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INSPECTION NOTICE
City of Tigard Building Department
P.O. Box 23397
T,gard, Oregon 97223
Phone: 839.4175
Type of Inspection —
Date Requested A.M.. P.M.
Permit
'7 1.3
Owner — ------ — - Lot
Builder
The following Building Code deficiencies are required to be corrected:
1.
Presented to _ _ _ F�'Approved
Inspector /y -J _—__ _ Ll Disapproved
Date
CALL FOR REMSPECT10N
CJ YES 0 NO
a.
INSPECTION NOTICE
City of Tigard Building Depa+lment
P.O. Box 23397
Tigard, Oregon 97223
Phone: 639-4175
Type of Inspection
Date Requested __ — :3 -e / — Time. A.M._______P.M.
Address s-1. Permit !
- - � 3 �� Lot #fr
owner _
Builder �L�LFit
The iollowin unci g Code deficiencies are required to be corrected:
6.
�F
r�-t��5��►. '^ ( .LCL —-
-�?s G C O� l.�l/7 Q Lam.- T r1 Y-✓1 r �1�ujl� A4 �
Pn.sented to ❑ Approved
Inspector (i visapproved
Date.
CALI, I OR REINSPECTION
Ci YES 01 NO
�SP��c Jut, �� 2 -� �i 1
INSPECTION NOTICE
City of Tigard Building Department
P.O. Box 23397
Tigard, Oregon 97223
Phone: 639-4175 / r...—•-...._�
�Type
Ad
of Inspection
Date Requested_��--3— ime A.MP.M.
Permit #
Address
Lot #
Owner—— (—
Builder �The following Building Code deficiencies are required to be corrected:
__—-- ❑ Appr,)ved
Presented to —"
�] Disapproved
Inape.tor _ � —
Date
CALL FOR REINSPECTION
❑ YES 0 NO
� a®
INSPECTION NOTICE
City of Tigard Building Department
P.O. Box 23397
Tigard, Oregon 97223
Phone: 639-4175
Type of Inspection ------
Date Requester)/ Time —.A. A. P.M
Address3
i
Owner ___ Loi #
Builder
The fcilowing Building Code defi^iencies are required to be corrected:
019
�' 02 en.Ap
-cF OF
-
4e "SIX
AMA-
CC
A
�w-E' 49
�� �-•�i.�..Q.vt.�� � � LL.� rte, LC'.c.!,
Presented to — E]�Zsepproved
uved
Inspector �� —
Date
CALL FOR,REINSPECTION
PY YES 0 NO
INSPECTION NOTICE
City of Tigard Building Department
P.O. Box 23397
Tigard, Oregon 97223
Phone: 639-4175
Type of Inspection
Date Requested Aex i Time AA(_ PIW
Address 'Permit -3!?:�
Owner Lot #
Builder
The following Building Code deficiencies are required to be corrected:
Presented to fApproved
Inspector ❑ Disapproved
Date
CALL FOR REINSPECTION
D YES F-1 NO
fti �
INSPECTION NOTICE
City of Tigard Building Department
P.O. Box 23397
Tigard, Oregon 9722?
Phone: 639-4175
C C—
Type of Inspections _ _�
Date Requested Time �.—�P.M.
Address —� 3 33 lo Permit #QZ1
Owner — _ Lot #
Builder --�`�JG1cTL_r-eL l.- -z
The following Building Code deficiencies are required to be corrected:
Presented to Approved
Inspector ❑ Disapproved
Date _ 1�
CALL FOR REINSPECTION
DYES ❑ NO
INSPECTION NOTICE
City of Tigard Building Department
P.O. Box 23397
Tigard, Oregon 97223
Phone: 6394175
Type of Inspection
Date Requested — Time A.M. _P.M.
Address _� 3, Permit
Owner Lot
Builder_ ��1� 1Z1 ltraQ
The following Building Code leficiencies are required to to corrected:
r`
Presented to
Approved
Inspector - ❑ Disapprovad
Date
CALL FOR REINSPECTION
❑ YES 0 NO
INSPECTION NOTICE
City of Tigard Building Department
P.O. Box 23397
Tigard, Oregon 97223
Phone: 639-4175
Type of Inspection �G�J ' – �_1�—�
Date Requested___—__". Time — A.M. 7a P���
Address
<Viernit # 1�
Owner--_ Lot # _
Builder �! a
The following Building Code deficiencies are required to be corrected:
1
Presented to __ Approved
Inspector Ll Disapproved
Date
CALL FOR REINSPECTION
❑ YE8 ❑ NO
INSPECTION NOTICE
City of Tigard Building Department
P.O. Box 23397
Tigard, Oregon 97223
Phone: 639-4175
Type of Inspection A�4
Data Requested P.M.
