14821 SW KENTON DRIVE .«w...++�,.».w+.,wa..m�,.ww+w..«,...,�...awwryur.ro �+:w�www�+..w+��n4wr+u.>,ynw,wy1FM"twit�wMrN+IMVMA ra+warWWnwr.i w..wuw�Wwon'wwn..We+n.aa/YAkpWWy.pyiyRWq�►1A151Ww..' .+r+Cw�4tk.MwlK�'r".NWkM#M►'WMln
T
14821 SW KLw .ri: ORTVE -
CI1YOFTIGrARD CrFYOFTIOND CERTIFICATF OF
COMMUNRY DEVEMIMENT DEPAMMENT 0914*" n( r.tjpAN(l.Y
13126 SW HWI Blvd.P.O.Sm 2V 1.Tip,, -W 97?23("A*75 PFRM.1'r #. . . . . . . , M3131-0243
140F ISSUED: 06/25/92
`!ITE ADDRESS. . . i t46c'-1 SW KENTON DR PARCEL.: 2SI12Cd--AQ149
'IJBI)I V 113 1 ON. . . . a ASHFORD OAKS 3 ZONING R-7
+LOCK. . . . . . OT. . . . . . . . . . . . . 1149
--- ---------------
CLASS OF WORK. 3NEW
OF USE. . . :SF
OCCUPANCY GRP. ik-i
FICCUPANCY LDAD1225- 4
-11.-NANT NAME. . I
Rem&rkv :
MELVIN WAYMIRE
00 BOX 231164
TIGARD OR 97223
Phone #s 639-t,748
Lontractors
MELVtN W AYMIPE
PO 8,)X 231164
TIGARD OR 477`23
Pho;le *:f 631674c'
Ring #. . 4 35976
occupency of the above referenced building is 1-vreby given, and r2ertifies
the compliance with the State OF Oregon Specialty Codes for the grout-.1,
oce:ur)A.TlCy, And use unden which the referenced permit wig i %nuecj.
FIRE DCPARTMFEN7— 49ILDING TN--
el e—
FICIAL
POST IN CONSPICUOUS PLACE
Tmi NOTICE
City of ?!i.gard Building Department
13125 SW Ball Blvd. Tigard, Oregon 97223
Inspection Line (Rec-O-Phone): 639-4175 Runi.neas Phone: 639-4171
Inspections —�—
rooting Plbg. Underalab Mech. Rough--in Appr/Sdwlk
Found. I'.bg. Top Out Gas Line FINAL:
-Bl
dg.
`1
Poet/Beam Struck. San. Sewer Fraening . fInsulation -PU3
Poet/Beam Mech. Rain Drain =-Mech.Plbg. Underfloor Water Line OYp• Rd.
Date Requonted:�
/y Permit it
Addreen:_ IJ.L rr
---------
Builder. -41
ullder: -41 �! REQUIR _
THE
pOLLOAR
WINO CORRECTION E ED:
Inepecto
Date: I f�
APPROVED DISAPPROVED APPROVED SUBJECT TO ABOVE'
Call For ReineP.
INSPI�CTI9N PO��CE
City of Tigard Building Or:partment. /!
13125 BW Ball, Blvd. Tigard, OrEKmn 97223 : �_
Inspection Line (Rec-O-Phonel: 639-4175 Huai-neer Phone:l634-4171
Inspection:
Rooting Plbg. Underslab Mech. Rough-in Appr/Sdwlk
Found. Plbg. Top Out Can Line FINAL:
Post/Beam Struct. San. Sewer Framing -Bldg.
Pest/Beam Mach. Rain Dra.'-n Insulation Plumb.
Plbg. Underfloor Water Line Gyp. Bd.
-Hoch.
to Requested:_ ��+ J 1 X _
Time: _AM
..cess:.`y lY / / /il7l�/ Permit #iY—z -�1 �
Builder: _ =RM
THE FOLLOWING ODRRECTI EQUIRED:
a
I
Inspector: Data t
_ `APPROVED DISAPPROVED ` APPROVED SUBJECT TO ABOVE
—Call For Reinsp.
�NSYBCTION NONCE _x�
city of Tigard Building Departaent
13125 ON Hall Blvd. Tigard. oragon 97223
Inspec*ion Line (Rec-o-Phone): 639-4175 Business Phone: 639-4171
T n a Fec t ion: --��
Footing Plbg. Underslab Mach. Rough-in Appr/Sdw1Tr )
Found. Plbg. Top Out Gas Tine YINA ,s
Poet/beam Struct. Ben. Sewer Framing -Bldg
Post/Beam Hoch. Rain Drain TnnulatLon -Plumb.
