' " 'rt kIx' " 11 Iv
-,38. Final Plumbing :f N I _ 1 P' = r-- la al
IF "29. Water Service-Finale I I Y " .Th "0tr1 n W. C
fri ` 'T,40. Gas Service-Final r n = S • C v,� ya
;:41. Solar Domestic-Finals ^ T =' I °" '• e'^" ''-' * ' 1
- +
-'42`-Backflow Preventet - i1 -
__
43. Backflow Irrigation h { z0 ' C
o ,.� 's tAP-AHEUs _,
- 44. Landscape Irrigation System1.,1,-„ a; X +. _ C :r ,, .c it-..-3 .�
45:,Sound Attenuation i--4-.C:• 1' .- '- - 1" ° •` ` -C< 1
3' S C/ ✓,wcd_.:
X46-',Handicap Regulations a• trate.
- :, ,Z . 1g
..,F.N.nc srRcicrVRE& BUrLOING i t "'- ' - _ t
o i
48 FINAL PLANNING ' - i ti :: ;,; ,y '
49;-Ele`ctric`Release to Edison ; II Its; - t.
'50..GasrRelease to Southern California Gas Co l ii _ S `,
,'51.'CERTIFICATE OF, OCCUPANCY . y ; ;R [c. , t c
No._ _ _ Date
41.f,, Applicant to fill In all spaces within heavy border lines and.sign all appropriate declarations.
j CITY Y OF-COSTA MESA ' PERM NO. - - • • TRACT NO. ' LOT NO. BLDG.NO. - - • "' .- ' -- -
CONSTRUCTION PERMIT ;1716 Pa "" - "
�1 _ 'E3054_ II/09_%8_ I � _6.00 .TLi
l Project Address r 7 (FS yaw -J v /(/" S TYPE OF CONSTRUCTION - ..
Owner / . r Phone �• p t - - - -
K A9 Q Q� �j�-�pp : ❑ NEW ❑ ADD ❑ALTERATION ,
Address S .e - -t - . 0 REPAIR 0 CONVERSION ❑DEMOLISH
.Arch/Eng. - - - License No. 0 OTHER. '
'Address .. DESCRIPTION OF WORK
,Contractor �j„ ��•
d Phone 37_ i7 a - TYPE OF PERMIT -- - -
c • -•
Address // �� G; - ❑ GRADING ❑ FOUNDAT,,II�O�NN 0 STRUCTURAL- --' SIDE VARD - - _
•
LICENSED CONTRACTOR OEC LA-'-TION - �-TENANT- ❑ ELECTRICAL LHPLUMBING OMECHANICA SIDE YA'• - - - - - -
I hereby affirm that I am licensed under provisions of Charter 9(coin- j - RIGHT . '
mencing with sectIon• 7000) of -Division -3-of the Business and -❑ OTHER - -
Professions Code, and my license Is in full force aif fe L REAR YARD(TO P/L) _
• PROJECT DESCRIPTION _ _ _ _
Llcens Class - • Li ;Ise No • . - PKG.SPACE REQ. PROVIDED'
Date.”----4 Signature - - SQ. FT. • _ _
WORKERS'-COMPENSATION DECLARATION - .. . OCCUPANCY_CONSTRUCTION TYPE• STREET WIDTH PARK FEE$ • '
1 hereby affirm that I have a certificate of consent to self-insure or a VALUATION ZONE ZONING APPROVED BY- I DATE . - -
certificate of Workers' Compensation Insurance, yrp certified copy - __
thereof(Se oc34,C ,J2br C.). j / / GRADING CU.YDS. ACRES SPECIAL CONDITIONS: -, s
Policy No. C1 cCO// Company �--1/`_ - ._ _. __ - _ _ '
0 Certified copy is hereby furnished. . . REMARKS: • - . _ - .
tified copy is filed with the city Building Division. .