Address � �� { Permit
Owner Lot flt
Builder
The following Building Code deficiencies are required to be corrected:
Presented to
"Approved
Inspector U
Date Disapproved
r
FS'—�2: -�
CALL FOR REINSPECTION
❑ Yet ❑ NO
NOTICE
City of Tigard Building Department
P.O. Box 23397
Tigard, Oregon 9723
Phone: 639-4175
Type of Inspection
Date Requested.__ s' Time
Address Permit #
Owner Lot #
Builder
The foil ing Building Code deficiencies are required to be corrected:
L-4 Z,
at.." L4
f
--
Q� -�
eA
Presented to _
Approved
Inspector 5� f�f-Disapproved
Date. U t� f4-51
CALL FOR REINSPECTION
L� YE8 f� NO
INSPECTION NOTICE
City of Tigard Building Department
P.O Box 2.3397
Tigard, Oregon 97223
Phone: 639-4175
v '
Type of Inspection
Date Requested,,- .7 Tine A.M._` P.M.
Address - - } J �C L� C.Permit
Owner Lot #
Builder {4 _
The following Building Code deficiencies are required to be corrected:
Presented to r Approved
Inspector -
P c-- p ----- --- � i Disapproves
Date. C.�
CALL FOR REINSPECTION
❑ YES I_1 NO
a
I
INSPECTION NOTICE
City of Tigard Building Department
F.O. Box 23397
Tigard, Oregon 97223
Phone: 639-4175
Type of Inspection
Date Requested
/.--_L_� Time—_.A.M.__ P.M.
Address e--Permit #L21
Owner Lot # 3�
Builder
The following Building Code deficiencies are required to be corrected•.
Presented to _ _� _ _ __ pproved
Inspector _ U Disapproved
Date
CALL FOR EI_NSPF,CTION
lea 040
INSPECTION NOTICE
City of Tigard Buildinq Depar*, int
P.O. Box 23397
Tigard, Oregon 97225
Phone: 639-4175
Type of Inspection
Date Requested Time A.M. P.M.
Address 3 Permit #---
iii
Owner Lot
Builder 2
The following Building Code deficiencies are required to be corrected:
A"
V"f f
i of
',-V ,
J
Presented to ❑ Approved
Inspector n Disapproved
Date 7
CALL FOR REINSPECTION
YES El NO
W FW
INSPECTION NOTICE
City of T'.gard Building Department
P.O. Box 23397
Tigard. Oregon 97223 Orr .
Phone: 639-4175
Type of Inspection
Date Requested— d�2 Time A. l P.M.
Address 31a Q)
IT
Owner --- Lot
Builder
The following Building Code deficiencies are required to be corrected:
Presented to (!/Approved
Inspector -A�E Disapproved
Date
CALL FOR REINSPECTION
YES L] NO
HU1 I D11N16', I::+-:AMT*T`
Ci TY OF fl��RD FIEPM11' N(3 . : DU(39 1.3123
C I n:'0jF TWA D(YTV. 6/i . 9
0111100H
COMMJNITY DEVELOPMENT DEPARTMENT 001M . PMU . NO . 01911.323
13125 S.W.Hall Blvd.,P.O.Box 23397,Tigard,Oregon 97223.(503)639-4175
kJOH 1')I*.)I*)I:2r,.:.!.T!,.i—T747,3-."ie., W Scorl C,I.
'TAX MAI::'/I.f-1T .1 eq(-%f: 1 :711 1-3K
/11.00 SUS,: MOANTNC.', H' L..L..
1-AND USE : P-el .5
I-OT S:I*ZE: : VAI...UAT10N : tb 7P. -7.".3:3 SE'11"BACKS
F'PUNT : 20 PEAR: 18
WORK GI-ASS : NEW UN'
'TG : 1. 1.r.':? AT.GHT : 3*13
I'YPE : nIN(.,L..E F:'AM:I:L..Y NO. 13F.A.)POOMS : 3 EXT .WAI I... CONS'T :
VN NU. RA TI-11i : 3 N: S : 1::: : W:
O(XUP .G',PI::1 . : P3 PPO'T . OPEN 1 N(*..'PS :
(X'C3.IF1. I (JAI) N S E W
'T01'AL.. ARF.::A : 1.tV7 5
NO . STOP 1:r-.:S : 2. :1.S T' 1360 GUNS'T : C, FA:PE NET
I.-Rd'.1(*.4-11' : '.?0 2ND 71 b APEA SEPAP7 PAI'EU:
13ASEMEN'T"? 31A): 0(,.;(:,UP . SEPAR7
F &M'T
-'I AS ..
F*UJOP I OAU : 40 6"A 1:4 A(:;1-'. 306 F IPE 5 1-44 K 1 147 Al-ARM7
F'I-.(:)W(L.)PM) DE'T'ECT ? 'YI; S
A S D I A I'.PE,S S'?