P1.hg. Underfloor Water Line �j Gyp. Bd. -Hoch.
Date Requested!— J
iJ ( Z.r --Time AH ---PH
Address: � Perm 14-
Bui_lder:_— __ - ------- -'
THE FOLLOWING CORRECTIONS ARE REQUIRED:
i
vx
Z c w 0 C>� J C c�Vl, LJ 1 9-
LY
----�
Inspector: Lv� ;azet-' Date:
App�D DIBPP APPROVED SUBJEC^ TO ABOVE
Call for Reinap.
INSPECTION NOTICE `
City Of Tigard Building Department
13125 HSI Hall Blvd_ Tigard,
n 97223
Inspection Gine (Rec-O-phone): 639-4175 Business Phones 639-4171
Inspections
footing Plbg. Underslab _Y
Meeh. Rough-in Appr/Sdwlk
)Pound.
Plbq. Top Out Cas Line
FINAL:
11a Struct• San. .Sewer
Framing -Bldg.
Poet/Hoam Ho,:h. Rain Drain
Insulation -Plumb.
Plbg. Underfloor Water Line
_ � -Rech.
Data Requested, _r ;
_Time, \ AM PH
Address,
- Permit
Builders L (° -
THE FOLLOWINGS CORRECTIONS ARE RRQUIREn:
inspector: -
n ___ ___spector:
APPROVED DlShPpROVp[r
__---- APPROVED SUBJECT TO ABOVE
Call For Reinsp.
IE('TION N iCE i
City of Tigard Building DePar—It
13125 ON Ball Blvd. Tigard, Oregon 97223
Inspection Line (Rec-O-Phone): 639-4175 Bueineee Phonei 9-4171 1
I n spect ion• —_--
Yooting Plbg. Underelab Nech. Rough-in Appr/Sdwlk 1
Pound. Plbg. Top Out Gas Line FINAL:
d
Post/Beam Struct. San. Sewer Framing -Bldg.
Past/Beam Mech. Rain Drain
Insulation -plumb.
8d. - .
Plbg. Underfloor /Water Line h
/
Date Roqucaeted:— �[-.:<T PN
Addreon:
Permit 1s-`
Builder:_ -,�
THE FOLLOWING WR IONS ARE RBQUIRED:
Inspector Date r
APPROVED DISAPPROVYD APPROVED SUBJECT TO ABOVE
Call For Rainsp.
LNSPL+CfIt'N NOTICE
City of H9ard Bu,lding Department
13125 BW Ball Blvd. 7'ticard, Oregon 97223
Inspection Llne (Roe-O-Phone)s f.10-4175 BusineeR Phone: 639-4171
Inspection:.____ _ ---- -�
Footing Plbg. Underslab Mach. Rough-in Appr./Sdwlk
Found. Plbg. Top Out Gas Line FINALt
Poet/Beam Struct. San. Sewer Framing -Bldg.
Poet/Beam Mech. Rein Drain Insulation -Plumb.
Plbg. Underfloor Water Line Gyp. Bd. -Mach.
Dat" Requestedt4 �Tt All ✓ ��PM
Address:_� � = � 7 G - Permit #2!&_
Builder: �-
THE FOLLOWING OORPJ1qj ONS, ARE REQUIRED:
i
inspector: Dates
AFFRMI) DISAPPROVED APPROVED SUB.TEC'r TO AROVS
Call For Reinsp.
INSPECTION NOTICE
Citp of Tigard Building Dopa=tent
13125 8N Ball. Blvd. Tigard, Oregon 97223
Inepertion Line (Rec-o-Phone): 639-4175 Bueinene Phone: 639-4171
Inspection:
Footing Plbg. Underslab Mech. Rough-in Appr/Sdwlk
Found. Plbg. Top Out Gas Line
PLNAL:
Pont/Beam Struet. Ran. Sewer Framing -Bldg.
Puet/Beam Hoch. Rain Drain Inaulati.on
-Plumb.
Plbg. Underfloor /l Wafter Line Gyp. Bd. `� ,,-MMach.