mor
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION - _ -
(This section need not be completed If the permit is for one hundred - - i
($100) or less), - - - ' - - -
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- -PLUMBING . - • PLAN CHECK - ELECTRICAL PLAN CHECK ,
subject to.the Workers.Compensation Laws of California. . . - uWhLLING t.ARAG7= -
Date Signature • BATHTUBS SHOWERS - - • • -
tothe : If after making this declaration, you should become subject TOILETS- , URINALS GENERATOR 0-1 •Kw_1-30 KW • • 1
to the Workers' Compensation provisions of the Labor Code,you must - TRANSFORMER
forthwith comply with such provisions or this permit shall be deemed LAVATORIES DOUBLE'LAVS APPLIANCE 10-50 KW50+ KW - f
revoked, •. - __ _ _
CONSTRUCTION LENDING AGENCY KIT.SINKS' '- - -DISHWASHERS MOTORS 0-1-HP_1-10 HP
I hereby affirm that there Is a construction lending agency for the per- SERVICE SINKS ' ' SUMPS (INC.SOLAR) 10-50 HP 50+ HP '- -
formance of the work for which this permit is Issued (Section 3097 • - -
Civ. C.).- • - - ' - - FLOOR SINKS FLOOR DRAINS FIXTURES OUTLETS SWITCHES
Lender's Name _ _ _
Lender's'Address DRINKING-FOUNTAINS - -- - GAS TUBE SIGNS - - -
OWNER BUILDER DECLARATION - INTERCEPTORS CLARIFIERS 'POLE'LiGHTS - '
I hereby affirm that I am exempt from.the Contractor's License Law for
the following
reason 7031.
(Section 031.es Business loess todto roessins u Code: L SWIMMING POOPTRAP - ONUL ION
Any city orng countywhich requires a permit construct, alter, POLESNSI t, METERED
improve,demolish or repairanystructure, prior to Its issuance,also re- WATER SERVICE. ALTERATION' PANELS ' MAIN' ' SUB
quires the applicant for such permit to file a signed statement that he -
Is licensed pursuant'to the provisions of the Contractor's License'Law- SERVICE OUTLETS 'SERVICE - -- ' AMP
(Chapter 9 (commencing with Section 7000)s of Divisioner3 of the
�®
Business and Professions Code) or that he I5 exempt therefrom and th- , • ^2
basis for the alleged exemption. Any violation of Section 7031.5 b
any applicant for a permit subjects the applicant to'a-civil penalt •s. -
of not more than five hundred dollars ($500).
0 I, as owner of the property, or my employees with wages ai their SOLAR TANK
sole compensation, will.do the work, and the structure is not intended
or offered for sale, (Section 7044, Business and Professions Code; The SOLAR PIPING SYS.
Contractor's License Law does not apply to an owner.of a property
who builds or improves thereon, and who does such work himself or 3 ,r d APPLICATION APPROVED BY • '
through his own employees, provided that such-improvements are not
intended or offered for sale. If, however, the building or improvementMECHANICAL PLAN CHECK SUMMARY -
Is sold within one year of completion,the owner will have the burden
'of proving he did not build or Improve for the purpose of sale). SYSTEM 0-100,000 =
❑'I{ as owner 'of the property, am-exclusively 'contracting with • DHEATINGUCTINGit
licensed contractors to construct the project (Section 7044, Business 100,000 and Professions Code: The Contractor's License Law does not apply to
an owner of property who builds or Improves thereon, and who con- REFRIGERATION 0-100,000 :
tracts from'such 'projects'with a contractor(s) licesned pursuant-to
the Contractor's License Law), 100,000
❑ I am exempt under Section • B.& P.C.for this
I •
. BOILERS BTU
reason - - PLAN CHECK §
Date Owner - _SYSTEM REPAIR,ALTERATION ' " 7 TOTAL FEE 8 ‘••./0 0
-
I-hereby certify that I have read this application and state that the above EXHAUST SYSTEM MULTIPLE LESS AD- 1
information is correct. I agree to comply with all city and county
ordinances and state laws relating to construction,and hereby authorize
representatives of Os city toe r upon the above mentioned -— f I
FINAL FEE $ 6 .0Property.for 0y ec ,•n pure•
Signature .6\ s Date�t ire- (y M.
,
Drivers'License or SS 9• * '-/ •/yam
CMF 0865-46 White-Building;Canary-Applicant; Pink-Accounting;Goldenrod-Assessor If
s`e.
CONSTRUCTION AND PLANNING • .POOL&SPA. .
JT ':O.d iptlu� u'+rr Date Inspector Date ,Inspector- :
APPROVALS Permit # APPROVALS Permit# -
1. TemporaryElectrical Service or Pole t L-'
Q 43. Pool & Equipment Location
2. Soil Pipe•Undrgrn 44. Steel Reinforcement' • - '
- 3. Electrical Conduit Utility-Undrgrn 45. Forms
-4. Electrical Conduit-Undrgrn - . . _ 46. Electrical Bonding - •
5. Steel Reinforce47. Rough Plumbing & Pressure Test '
. 6. Electrical LIFER Grn 48. APPROVALTO COVER-GUNITE .
