Loading...
12655 SW FALCON RISE DRIVE-1 1MN�aYk1NNWN4 WYWYYMwry�q�lyr�y�{M{ajyllgtC WukbL�Y,�t.eti�ee.�..w a,:�hrt x4(.. l P 12655 SW FALCON RISE DRIVE CITYOFTIFARD COMMUNITY DEVELOPMENT (DEPARTMENT MYvsn oW4 CERTIFICATE OF 13126 SW FWI Blvd. P.O.Bar 233G7,T*M.O"m 97223(603)63"175 � OC r E IANC Y 639-4171 UA'TE. ISSUNDs 01104/933' t�I T Ei ADDRESS. . . s 12655 SW FALCON R I tib: DFS PPP FI_s 1 S 1:.3::3Ut)_.W111400 !:yWID I V I S 1 ON. . . . s V I t..l_AGE AT SU14ME R LAKE-- 4 7_f.1N I IViy t R--4. 5 BLOCK. . . . . . . . . e LOT . . . . . . . . . . . . . s 1,31 CLASS OF WORK. a NEW T'YPC OF USE. . . s SF OCCUPANCY EIRP. s R:3 OCCUPANCY LOAF)s PP-7 4 TENANT NAME::. . . s Remarks t PrITH 1 Owners — .._.__.._.__ ._._.__......__. ..__....._._.._.__.._._. ___ .._,...__.. DON MORISSETTE BUlt_DERS, INC. 15555 SW BAN©Y RD. 0201 LAKE OSWEUO OR 97035 Phone #s E2+O-7538 C;tyr'rt►^elll�tnr^c �__M_...._.,.__.........._._._._..._... ....._._._ ..._....._........._ DON MOR I SSET TE BUILDERS, INC. 155!75 SW DANGY RD. 14201 1.-Al<k 0E3WF'.'LA-1 UR 97035 Phone 444 620-7538 Rep #. . o 3,55.3:3 Ucrupmnr_y of thee above referenced bt.lilc!inR is hereby given, and cortifieea fhe compliance with they State Cif OrsUon ,peeciaxlty cot-fes for the grOUrr, 0C*'c71Ul:ranry, and use under which the rerfereri. Mrd 171?rmit wmiH J asueed. F 14.C' r}E:C AEt'CI IE'N1' � BUILDING INSPECTOR r;?'k1iJ.f i D-I mr; c)rr I C I r4t.. POST IN C.E:1NF:P I Ct 1(71.103 Pt-AC �r INSPECTIONNOTICE (it.y of Tigard Building D%3"*joent 13125 sW Hell Blvd, Tigard, Oregon 97223 Inspection Line (Rec-o-Phone): 639-1175 Buoiness Phone: 639-417 1-- A c/Sdwlk Plbg. Underslab Mech. Rough-in pp y oot.l ng FINAL, #` To Out Gan Line FIN Plbg• P t i pound. -Bldg. Framing San. Sewer Poet/Beam 9tr'� t• -Plumb. Insulation Pas`/Beam M ch. Rain Drain Gyp. ed. P1. Water Line ..__----��X�4� ••"--� M;. underfloor _hM _Time 2 Date Regunsted:. Permit � —� Pi i t s- Address: - Builders THE E01j OWING CORRECTIONS MR RSQUIREDs —---------- -- Inspectors _ hpPROVf.D SUBJRCT TO ASO" hPPROVED DISAPPROVED Call for Reinsp- ZNSP6�'I`ON NNOTICE �, City of Tigard Building DepaL'tnnnt 13125 SN Ball Blvd- Tigard, Oregon 97223 9-4175 Business Phone: 639-4111 Inspection Line (Roc-O-Phono): 1 _ Inspection t �_ / Mech. Rough-in 1►ppr/Bdwlk Footing Plbg. Unblab L Gan Line FINAL: Found. Plbg. Top Out post/seam struct. Ban. Sewer Framing -Bldg. Poet/Beam Mech. Rain Drain Insulation -plumb Plbq. Underfloor pater Line Gyp. ed. -Mach. Time= --/ PM Date Requested: yL► r-r _ / Lc/ it #: C'o Addresa:. Bui..lder: �L_ THE FOLLOWINC CORRECTIONS ARE RiW"MM:--------------- ��Grr�h^,w1�N CONLinALI Lill-, _ ANd 0 , v 5 �r�� Date: Inepector:— LIL-- /� APPROVED 1 I DISAPPROVED APPRfNED SUBJECT TO ABOVE �� Call For Reinsp. INSYECT�o'+0 NOTICE City of Tigard Building DRr-rtatent 13125 BW Nall Bl,,d. Tigard, Oregon 97223 inspection Line (Rec-O-Phone): 6.19-4175 eusineno Phone: 639-4171 Inspection:__—.