Date Requested: a7 �L/ `� Xf
PM
Address: Permit /:
Builders
THE POLLOWING ODRRECTIONS ARE UIRED:
Inepectors� _. Dates�,<�-�i/
�/TAPPROVED DI51►PPROVED y _ APPROVED SUBJECT TO ABOVE
____Call For Reinap.
f
f
NS EC1'I0 N(ITICS �/
City of Tigard Building Department l_
13125 SN Hull Blvd. Tigard, Oregon 9722 -
Inspection Line (Rec-O-Phone)s 639-4175 Bu::iness Phone 96 9-4171
Inspect ion:. --
Footing Plbg. Underslab Mech. Rough-in Appr/Sdwlk
Found. i Plbq. ToF Out Gas Line FINAL:
Post/Beam Struct. 'an. Sewer Framing -Bldg.
Post/Beam Mech. Rain Drain Inwilation -Plumb.
Plbg. Underfloor Nater Line Gyp. Bd. -Mech.
Date Requested: __.---- Time: AM �PN
Addross:_1 ; ��_-- Permit 1e�_� L�-•
HR FOLLOWING CORRECTIOeS ARE REQUIRED:
A
Inspector -�� ` Date:
APPROVED DISAPPROVED APPROVED SUBJECT TO ABOVE
Call For Aeinsp.
ZN PS IO�I.NOTA
City of Tigan Build.
13125 Bp Ball Bl,,d. TldingPa
Derteent
Inepacri,on Line (Roc-O-Phone): 63igard Oregon 97223
Inspection: Business Phone: 639-4171
Footing
Plbg. Undarela�, M
Found. 111- Rough-in
Mg. Top Out APPr/sdwlk
Can Line
et/Beam struct FINAL:
-- S
--.. en. Sower
By Framing
Pont
/ am Mach. -Bldg.
Rain Drain
Insulation
Plbq, Under~ioor -Plumb.
Nater Line
Date Requested, 3 GYP. Bd.
—/_' -Mach.
Addrees e`�y
•-�rt•��L./ Gam.. -���PM
Ruildere —• Permit
TNTC FOLLOWING - c�
Q CTIONs ARE RSQUIRSD: --- "-
--Lzi `t-
Inspector
'_�APPROVEb -- Dater
DISAPPROV]R L
_ APPROWD S[.,"CT
__C411 For Reinap. ABOyE
1NSPECTIQN N'YT109
City of Tigard Building ' ♦rtment
13125 SW Hall Blvd. T'-y--I, egon 97223
Inspection Line (Rec-0-Phone)s 639-417S usinese Phones 639-4171
Tooting Plbg. Underelah Mach. Rough-in Appr/Sdwlk
Out Gas Line FINALS
Found. Plbg. Top �
/-�
Pont/Beam Struct. •tSan.--lowo",
Framing -Bldg.
Poet/Beam Mach.
rain Insulation -Plumb-
Plbg. Underfloor L q Gyp. Bd.
C� ! 2 ' ( 2- Times —._.-AM
Date Requested: —
J C j:2- ( perm Lt
Address:.
Builder:
TIIE FrOLLOWING CORRECTIONS ARE RRQUIREDs
Inspectors —_----
Date I
APPROVED DISAPPROVED APPROVED SUBJECT TO ABOVE
call For Reinsp.
`j
INSPECTION _NO_T10E
City of Tigard Building Department
13125 817 Ball Blvd. Tigard. Oregon 97223
Inspection Line (Rec--O-Phone): 639-4175 Bueineee Pho s 6 -4171
Inepeation:
-- ---- _�_—_— ��
Footing Piby. Underslab Hoch. Rough-in Appr/Sdwlk
Found. Plbg. Top Out Gas Lina FINAL:
Poet/Beam Struct. San. Sewer 1*raming -Bldg.
Poet/Beam Koch. Rain Drain [nsulatlon --Plumb.
Pl.bg. Underfloor Nater Lille Gyp. Bd. -Mech.
Date Requesteds -Time: _ AH PM
Addreaat ( — Permit #: s._l J —i
Buildarl
THE FOLLOWING CORRECTIONS ARE REQUIRBD:
C
fi
a
— --- -- ------- ---
Inepeotorl
-_
APPROV20 DISAPPROVRD APPROVRD SUBJECT To ABOVF
Call For Rainap.