4.11
PI'--MARKS :
PE1SSUE: OF' NO.
I-AS'T' PEISSUE
TT77;
Pk;.PM IT $352 00
NOR'T+IWI;*:S'T* ("Ulli'TOM HOMIL"�:i I
0 o 2.5 COUNTPY GAA.18 RD PIL-ON Pr-.:V:11--:W $P213. 00
W
N I AKki. (3SWI:;-'(A'1 OR F*,I*.pl"-K
E S'tATEF 'FAX $17 . 60
R
LI'T'HE:P
DEVEL-CIPMEN'T UHA
C NORTHWES1' (Nis,113M VIOMES soC"1151,(:114M) 111P1150 . 00
0 NOP'THWIR:51 CUSTOM ll-101`11--5 S D C 11 1 511'T RI-'.E:"T 1 $600 . 00
N .I --..iXWIN VPY (A US PD 5
11120 . 00
T PPEPA11) < $1.00 . 00)
R I AlKli*-: OSWI: [-.X) 0 P 9 70:3,(I
A 1::,I-.IONL-' U50'311 635--70,55
C TCYTAL.. : $1 ,m.�98_el()
T NEU:LSTRATIUN NO. el9466
0
RECF-1P NO. 16q sq-i
..............
This permit IS issued subject to the regulations contained in Title 14 14-.11I.E.1131C.-A) T NliPECT 1:(INS
of the TMC, State of Oregon Specialty Codes, zoning regulations F'0011:N ' SEWEP
and all other applicable codes and ordinances, and it is hereby VOUNDAT10N WAL.I PAIN DPAINS
agreed that the work will be done in accordance with the plans and
specifications and in compliance with all applicable codes and POST & DEAM WA'TEP L.:I'.NF.::
ordinances. The issuance of this permit does not waive restrictive PI-8 . UNIAL'.:14190 AS (::I VY A P P 1:4 CH SW
covenants. Contractor and subcontractors shall have current city 51AD V3:NAL
business tax permits. This permit will expire and become null and IN VOPOU'l,
void if work is not started within 180 days,or if work is suspended or
abandoned for a period of 180 days any time after work has II:PAM1 NGI
comm, iced It shall be the responsibility of the permittee to assure 1::'T PEPI A(:',F.
all required ad and approved CAS I I NE.
INSUI A'Y*I ON
G Y P . R 0 A P D
Ppimittee Signature
CAL.L.. F'OP 1NSPE(:,'TTON 6139-11.75
Issued By -------(-�--- --- - ----
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE
N
CITY OFTIIFARD O !:il�
. : J'391.349
CITY
COMMUNrrY DEVELOPMENT DEPARTMENT CIP1100N DA'TE T.G50HA) 6/27/89
1?125 S.W.Hall Blvd.,P.O.Box 23397,Tigard.Oregon 97223,(503)639-4175 PRIM. V-'M*I* .NO . 891323
JUrs ADDRIESS : 1-1,336 SW UAIDGE C-T' USA NUMIDEN: 37559
MAI'/LUT' P51. AAP d1100 SUB: MOPNING HILL. 3 DK :
I.-AND USE: : Ad'4.3
I ('.)T SIZE:
!-.i1:-"C 1JUN: '41 phi P N It,: J.w
W(:)PK CLAS15 : NEW
GINGI.-I": FAMII Y
i;q1r,io.eia tc) C.�cllnl:)].y With ekll r.tiieui iikrici regi.iIiati(iiini lif thro Llrli-lliccl
I'h4:! P ci?r-Ini t e X li i r,lv.�% IPP (1 ia4% T r-t3 in t h e cI iii,t 4?? 1 it;a-4 -I k!cI The ttltail.].
;mnii311l'11, rm:1.J.cl wil]. bel if the Px1:):i,r*e%i . 'Thr! Aclsi:iric�y chiet; r1c)t ciclar
ifixitee.. th411 (if thci Itic.:attitiri (if thii:y v;i(i4:? iiiewer* If the."
ricit lcit-ate?(:1 PLI. thp.) inC-1Iaf!;I.11-'C.1trll giviel-l ' thiv., inhaki.l. '3 Tv.m.)-t, J.1.1
d1.l(.-r..--tA,c.Il1!ii fl-cill" t.hry giveta li . If I-Itit so thel :1.1 t.at 11.4:a r, !i;1.1 Is.I I
cl "'Tillp aki-ld 5ick! POI'Mil, i;Ll')(:l the Aljlr..lric• y wJ.'I 'l. J.ri%vtii0 '1 al.
INS'T'ALL . 'T'YF)F..: BUTI DIN(*.. SE:Wr.:.'I:l AREA
I F.NAN'T J*MPrX)VF.;11E.N*T
VI 1.1:NG UNI'T'S I
OF
0 NOP'THWELVT C1.1S1'0M 1..I(JMI: $35 . 00
W 5 GOUNI'll- Y U U 1:11) (.,('.)NNV G VION CHAPGE $I. Ioo . 0
( ' Nti"I'Al L
N L 3:Nfi_": *1' 1:1 .1.