— --- + Appy/gdwlk Plbq. underslab mech. Rough- Rooting FINAL+ To O��t Gas Line pound. Plbg. P Framing -Bldg. Ban. Bever Fr ---- Post./Beam Struct. _Plumb. Rain Drain Insulation Poet/Beam Hach. Line nyp. Bd. -Hoch. Water L Plbg. underfloor PN —•� Ti°°t Date Req:testedt Permit Addresst ` Builders THE FOtj OWIN(f CORRECTIOBB ARE REQtlIREDt —_v ------------ I Inspect7717&�_ -- -- X_APPROVED DI611PPAOVED APPRoVLD tiuBJEC'T To ABOVE Call For Reinep. ( ' v ..�el9ION N(YTICE 'Tigard BuiLAioy , W int City of ?iq ?i � or 97223 13125 Sfi Ball Blvd. g 6:39-4171 Inspection Line (Rec-O-Phone): 639-4'175 Business Pltune: Inspections_ ---�_� -- -- 'r/Sdwl Plbg. Underslab mech. Rough-i:: 6' Footing FINALS Plbg. Top Out Gas Ling Found. Framing San. Sewer -Bldg. Post/Be+M Struct. -plumb. insulation Rain Drain ��a� Post/Beam Mach. -Mech. JL Gyy. Bd. Plbg. Underfloor W+aL:er Lirie _ n PK Times --AM Date Requested: I Z I Z ' S 4 �Q1N l�)`���► `-_ Permit is - 1lddreees �C�� Builders- TBE FOLLOWING CORRECTIONS ARE REQUIRED' n -7 ----------- — _ ----------- - --^ __-- -- c1.z f --L --a��.,tJ�s��-.__ Dates Inspector:_(���� OV DISAPPROVED APPRED STIBJECT TO AB APPROVED OVE Call For. Reinsp. • INSPEC;'i P NpTIC:B City of S",gard Building Department 13125 pall Blvd. Tid, Oregon 97223 gar Inspection Line (Rec-O-Phone)s 639-4175 nusiness Phone: 639-4171 Inspection._ -- _�_---..---- Footing Plbg. Underelab Mech. Rough-in Appr/Sdwlk Gas Lin* FINALS Found. .>r Top Out _ 8raminq> -Bldg. Post/Beam Struct. San. Sower Rain Drain Insulation -Plucub. Post/Beam Mech. ayp. ad. -Mech. Plbg. Undertloos: Nater Lina —P Timm ____AM Date Rc+yuested: I�' � -� Addrose:— Builders_,__ THE FOLIA)Wl"O CORRECTIONS Ar',S RSQUIREDs r -- — _ 2 fDates. 1. Inspectnrs Z--d---- APPROVED —'" DISAPPRI�VED APPRO�►ED SUBJICT TO /►BOYS Call. for Reinsp. it!SPBCTION NOTICE City of Ti.y�rd Building Dnpartnent 1322 SW Ball Blvd. Tigard, Oregon 97223 Inspection Line (Rec-O-Phone): 639--4175 9usiness Phone: 639-4171 Inspection: — -- -- ---- Footing Plhg. Underelab Mech. Rough-in Appr/Sdwlk Found. Plbg. Top Out Gas Line FINAL: Post/Beam Struct. Sart. Sewer Framing -Bldg. Post/Beam Mach. Rain Drain Insulation Ylumb. Plbg. Undorfloor Nater Line Gyp. Bd. ' -Meeh. Q / L Timet -- AM '---PM Jets Reguestede — Address s ---fs permit Builders/ Tag VOLLOWING CORRECTIONS ARE REQUIRED9 C _ Inspector•___t.� ./.