CITYOFT167ARD '
MASTER P'ERMIT
COMMUN.,Y DEVELOPMENT DEPARTMENT oR@ac oon r-r_RM I T #. . . . . . . : Mei 9 l
13126 SW Kdl Bhrd P.O.B 23387,T*d,Ore07223(50318.98.4176
639-4171 --- D--AE ISSUED: 03/05/92
SITE ADDRESS. . . : 14821 GW KE ETON DR PARCEL: 2 S 1 12CB-•A0149
SUBDIVISION. . . . : ASHFORD OAKS 3 ZONING: R--7
BLOCK. . . . . . . . . . . 1-01 . . . . . . . . . . . . . : 149
__...__________.____,_.-.-•-----___.____ BUILDING
RE I SSUE: DWELLING UNITS: 1 BASE':MENT. . . . . . . . ..0 s f
CLASS OF WORE;. :NEW 1_EDRMS:4 BATHS::3 GARAGE. . . . . . . . . . :418 s f
'TYI:'E OF USE. . . :SF= FLOOR AREAS------------- REQUIRED SETBACKS-------
TYPE
TRACKS-____.._-..__-_.-__TYPE OF CONST. :5N FIRST. . . . :899 sf LEFT. . -0 ft RIGHT. : 10 ft
OCCUPANCY GRP,. :R3 SL_COND. . . :871 5f FRONT. :20 fit REAR. . :.34 ft
STORIES. . . . . . . .2 'rHIRD. . . . :O sf REQUIRED-----------.___--_._.-
HEIGHT. . . . . . . . :25 ft TOTAL----------: 1770 of SMOKE DETECTORS. -,Y
I-LOOR LOAD. . . . :40 psf VALUE. . . . . $ 88944 PARKING SPACES. . :O
Remar^ks :
F''LUMBTNC
SINKS. . . . . . . . . . .. 1 FLOOR DRAINS. . . . :0 BACKFLOW F'RF VISI TRG. . :10
LAVATORIES. . . . . :4 WATER HEATERS. . . : 1 TRAPS. . . . . . . . . . . . . . :0
TUB/SHGWERS. . . . :2 LAUNDRY TRAYS). . . :0 CATC:Fi BASINS. . . . . . . .0
WATF':R CLOSETS. . .3 SEWER LINE (ft ) . :0 GRFA E -rRAPS. . . . . . . :0
D19HWAGF•ICRS. . . . i 1 WATEP LINE ( ft ) . : 100 OTHER FIXTURES. . . . . ..17)GARBAGE DISC'. . . : 1 RAIN DRAIN (ft ) . :0
WASHING MACH. . . : 1 SF R()I N DPA I NS. . : 1
-------- MECHANICAL ..-.._._.---- FEES
FUEL TYP,ES------------ UNIT HTRS. . :0 type amo'_Ir7t by date recpt
/CAS/ / / VE:NT'c . . . . . :0 TIF $ 1.380. 00 JLH O3/05/92 -
MAX INPUTcO BTU VENT FANS. . :4 BPRT $ 400. 00 JLH 0.3/05/94_ -
FURN ( 1O0K . . : I HOODS. . . . . . : 1 BF-'LC $ 40. 00 .JLH .12/23/91 221091
TURN > -100K . . :0 WOODSTOVE5. :0 B5PC t 220. 00 JL_H 03/O5/92'' --
FLUOR FF'URN. . . . :0 CLQ DRYERS. : 1 SSDC $ 280. 00 JLH 03/05/92' -
BOIL./C14P ( 3HP'.0 OTIAER UNITS:O F'ARK 4 500. 00 JLH 03/0`.3/9;_
GAS OUTLETS: 1 MP,RT $ 39. 00 JLH O3/05/92 -
(:)Wner ___..._.._.___._._.___...._....__._______._.___.__. .___._ MPL.0 t '). 75 JL..H 03/05/92
MLLV I N WAYMI RE M5F-*,C $ 1. 95 JLH 03/05/92 -
t='O BOX .;1. 164 F'PRT 4, 140. 00 JLH O3/05/92 -
P'SF'C 4 7. 00 JLH 03/05/92 -
TIUARD OR 9 , ` PIDI A." 4• 15. 00 JLH 03/05/92 -
Phone #: 63'?