7. Footings - 49. Electrical Conduit-Undrgrn
8. Foundation 50. Gas Pipe, ❑Undrgrn,Test •
9. Water Pipe-Undrgrn 51. Backwash Lines. P-Trap. ❑Undrgrn
'_ 10. Structural Floor System . 52. • APPROVAL TO DECK
11. Property Sewer Line & House Connection 53. Backwash & Receptor-Final •
12. Street Sewer Connection _ . . 54. Heater & Vent-Final _
13. Rough Plumbing 55. Plumbing System -Final
14. Rough Electric-Conduit - :56. Electrical-Final •
15. Rough Electric-Wiring 57. Solar System-Final
16. Rough Heating &Air Conditioning b8. Fencing&Access Approval
17. Ducts, in Structure 59. APPROVED FOR PLASTERING .
-18. Ducts, Ventilating - . . . • .
19. Gas Pipe-Rough &Test 60. POO L/SPA'SYSTEMS FINAL '
20. Roof Framing
21. Roof Sheathing
22. Frame and Flashing . -NOTES: - ,
23. Insulation •
24. Lathing & Siding -
25. Drywall Nailing - - .
26. Plaster Brown Coat .
27. Electrical Power Meter-Final . . - .
28. Final Electric -
' 29. Final Heating & Air Conditioning -
. 30. Final Gas Pipe-Test . ,
31. Final Plumbing "Hi/ Ss
32. Water Service-Final .
-
33. Gas Service-Final .
' 34. Solar Domestic-Final ,
35. Landscape Sprinkling System
36. Sound Attenuation . ,
37. Handicap Regulations V -
38. FINAL STRUCTURE & BUILDING '
39. Special Requirements Completed .
40. Electric Release to Edison
41. Gas Release to Southern California Gas Co.
42. CERTIFICATEOF OCCUPANCY . .
No Date .
IP _ .,n9-6-6-QCIcosTA 7nO2 ****99:00
189021
COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX 317 COSTA MESA. CALIFORNIA
For Applicant fo Fill In Completely APPLICATION FOR PERMIT
p TYPE OR PRINT BUILDING
BUILDING
ADDRESS 2785 San Jnnn Ln.
COSTA MESA. CALIFORNIA For Office Use Only
RECEIPT NO. PERMIT NO.
OWNER Nes Del Mar Develnnment I+ O_. (8J9 2
MAIL RECEIV O BY DATE CEIVE D YB ISSUE
ADDRESS 3800 E. Coast Hwy. - � I � et EI I 1 6 isi:d
CITY Corona Del Mar No.UR 34220 ADDLRESS
ORCENGE EER MR-C CO Realty CO. NO.TEL.OR 3LtL20 COSTA MESA. CALIFORNIA /�
ADDRESS 3800 E. Coast Hwy. FIRE
ZONE TYPE— GROUP & Sy
CONTRACTOR MaCen Realty CO. APBY
DATE
ADDRESS 3800 E. Coast Hwy ZONING 46 ,ZONA. 1 NO.OP USE OP NE
CITY Corona Del Mar ' jt 4'F r I PLANS �BUILDINtLn%1/((�
9
UOTNo.2073)13-A-SB-I TEL OR 3),220 DESCRIPTION` ` T.nt. /in Tract, 1,808
1
SIZE 1 NOBLOTS
OFLOT 660Q S F: NOWWON LOT None A.P.NO, j\.-�---
USE OF None YARDS EVES
EXISTING BLDG. - APPROVED ALLOWED
SETBACK NE FROq q (CENTER LINE ST.) _
'414/j'
CENTER OPLISTREET 4�1 REAR YARD22I FRONT FT. J IN.
SIDE YARD I LEFT 57 I RIGHT 101
R.SIDE I ` V FT. IN.
DESCRIPTION OF WORK- t-,--
L.SIDE ✓ FT. IN.
NEW X I II ALTERATION I II ADDITION
II I II DEMOLISH I APPROVE:_}' �/ IN.
REPAIR��aa,, 'MOVING BYt-..,4111LA,W\ DATE&�� ��
SIZE DINOlI-61tX5u1211 ROOMS 6 STORIES 1 - J
~
EXTERIOR WAI.L„atllCCO I ROOFIOOd shake & Rock
COVERING 6C 00CC11 COVERING
USE OF BUILDING-AND WORK TO-BE PERFORMED
1 Single -family res. w/att. gar. Living Area: 1896 S.F.
Plan # hon-A Garage Area: L:83 S.F.
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 t //
SIGNATURE OFPERMIT FEE $ Imo"
PERMITTEE Mesa Del Mar Development- / Co._ 20,288.00
^� a
By�"�i/�11P�� s20,268.00 PLAN CHECK $ J9 E
AUTHORIZED AGENT ��,�-L�-�� �! z
TOTAL FEE • $ 9/ � �
11 /