HomeMy WebLinkAbout2836 SHANTAR DR - Building Permits 4`,OH Mt. CITY OF COSTA MESA
BUILDING DIVISION
• -•,,; ,I DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
��i� PERMIT
ORaom 04-01121
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 2836 SHANTAR DR Status: ISSUED
•
Suite: Applied: 06/18/2004
Vicinity: Issued: 06/18/2004
Parcel Number: 13944501 Zoning: R1 R1
Applicant: FERGUSON, LEWIS - ISSUED BY:
Address:
Phone:
Zip:
Owner MC LAUGHLIN, ROBERT F TR
Address 2836 SHANTAR OR
Phone:
' COSTA MESA,CA Zip: 92626
Contractor: MC CORMACK ROOFING
,Address: 4091 E LA PALMA -
SUITE D Phone: (714)630-5543
ANAHEIM,CA
Zip: 92807 License: 643700
Arch : Eng:
Address: - Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
REROOF:T/O SHAKE ROOF,FILL IN SPACE SHTG AS NEEDED, 1 LAYER 30#FELT&29 SOR'S OF OWENS CORNING 30 YR.COMP.
ICB0#5443.
• FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $6,000.00
Permit: $125.25 Claim Valuation: $6,000.00
SMIP Res: $0.60
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $125.85
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
•
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)754-5625
1
2446-46(8/00)
DECLARATIONS (3 C )
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-
Wiork for which this permit is issued.
lihave 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'crynpe sedan Insurance carrier and policy number are: �,�3 C^�b(�
,Cartier: Polley-Number- / .! O
V(Thls section need not be completed if the permit is valued of one hundred dollars(8100)or less.) 1\/J
❑ 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, : • agree that' sho Id become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these pro; '•ns. ,
--Applicant Signature: a. i a Date 0 ,D / el
.WARNING:FNLURE TO SECURE WORKERS'COMPENSATION COVE-In WPM AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE(S100,000),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 un erffffrevisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professioo]a Code,and my license is in full
force and effect.Lic.# toEi -/UD Class,x C 3 9 !3
pail; Signature: ^ tan. �wQ D�:� C9(s/ !gia
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.). •
❑ 1,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,Ad 2,Sec.
341,Title 8,California Administrative Code).
❑ 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 Califomia 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? 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 a plication appermit for such construction or modification
from the South Coast Air Duality Management District or from any other air pollution control district or agency? 0 Yes LJ 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 ❑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(Duality 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 COMPUANCE 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,end 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.
Sirgnature •' egal • ner(s) D to
l 0 6/1 6
And/Or Autho'• Applica'
Da
CODE I 745PFCTION TYPE PATE INTTT1AL$ CODEI INSPECTION TYPE PAIL ItL1�lS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof id-04/ 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
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KEN O ' B R I E N & ASSOCIATES
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�q�;Yr ..-.lO al::t �1 r,•ul, ut I0t'' I 1„e IIc1). g•+iiir ,ru 'IL 'JL(MO 71.1-(17:(-ORS l
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•
REPORT OF COMPRESSION TEST
GUNITE TEST CYLINDER
JOB NO: #9000-19
PROJECT: 16X38 Swimming Pool
2836 Shantar Drive, Costa Mesa, California
SAMPLE FROM: Bond Beam - Deep End
ARCHITECT : Tabor Gyimesi
CONTRACTOR: Royal Pools
MIX : 4 - 1/2
SPECIFIED STRENGTH, PS1 :2,000 psi at 28 days
Cylinder No: 3144 3145
Mark No:
Size: 6.0"x12.0" 6.0"x12.0"
Made by: J. Henley J. Henley
Dote cost : April 13, 1965 April 13, 1965
Date tested: April 20, 1965 May 11, 1965
Age of test, days: 7 days 28 days
Max. load to destruction,
lbs: 107,500 105,11%1 12
Compressive strength, psi : 3
3,803 . R 4.