r. ontr-a tov-,
MELVIN WAYMIR
PO BOX 231164
T IGARD OR 97223
1='hone #: 639-674
Req #. . . 35976 _._-_____.._.___.___.__._.___._____..____._---_-__
3 2832. 70 'I 01 AL
This pereit is issued subject to the regulations contAined in the -- -- -- REQUIRED INSPECTIONS - - -----
Tigard Municipal Code, State of Ore. Specialty Codes and all other Foot/foornd Insp Fi-eplace Insp
applicable laws. All work will be done in accordance with approved Floc-;t/Beam Str^l.1ct Gi.s Lint, Insp
plans. "h:r per@it ;ill Pvp4re if work is no: started within I8@ F='ost/Beam Meehan Ins�llation Insp
days of issuance, or if work is suspended for @ore than 188 days. p'Im/Lindslab Insp Gyp Board Fnsp
1'L._M/Under^floor Frain dt-ai.n Ir1sp
H Ear^mittme! Sigitat�ar'e : _,.•_.. . .___.____._._. ---..---...._.__.
Mechanical Insp W. er Line 1nsl�
plumb Top Oi.It Appt,/5dW11t Insp
IsiSLIe t By _....__. _....._ .... ...__ _.___. . 1;r•amin9 Insp hle .:1<�nicaI Final
Call for inspection - 639-4175
wCWTIGrARD --lanD PLUMBING PERMIT
COMMUNITY DEVELOPMENT DEPARTMENT mi7 PERMIT 4. . . . . . . :
13126 8W HWI Mod P.O.Bm 23307,T*M,O"Wn 9=(503)630,4175
.)ITE PDDREFS. . . : 1.466 1. SW KENTOC DR PARCEL: c2G112CB--A()ti
`3UbT)IV I SJe'q. . . . : ASHFORD OAKS 3 ZONING: R-7
BLOC". . . LOT. . . . . . . . . . . . . : 141)
�-:L.ASS OF WORK. . -NEW GARBAGE D I SPOSALS. . . 1
FYPIE OF USE. . . . :SF WASHING MACH. . . . . . . : 1 BACKFLOW PREVNTRS). . :0
OCCUPANCY GRP. . :R3 FLOOR DRAINS :0 TRAPS). . . . . . . . . . . . . . ;0
f OR I _5. . . . . . . . :2 WATER HEATERS. . . . . . : 1 CATCH BASING. . . . . . . :0
1:'!XTUREc,-------- LAUNDRY TRqYS. . . . . . :0 F' RAIN DRAIN5. . . . . : 1
3INKS. . . . . . . . . . : 1 GREASE TRAPS. . . . . . . :0
LAVATORIES. . . . . :4. OTHER FIXTURES. . . . . :0
T"US/SHOWERS- . . . - SEWER LINE (ft ) . . . . :0
WATER CLOF-',ETS. . :3 WATER LINE (ft ) . . . . . 100
D I SHWAS HERS. . . . : 1 RAIN DRAIN (ft ) . . . . :0
Remarks :
JWNLR:
AELVIN WAYMIRE TIF' f 1380. 00 JI-1-4 03/05/1,)2
;--'0 BOX 231. 164 BPRT 400. 00 JLH 03/05/92
IAPI-C $ 40. i1,10 JL+1 12/23/91 i x'1091
TIGARD OR 97223 J'0,. 00 JLH 0,?/051/912
'hune #: 639-6742 SEDC 726CA. 00 JLH 03/05/92
(A R K $ 500. 00 JLH 031/0`:;/')x'
M P RT $ 39. 00 JLH 035/05/9,7'
MPL.0 $ 9. 75 JLH 03/05/92
Ila m e M5Pc $ 1. 95 JL.H 03/05/92
Address -,RT
Pr $ 140. 00 JLH 0'3/05/92
C i t y States P13pc $ 7. 00 JI-1-4 03/03/92
Z i p I Phone#: BF ' .$ 15 00 JLH 03,105/92
RFOUIRED INSPECTIONS
This permit: it; issued st-ibiert to the req-
1.tlAtions contained in the Tigard Mi-micipal Foot/found Insp Rain drain Insp
Code, State Of Ore. Specialty Codes And all post/Beam Stru(-t Water Linp Insp
other applicablf., laws. All work will be done Post/Beam Meehan Appr-/Sdwlk Insp
in acr.ordaijcp with approved plans. This Plm/undslab I-isr) Mechanical Filial
permit will expire if work is not started PLM/Underfloor PlUmb Final
within 16171 days Of issi..ianre, or, if wort-: is Mechanical Insp Buildinc3 FiT181
suspended for more than 180 days. Plumb Top Out Erosion-Cont-ol
Framing Insp crawl Drain
Pireplace Insp
Gas LiT)e T.n-.p
Insulation Insp
V'064 Gyp Board Insp
fT-Iorized '-lu- ln�k actor Signeture
mb lcl�on�a t
Call for Lispection - 639-.41.75
—------ SEWER CONNECTION
PERMIT
T c3WR92--QiCA17
1 .