� — Datea _ �—� APPROVED DISAPPROVED _ APPROVED SUBJECT TO ABOVE Call For Reinep. -- i INSPECTION NOTICF. City of Tigard Building [k:partaant 13125 811 Ball Blvd. Tigard, Oregon 97223 Inspection Line (Rec-O-Phone): 639-4175 Business Phone: 639-4171 Inspection:- Footing Mg. Underelab Mech. Rough-in Appr/Sdwlk Found. Plbg. Top Out Gas Line FINAL: Poet/Beam Struct. San. Sewer Framing / -Bldg. Post/Beam Mech. Rain Drain `In"lation�; .-Plumb. Plbg. Underfluor Water Line Gyp. Bd. -Nech. :� Date Requested: Time PM Address- � rp s_� rmit /t [�UU Builder: THE FOLLOWING CORRECTIONS ARE REQUIRED: i l r lnspert:rr: z 7� i _ .__APPROVRD DISAPPROVED ` APPROVED SUBJECT TO ASM _ Call For Reinap. City of Tigard Building Departrnrnt. 13125 S# Ball Blvd. Tigard. Oregon 97223 Inspection Line (Rec-O-Phone): 639-4175 Bunineas Phone: 639-4171 Inspection:_-_ - -- -�'—" Footing Plbg. Underalah Mech. Rough-ih Appr/Sdwlk Found. Plbg. Top Out FINAL: Past/Beam Struct. San. Sewer Framing -Bldg. Post/Beam Mach. Rein Drain Insulation -Plumb. Plbg. Underfloor Nater Line GIT. Bd, -Mech. Date Requeetedt ) -Time: __ AM Addrr Fin s - ,� ZormIt i s r Builder: - --- THE FOLLOWING CORRECTIONS ARE Ds ,l Inspectorp - -!_ Date —APPROVED DISAPPROVED APPROVED SUBJECT TO ABOVE call For Reinsp. in INSPECTIQff NO c8 City of Tigard Building Depwrtaant 13125 Sw tial! Blvd. Tigard, Oregon 97223 Inspection Line (Rec-o-Phone): 639-4175 Business Phone: 639-4171 Inspect inn: Footing Plbg. Underelab Mach. Rough-in Appr/Sdwlk Found. Plbg. Top Out bas Lina FINALi P0et/81eam Struct. San. Sewer Framing -Bld q• Post/Beam !tech. Rain Drain Insulation -Ply. Plbg. Underfloor Watery Lin&& Gyp. Bd. -Meeh. h `T/ Date Requested:_ Y �0 -C T i ✓�' \AM PM Address sPermit t: Builder: `� r1' 1 VA THE FOLLOWING CORRECTIONS ARF REQUIRED: 01 ajr— of - , 1 Inspector:_ .__ Date:_ APPROVED DISAPPROVED APPROVED StiBJECT TO ABOVE G CAll For Reinsp. LNSPECTIM NOTICE Clty of Tigard Building Department 13125 SW Hall Blvd. Tigard, Oregon 97223 Inspection Line (Rec-O-Phone): 639-4175 Buni.ness Phone: 639-4171 Inspections --- ------ --- -- -- tooting Q�P/lbg. Underalab Mech. Rough-in Appr/Sdwlk Pound. . Top Out Gas 1A11e PINALs Plbg Post/Beam Struct. San. Sewer Praminq -Bldg. Post/Beam Mech. Rain Drain Innulat_inn -Plumb. Plbg. Underfloor Water Lin* Gyp. Bd' -Mech. Date Requested:_ % Times AM __—PQM Addrese:� ) it Dullders � THE FOLLOWING CORRECTIONS ARE REQUIREDs Inspectors _1 �� _ - Dates 70(7 APPROVED _— DIEAPPROVED —�— APPROVED SUBJECT TO ABOVE Call For Rainsp. INSk 9-C,71O1t OTICB City of Tigard Building Depar:-Ment 13125 SM Hall Blvd. Tigard, Oregon 97223 Inspection Line (Roc-O-Phone)s 6.19-4175 Business Phone: 639-4171 Inspection: Footing Plbg. Underelab Mech. Rough-in Appr/Sdwlk Found. \\` Plbg. Top Out Gas Liae FINAL: Pait/Beam_$S�y San. Sewer Framing -Bldg. Post/Beam Mech. Rain Drain Insulation -Plumb. Plbg. Underfloor Water Line Gyp. Bd. -Mech. Date Requeuteds_ .Lf� Timet AM 7_ PM Address: trait #e > Builder: T"R FOLLOWING CORRECTIONS ARE REQUIRED. I` Inspectors_ Datol APPROVED DISAPPROVED APPROVED $DEJECT TO A9 Call For Reinsp. INSPECTION Mt CF City of Tigard Building Department 13125 &a Ball Blvd. Tigard, Oregon 97223 Inspection Line (Rec-O-Phone): 639-4175 Business Phone: 6313--4171 -- Footing Plbg. Underalab Mech. Rcur.h-in Apps!P.iwik Found. Plbg. Top Out Own tine FINAI.; Poet/Beam Struct. San. Sewer Framing -Bldg. Pont/Beam Mech. Rain Drair Insulation -Plumb. g. Underll«u Mater Lfne Gyp. Bd. -Mach. _...._ PM Date Requaste�i--L1� -----Times ,_ �1 Address; �J /-Q—'Permit 4t �'--- -r pv i 1der: --• - THE FOLLOWING CORRRCTION3 ARE REQUIRED: tic=. Inspectors_Z APPROVED DISAIPROVED APPROVED SUBJECT TO ABOVE Call For Reinsp. INBPE ON_pOTICE city of. Tigard B:i.l.ding, ncpartawnt 13125 an Ball Blvd. Tigard, Oregon 97223 Inspection Line (Rec-O-phone): 639-41.75 Business Phone: 639-4171 tnepectlrn: Footing Plbg. Underslab Mech. Rough-in -� A r pp /Sdw.lk Pound. Plbg. Top Out. Cas Line PINAL Post/Beam Struct. Framing -Bldg. _ 4• Poet/Seem Mech. ~ ain Dr n Insulation -Plumb. Plbg. Underfloor ,MAA Ater Lin gyp Bd -Mach. Date Requested: _ ��/ `_ `Time: AM Address: I Z Q' J _ `PM L .,_ Permit Builder: TBE FOLLOWING CORRECTIONS ARE REQUIRED: 00 - `—�_(C�-moi`-- Inspector: Date: APPROVED --— DISAPPROVED APPROVED SUBJECT TO ABOVE ____call For Reinap. I1YOFTIGARD (01Y� � MASTER PER11DEVELOPMENT11COMMUNrrY DEVELOPMEDEPAMME7639PERMIT #. . . . . . . . lylST')2 L71fl0 13125 SW Hell Blvd. P-0.Ba23W,TIORM,Or"M07223(603) 4176W "00" _f[T)0TF_' ISSUED: 10/ 06/132 SITE ADDRESS. . . : 12655 SW FALCON RISE DR PARCEL: IS133DD-09401il SUBDIVISION. . . . : VILLAGE AT SUMMER LAKE PARK 4 ZONING: R-4. 5 BLOCK. . . . . . . . . . 11 LOT. . . . . . . . . . . . . : 131 BUILDING REISSUE: DWELL1146 UNITS: 1 BASEMENT. . . . . . . . :0 s CLASS OF WORK :NEW BEDRMSs4 BATHS:3 GARAGE. . . . . . . . . . 1660 sf TYPE OF USE. . : :SF FLUOR AREAS--------- REQUIRED SETBACKS-­­­­­ TVPE OF CONST- :5N FIRST. . . . : 1025 St. LEFT. . :5 ft RIGHT. :5 ft OCCUPIA14CY GRP. :R3 SECOND. . . o- 1265 sf FRONJ. :20 ft REAR. . :44 ft S-T'ORIES. - o . . . . :2 THIRD. . . . -'O Sf REQUIRED_-- HEIGHT. . . . . . . . 127 ft TOTAL-------:2290 sf SMOKE DETECTORS. :Y FLOOR LOAD. . . . :40 PSf VALUE. . . . . $ : 1 PARKING SPACES- - :0 Remarks PATH I --- ------------------------------ PLUMBING SINKS. . . . . . . . . . : 1 FLOOR DRAINS. . . . 10 BACKFLOW PREVNTRS- - :0 LAVATORIES. . . . . :3 WATER HEATERS. . . : 1 TRAPS. . . . . . . . . . . . . . 10 TUB/SHOWERS. . . . 12 LAUNDRY 'TRAYS. . . :0 CATCH BASINS. . . . . . . :0 WATER CLOSETS. . :3 SEWER LINE (ft ) . :0 GREASE TRAPS. . . . . . . :0 DISHWASHERS. . . . : 1 WATER LINE (ft ) . : 100 OTHER FIXTURES. . . . . :0 GARBAGE DISP. . . : 1 RAIN DRAIN (ft ) . :0 WASHING MACH. . . : ] SF RAIN DRAINS. . : I FEES _---- _______________ MECHANICAL ----__--___--- --- FUEL TYPES--------.