REMARKS : ' "ECEO N
C) MAY 1.2 1965
City of Costa Mesa co
REPORTS TO: %pper� Building Dept. s
City of Costa Mesa, Building Department, 695 N. 19th Street, Cost-Z".Yt : Cal_�4 is
Royal Pools, 8702 Garden Grove Boulevard, Garden Grove, California ��II 9 ��
Signal Construction, 14361 La Jolla, Placentia, California
J. M. Henley, 1973 Newport Boulevard, Costa Mesa, California
Respectfully submitted,
KEN O'LARIEN & ASSOCIATES
April 21, 1965 r
May 11, 1965
By: / ' ( '• I:
RCE ,•35
K.0, B A.FORM-41
4 1514Fs9 CITY OF COSTA MESA
° yFst CALIFORNIA P. O. BOX 317
11.; `'s
� ./d FROM THE OFFICE OF THE DIRECTOR OF PLANNING
�4 'L=am 9a
• �oRPORNtE�\9
November 16, 1965
Mr. Alan Esty
2836 Shantar Drive
Costa Mesa, California
Dear Pool Owner:
The Costa Mesa Planning Department has been notified of the completion
of your swimming pool.
So that your pool will be a safe one and for the purpose of advising
you of your responsibility regarding the requirements of the Costa Mesa
Municipal Code, we quote Section 9298.9:
1. No swimming pool shall be constructed closer than five (5)
feet to any property lines, measured from water line of pool.
2. No swimming pool shall be constructed under any electric power
lines or on any electric power easement.
3. No swimming pool shall be constructed unless the yard
•
surrounding such pool is completely enclosed by a fence
six (6) feet in height and have a self-closing and
locking type gate or gates.
This courtesy letter is directed to you so that you will be aware of
our ordinances and can make a complete safety check of your pool area.
Sincerely/ yours,e
William L. Dunn
Director of Planning
OWNER PACESEIT N. WEST JO VENTURE DATE -22-63
JOB ADDRESS 2826 S11antar Drive BUILDING PERMIT NO. 19128
GENERAL CONTRACTOR indrns Land C.'n •Sny VALUE $ 211/2A-15.Go
AP No. LOT l4. TRACT 1t3 i FIRE ZONE DESCRIPTION OF WORK res alit ear
INSPECTIONS Signature DATE GROUP I&J TYPE V ZONE B1
SoltI=,t`� V-97---k-3" PERMITS ISSUED
Gas SUBCON'P1tAl;TOIt DATE NUMBER
Water OAP a -
Rough om. Refrig. 0 Air Cond. 0
Rough Healing 0-A- (,. X9-1,3 r' to .5-AZ-,C3 '-
Rough Plumbing 4, n /,-27-G3: - / lye y . ✓✓ _/ ,.7-63 /0 . .
Miscellaneous / /-. �7�� _ aa
Prop. Swr. Line B House Con. p St. Swr. 0 9f . (74-7a),1 �J G-47 43 61,5"-d1 �A' •,✓'��
Sprinkling System q'(.
Construction Pole
Underground :0. Power 0 las/
Rough Wiring r"/¶C) e67t4u�asu�..✓ L-rfG- 7- i
Trenches Forms Ir—Steel Reim 'I'd, a Z1 Z.-CC_
Floor System `» 9-2-p—(3
Bond Beam 0 Steel Reinforce ❑
Sheathing jc.y Pt b b-63
Frame and Flashing _ , Z
Lathing— In 0 Out.❑ �'/I( 7 �
-(f f 43
Plaster, brown coat /7/ E'r1i"3
Refrig. 0 Air Con. ❑ Final
Heating, Final UO-Q[ /Q-9 -L7
Plumbing Fixtures, Final f. f /or k-C?
Final Gas Test /4 W 9 t_4
Electric Fixtures, Final � _ A•�`t;
Building, Final -,.00 4.A-t7
OCCUPANCY '
Form BU9—SM-3-63--S-13 P
kHU/LIVED
19 128 MAR-2 2 1963
STA MESA BUILDING-SAFETY DEPARTMENT • FINANCE DEPT.
P.O.BOX 317 COSTA MESA.CALIFORNIA
CITY OF COSTA MESA
For Applicant to Fill In Completely APPLICATION FOR PERMIT .
cjr'el Lel K TYPE OR PRINT ,, i,..-1, L BUILDING ..
// For Office Use Only
BUILDING d• 0 fL. �^
ADDRESS (P yyL��J.�/L) l� RECEIPT NO. PC NO.