Clorf OF
�'��� CMYi�RMWD PERMIT'J",
COMMUNITY DEVELOPMENT DEPARTMENT
13125 SW HWj Blvd. P.O.em 23W.'Towd,0r690"97223(6m)039"176
----------- PARCE 1 j2CB-ArC-1 149
SITE ADDRESS- W KENTON DR ZnNING: R--7
'HF S 3
SUBDLOT,IVISTON. ASHFORD OAK. . . . . . . . : 149 -------------------
BLOCK. . . . . . . . . . .
--------------------
TI.-NANT NAME. . fxTURF UNITS, :
USA N0. . . . . . . . . . : DWELLING UNITS— ZI
9: 1
CLASS or WORK. . . -NF-W NO. OF BUILDING S f
TYPE OF USE. . . . . :5F IMPERY SURFACE. . "
INCINSTALL- TYPF.- - . -DLJGWR
FEES
a y date V,Pcpt
type In 0 I-in t b
"'r'erWAYMIRE PRMT $ 1900. 00 JLH 03/05/92
MEL�I�L -31164 -)P 1 35. 00 JLH 03/07J/92
BOX 2.
IN7
T I C-.',ARD OR 97223
Phune #t 639-6742
CONTRACTOR NOT ON FILE
$ 19 ,5. 00 TOTAL
PtioneREQUIRED INSPECTIONS
Re #. . :
This Applicant agrees to cglply with 811 Inrpec!ti0TI
he rules and regulations Sewer IN days frov
of the Unified Sewage Agency- The pereit tl(Pires
the date Issued- The total agount paid will be forfeited if the
,erlit evoires. The Agency does --pt guarantee the accuracy of the -------
3�prals. If the sewer is not located at. the le"ure'"t
side sewer -ospect 3 feet in all directions frov
given, the installer shall PI the ins a ler shall Durchpse
the distance given. If not so located nstai'l a latval.
a "lap and Side Sewer" Persit ard Onr
GIpr-m> ttee
Y3 9 -4175
Call far' inspect ion
CITY OF' T 1 CARD - RECEIPT OF PAYMENT RECEIPT NO. 0P-28415P
CHECK t4Mllt JN'T a 4727. 70
NAME a WAY11 i RL, mr-il C:A.93H AMOUN T a Qt. 012
iaC)r)iZC iE; a PA-(MEN'T DALE G 03/0!5/9c
SUBD1V1SION a
PURPOSE QF PAYMENT AMOUNT "ATL) f-9.1FtPOSE= OF PAYMENT AMOUNT EMAIL)
PU X{_D J.NC3 r°FEIN 400. 00 PLUMBING PrRM T4 Q30
MECHANICAL PE: 39. ovi ST. BUILD PER . 00 00
PLAN CHECK FE24. '75 SIE'WER USA 190000.
SEWER INSPF"CT 3 5. (XPi RESIDENTIAL TRAFFIC FEF113 1280, 00
PARKS SD(': "`;00. 00 S310RM 1)QAI N 13170 00
MAscs, `E'BANS I T T 1 F F-*EF,'S 10o. 00
i
i
i
LOT 1:3 ASHF=ORD OAKS #?
148'c"t SW KE;NTON UR
I
i v1i. OMOUNT Pn l f1 > 47 1. 70
l
mom
NT F�Fc,[,-IPT NO.
CITY or:, TiUiARD RUCCIPT OF' PpYMV CHECK AMOUNT 0 40.lb@
CA,63H AMOUNT % 0. 00 .
wAY M L RE MEL V I I'l G. y Bl.D R pf)YM(7N'f Df'4TF 91
BOX p31164 I(IN
T lof-ARD, OR
WU23- NT Amot.jN,r PAID
PURPOSE
or PAYMENT JIMOUNT PA ID PURpoSC OF POYME
L -.,153R
pM(3UN*f PAID 40. 00