--- UNI1 HTRS- 10 type amot.trit by date /GAS/ VENTS . . . . . 10 TIF $ 1380. 00 JH 10/06/92 MAX INPUTil@ BTU VENT FANS. . -4 BPRT $ 478. 00 JH 10/'06/92 FURN ( 1001' 10 HOODS. . . . . . 1 I BPLL $ 250. 00 JLH 05/01/92 226754 FURN ) =100K WOODSTOVES. :O B5PC $ 23. 90 JH 10/06/92 - CLO DRYERS. : I SSDC $ 280. 00 JH 10/06/92 -•FLUOR FURN. . . . 80 SOIL/CMP ( 3HP:O OTHER UNITS:O PARK $ 250. 00 JH 10/'06/92 - GAS OUTLETS: ! MPRT $ 40. 50 JH 10/06/92 - Owner: IYIPLC $ 10. 13 JH 10/06/92 DON MORISSETTE BUILDERS, INC. M5PC $ 2. 03 JH 10/06/92 15555 SW BANGY RD. PPRT $ 132. 50 JH 10/06/92 #201 P5PC $ 6. 63 JH 10/06/92 LAKE OSWEGO OR 97035 Phone #: 620-1'538 ---------------- Contractor': - DON MORISSETTE BUILDERS, INC. 15555 SW BANDY RD. #201 LAKE OSWEGO OR 97035 phone #- 620-7538 Reg #. . : 35533 $ 2853. 69 TOTAL 1his ptritt is issued subject to the regulations contained in the REQUIRED INSPECTIONS Tigard Municipal Code, State of Ore. specialty Codes and all other Foot/for-end Insp Gas Line Insp applicable laws. All cork will be done in accordance with approved Post/Beam Struct Insi.ilation Insp plans. This persit r '1 expire if work is not started with tn 1816 post/Beam Mechan Gyp Board Insp days of i5suance, or if work is suspended for sore than iPA ays. Plm/mndslaInsp Rain drain Insp PLM/UnderfloorWater Line Insp Pet,mittee Mechanical Insp Appr/Sdwlk Insp Pli-imb Top Out Mechanical Final Insp Plumb Final ici-,i-ted By ' f C1 Framing 'J ll Call for LpApec�tiolj - 639-4175-- SEWER CONNF.C'TIDN CITYOFT14FARD MO-FIRM PERMIT TMO PERMIT #. . . . . . . .. SWR92---0152 COMMUNrrY DEVELOPMENT DEPARTMENT one" 13125 SW HWI Blvd P.O.Bax 23M,TOW.Or"On OW(503)639-4175 (2:; 4171 ' SITE i-4DDRESS. . . 12655 SW FALCON RISE DR PARCEL: IS133DD-09400 SUED V ISION. - - - V ILLOGE AT SUMMER LAKE PARK 4 ZONING: R-4. 5 LkLOCk. . . . . . . . . . LOT. . . . . . . . . . . . . : 131 TENANT NAME. . . . . : FIXTURE UNITS. . . USA NO. . . . . . . . . . : CLASS OF WORK. . . :NEW DWELL-ING UNITS. . : 1 TYPE OF USE. . . . . :SF NO. OF BUILDINGS-. 1 IMPERV SURFACE. . : : sf INSTALL TYPE. . . . :BUSWR Remark lc PATH I Owner: FEES DON 11ORISSETTE BUILDERS, INC. type amol.111t by date recpt 155,55 SW BANDY RD. PRIIJ $ 2100- 00 JH 10/06/"i-, #LIO I INSP $ 33. 00 JH 10/06/92 LVIKE OSWEGO OR 97035 pliolle #-. 620-7538 Lontractor: CONTRACTOR NOT ON FILE Phone #- 2135. 