COSTA MESA. CALIFORNIA r923-
� ////////JJ ��''JJLL__�� L RECEIVED BY DATE RECEIVED DATE ISSUED
3 OWNER Le?.. �.PQC�LLyT) I MI 1/ t✓ "..--
BUILDING
{/� "/3--E 3 MAR 2 2 pL.fi3
ADDRESS i ;_ ///. --7,-cYZ-f�.C.. ,� BUILDING
MAIL }}jj ��.1FIRE
ADDRESS ��}//� /}�(�
CITY (YAde; //(LC _x NO. p3 ! ZONE TYPE GROUP "• �U
77 _. APPROVED
ARCHITECT t /J� TEL. BY DATE
OR ENGINEER it./�/ p.�// ///�A� NO��3 3� Co I ZONING
ADDRESS '�/77� /�t{.[(d)I�Gyp aid__ L' ((L i ZONP�-� _'/ 1.0.OF I USE OF NEW yam/ -.-
CONTRACTOR
/
(,ii /q/ OI�yLJ ��1 /VVV, ). PLANB -NI BUILDINGo//�L( {/ ,F1
CONTRACTOR �9�-rte' - a
��j ✓ LEGAL
ADDRESS /G s9 .22 c 2CiL DESCRIPTION
/n7 p
CITY dpi 2.2,Oit J A.P.NO. Y�J Vim• 3 t'l
/ r� ` _ NOTE: NO EAVE OVERHANG SHALL BE LESS THAN
LIC.TNO. /�/1 /� NO. S 919-,:,3 , 5 30*TO SIDE OREAR P.L.
EAVES •
SIZENO.OF BLDOS. ALLOWED (U.B.C.REQUIREMENT)
OF LOT a2'CIO 0 I NOW ON LOT • n • YARDS APPROVED .YARDS APPROVED
USE OF MAIN BUILDING ACCESSORY BUILDING
EXISTING BLDG. "' ' �/�n{ �/L STREET/ D
r/l/ REAR YARD
1 t/ FRONT(FROM CSO FT. st1. _ FT.
SETBACK LINE FROM
CENTER OF STREET •
S
SIDE YARD' LEFT 1 V" 1 RIGHT I R.SIDE / / f.�//
FT.
DESCRIPTION OF WORK L.SIDE 1/4" Fr.
NEW ALTERATION ADDITION REAR p 1/FT. IG l
/� FT.
DISTANCE BET. ' BET.MAIN A
MAIN BLDGS. ACCESS.BLDGS.
REPAIR - MOVING - DEMOLISH
BUILDING NO.OF VAR.# DATE
SIZE �.2bO ROOMS 7 Sr RIE R C.U.P.# /�� APPROVED,/]
EXTERIOR WALLI COVE / /�lC' L/ _ �J APPROVE \I V,..AA 3�/ �rj2
COVERING ... /-(Cd COVERING LGSM-(/y.GC- AP T'-V�AA,v\ DATE J
USE
7OF BUILDING AND ORK TOB PERFOQRMIE! ,. ' Fi-f
/ //_ / SY )0 /c25cZt/SQ.FT.J %ao °' 1
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWNUNDERVALUATION IS FOR THE
AND STATE THAT THE A E IS CORRECT AND AGREE TO COM. PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. E .
PLY WITH ALL CITY O INA CES AND STATE LAWS REGULATING
BUILDING CONSTRU ON. VALUATION �/
- / /% tre2 PERMIT FEE $ 7.J
SIGNATURE OF �/ C / m
PERMITTEE -� �' I'AC_� ' O
$ „ 7 E
AUTHORIZED AGENT
TOTAL FEE $ /77,._
OWNER LSfl, ALAN -. - DATE 1/5/65
o JOB ADDRESS 2836 Shantar Drive BUILDING PERMIT NO. 23367
GENERAL CONTRACTOR Royal Pools VALUE $ 3,000.00
AP No. 139-145-01 LOT TRACT FIRE ZONE 3 DESCRIPTION OF WORK Pvt. Swim Pool
INSPECTIONS Signature DATE GROUP J TYPE III ZONE Rl
Soil PERMITS ISSUED
Gas SUBCONTRACTOR DATE NUMBER
Water
Rough Corn. Refrig. ❑ Air Cond. ❑
Rough Heating --
Rough
Rough Plumbing �r1 - /fir -nai.' , -_ /- St-4 r- _-' �[6 a YMiscellaneous ' ' / - i-6_-Cc_ 51y sS=
Prop. Swr. Line 0 ouse Con. .❑ St. Swr. 0
_
Sprinkling System
Construction Pole
Underground ,n Power
Rough Wiring - ,/1,41--�7+ -Z- i-4--- ` S- 3d'e7
Trenches;p— Forms E❑ Steel Reinf. 8, X- --- -� •
Floor System � = _ sr&
Bond Beam j - Steel Reinforce ?Y err ' ", t�590°' " ,,,atm
Sheathing o°v.". • to
Frame and Flashing _ ' n
Lathing— In 0 Out 0 _
Plaster, brown coat
Refrig. ❑ Air Con. ❑ Final
Heating, Final
Plumbing Fixtures, Final aJ//W.