00 TOTAL keg #. REQUIRED INSPECTIONS -------- Thts Applicant agrees to comaly with all the rules and regulations Sewer Inspection of the Unified Sewage Agency. the permit expires 180 days from the date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee the ac-curacy of the side sewer laterals. If the sewer is not located at the measurement given, the installer shall prospect 3 feet in all directions from the distance given. if not so locatpO, the installer shall purchase a "Tap and Side Sewer" Permit and the Agency will install lateral. Pi-rimittee Signature : —4— Call for inspection 639-4175 CITY OF TIGARD RFCEIPT OF PAYMENT RECEIP'T NU. s 92-232432 CHECK AMOUNT a 4799. 39 NAME n DON MORISSETTE CASH AMOUNT a 0. 00 PDDRESS) n 15555 RANGY ROAD PAYMENT DATE n 10/06/92 LAKE 083WEGO SUBDIVISION PURPOISE OF PAYMENT AMOUNT PAID PURPOSE OF PAYMENT AMOUNT PAID *F-B 'NC)- 13r". Se. MECHANICAL PE 40. 30 13T. BUILD PER 3,E. 56 PLAN CHECK FF 70. 83 'c.;FWFR USA 4100. 00 SEWER INSPECT :"t. 00 PARKS SDS 290.lbo STORM DRAIN SDC 2110. 00 RF'SIDENTIAL TRAFFIC FEES 1280. 00 MASS TRANPji*r TIF FEES 100. 00 -113TO1_. AMOUNT P(41D 4 799. 2,9 r O1'�jTI(��� 1312SSW"'��. PLNCK/RECT 0 '475,CITY V Po0,12&W PERMIT 0 3 O ��U COMMUNITY DEVELOPMENT DEPARTMENT TW4 0r -Vw (SW)&W4171 DATE ISSUED � ll JOB ADDRESS: TAX MAP/LOT /5/ 3 3 (Q C) , i� y �1'l SUB: ���4i LOT: l LAND USE: VALUATION: OWN R SPECIAL NOTES NAME: .� L�-L�1_ 7C REISSUE OF: ADDRESS: �� LAST REISSUE: _ fL000 PLAIN/ SENSITIVE LAND: CONTRACTOR APPROVALS REQUIRED NAME: — _ PLANNING: — ADDRESS: _ ENGINEER14G: — _ FIRE DEPT: PHONE: OTHER: CONTR. BOARD 0: _—_ EXP DATE: NEMS REQUIREQ SUBCONTRACTORS: PLUMB: LIST/SUBCONTRACTORS: MECH: LEEE4 9US TAX: I�RCH ENGINES o TSP CALCULATIONS: NAME: 0 TRUSS DETAILS: ADDRESS: _— OTHER: _— PHONE: PROPOSED BLDG. USE: _ ----- — COMMENTS: --- -_ - -- Q APPLt�ANTIGIATURE Received By: -- Date Received: PERMIT R ACCT # DESCRIPTION AMOUNT AMOUNT PD. BAL. DUE 10-432 00 Building Permit Fees 10-431 00 Plumbing Permit Fees 10-431 01 Mechanical Permit Fees qv, 50 10-230 01 State Building Tax (5X) 3Z•s� — 3l'SL Building , ' Plumbing f.. Mechanical L' 10-433 00 Plans Check Fee Building Plumbing Mechanical 10-230 06 Fire -- 5Loe91 �j4G 30402 00 Sewer Connection 30-444 00 Sewer Inspection _ '-- 25-448-02 Commercial TIF Fees 25-448-04 Industrial TIF Fees 25-448-06 Institutional TIF Fees 25-448-03 Office TIF Fees — 25-448-01 Residential Traffic Fees 25-448-05 Mass Transit TIF Fees 52-449 00 Parks System Dev Charge (PDC) 31-450 00 Storm Drainage Syst Bev Chrg 24-445-01 Water Quality (Fee in lieu of) 24-445-02 Water Quantity (dee in lieu of) TOTAL nm/3581P.WPF . ^ �2b'i'S�i C1'f'Y OF T IGAPO R1wC:G i CI'Y OF F'lAYM N� (,-HEC-< AMOUNT s 9;:"250 1210 t ASH r-4MOUNT s W• 00 NAME s MORIciOETTE, DON pAYME'Nl DATE ADDRESS a �;Upoiv1 sIm i faMUUNT FSA I n i PURPOSE OF= PAYMENT AMOUNT PAID a�UF��C�� OF �'AVMF'>~1T _ _..... ._._ _. 5�. 00 t r jil 131. V ILLAUE AT SUMMERLAl4 J+ ;iW F -(',ON PIS DR II 1 AM0WNT MID -