Final Gas Test ' -Electric Fixtures, Final /-- ----- ._
/es7“;e d Y/.=.2 0/15- 7 dayS je'UJ i- /.
• 23367 •
FEE RECEIVED
STA MESA BUILDING-SAFETY DEPARTMENT . JAN 5 1965
P.O.BOX 317 COSTA MESA,CALIFORNIA FINANCE DEPT.
CITY OF COSTA MESA
For Applicant to Fill In Completely APPLICATION FOR PERMIT
TYPE OR PRINT BUILDING
net E. For Office Use Only
ADD
BUILDRESINSG 8'3
Si�N
RECEIPT NO. PERMIT NO.
COSTA MESA. CALIFORNIA 3 3
// �1 . , c-.5
�� --''yy.�T RECEI D BY I is.E gECE1V9. ft!? SU
OWNER` WA-A! GS7`� /6Q �/ ^''/•I (�/�
MAIL ADD ESS 28'3 co Si//^ysaa.6 p7 '- —
ADDRESS
FIRE T
TEL. ZONE TYPE 3 GROUP •..J
CITY NO.
APPROVED
ARCHITECT TEL. BY DATE
OR ENGINEER W/!/.eS NO. - a
ADDR (J �0 2 ZONING ZG� NO.OF USEOFNEW��/ O / I PLANS ' BUILDING
CONTRACT//�, /////����-� •
11 / ,/ ,�•/�//� ,Ly/ 2'l�/ (X
HV �d ./� _ /y4� ESCRIPTION`U r <i� 1 y\ 1 1/ I `�
ADDRHS C Y p /��fT/// "'���111�!!� 9 )�C/ J
CITY 9 1/•"�• _ A.P.NO. � 3 ! l T J` 1c-- 0/
/ / NOTE: NO EAVE OVERHANG SHALL BE LESS THAN
STATE
O. 3 TEL_. p�/ 30"TO SIDE 8 REAR P.L.LIC.
age";
�« EAVES
SIZE 6' IS/- 33 0 u I o.of awn. ALLOWED (U.B.C.-REQUIREMENT/
OF LOT �iN 5-7, 11 Y"I. 1(7 LOW ON LOT YARDS APPROVED YARDS APPROVED
USE OF MAIN BUILDING ACCESSORY BUILDIN
EXISTING BLDG. C7 -- (FROM C/L STREET)
k
CERK FTSE TM FRONT FT.
CENTENTER OF eTREET REAR YARDSIDE YARDI LEFT I RIGHT R.SIDE FT. 1[/
DESCRIPTION OF WORK L.SIDE FT. 7 Fr.
jDISTANCE BET.
NEW ALTERATION ADDITION REAR FT. FT.
BET.MAIN&
' MAIN SLOGS.
REPAIR MOVING I DEMOLISH ACCESS.SLOGS.
BUILDING NO.OF DATE
SIZE ROOMS STORIES C.U.P. APPROVEDJ
/`
EXTERIOR WALL ROOF - CAL �� (,I
COVERING I COVERING - t • ' E ) -- ✓
USE OF BUILDING AND WORK TO BE PERFORMED
l/-
MOLD `EQUIREMENTS
__,, bpe.f.- r , N I
N
SQ.FT. B
I HER:- ACKNOWLED E THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR HE F
AND =TATE THAT •- ABOVE IS C RECT AND AGREE TO COM. PURPOSE OF ESTABLISH I NG A PERMIT FEE ONLY. O
PLY ITH A ORDINANC STATE B REGULATING VALUATION ��n
BUI.DING CON--CTION.
SIGTUREO PERMIT FEE $ J ' j
PERM E AS G '
���� �� �/J ) $ 3000 - - . C. c
AUTHORIZED AGENT //�[4 !!/�G�a-- - •
/J/ TOTAL FEE $ /5