E
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0 11-1 F 1:4
C N D P'll I-I W E Si'T C11.1"'J"I'011 .-IDMF's
0
N NOPI'HWES'Y' tIUSTOM
T C,(')U NI 1:4 Y CA..I I H 11417
R
A I_AKI-K C)SWIRX.-10 ('.)P 9703A
C PHDNI (503) 635 '701515
T 5 "AIJON NO . 494166 'T UVAL $1. 11.33 . 00
PECEIP'T IND.
This permit is issued subject to the regulations contained in Title 14
of the TMC. State of Oregon Specialty Codes,zoning regulations
and all other applicable codes and ordinances, and it is hereby POUGH IN
agreed that the work will be done in accordance with the plans and
specifications and in compliance with all applicable codes and
ordinances The issuance of this permit does not waive restrictive
covenants Contract,)t and subcontractors shall have current city
business tax permits. This permit will expire and become null and
void if work is not started within 180 days,or if work is suspended or
abandoned for a period of 180 days any time after work has
commenced I tDhe..r"qonsIbiIity of the permittee to assure
all requir in 10 a I re )jested and approved
Permittee Signature!
Issued By: _ I )j- C,'AI L
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE
ME' IAN1 CAI Pl;::PM:I:'I'
CITY OFTIGARDOtt, PEPM11' NO . ME091.'3,eV3
DA11.: :ELSSUED . el/27/E)y
COMMUNITY DEVELOPMENT DEPARTMENT' I:)I:�'I.MJ)MJ' .N0 . 0911514-�3
13125 S.W.Hall Blvd.,P.O.Box 23397.Tigard,Oregon 97223,(503)639-4175
J08 ADI)PESS : 13336 SW !iJU3,11, I!1R1.l:l)GA:: Gy'
TAX MAI:'-'/I 0 RS3. 414AD X11.00 SUIS . M('.)1:4N'I'.N(:, I-I.I.A.1 3 L I : 7ZI Bl<
I-AND USE : P le:l.3
I S1 Z I,-:
:UTEM W.) NO
'E -):I P --I A
W]AK CLASS : NE'W FUPNA(�, <:1.0 0 K 1. ( , I N D L.k < :1.0
USE *T'Yl*-Ir--. : S11NIGUH: FAMIL.Y r-1.114INACE. 1.00K+ AT.P HANDI-11 100
['101SIS'Y' , *T'Yl:)E::. VN F1-0011:1 FILIFINA(1-K F-.:Vf)P.GDOLEN:4
W."311UP . (14-11P . : P3 I-ll:7A'T'E:I:l VL.::N*T' FAN
VEN'T' VI. N'T' . S Y ti)*1 E*M
BI-P/COMP <:3i!P 1-110(31)
NC). S*Y*DR:I*ES : 2 BI P/c(JMP 3 15111.) 1.N('..:ENEPA'T0P MAI
DWEI L. .UNUS : 1. lel-P/COMP 1.5-301-111:-N I:NGJ:NERA*T(J47(COM
1::*I.)F*I... *TYPE, GAS F.A.441COMID 30 11501-11.) REPAT P L)NJ:"I'S
MAX . :I.Nl:)tJ*T* 11-41-114 (:(:)Ml:) 504-1-11:1 (.,)THEP
FPE DMPPS'? (.,AS PIPING OUTLETS :1.
1-110I-I PRIE:Ssl?
I.X)w l:!,PF:S57
NOWTHWIii'S1 CUS113M HOME-5 1-14:PIM11,
VV !323 (:,(JLJN*T'I:IY CLUR PI) PI AN 14;V:1'1-.:W 11110 .08
N I AKE: C)SWEGO Op F:JX*I't.Jr4k,.:5 111;3 3 5
T A $2 . 1.0
01*11-111i.-J4
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PEC',E.I:P'T' N(J. AA/
Thir,permit is issued subject to the regulations contained In Title 14
of the TMC. State of Oregon Specialty Codes, zoning regulations PEWYMED 11SISPEC11C)INIS
and all other applicable codes and ordinances, and it Is hereby GAS I I N E
agreed that the work will be dons in accordance with the plans and POS1, tf< BlEAM
specifications and in compliance with all applicable codes and POA-4 TN
ordinances. The issuance of this permit does not waive rEtrictive
covenants Contractor and subcontractors shall have current city
business tax permits. This permit will expire and become null and
void if work is ,ot started within 180 days,or it work is suspended or
abandoned for a enod of '180 days any time after work has
commence all b !be-mVonsibility of the permittee to assure
all reclul in ho re uested and approved.
abandoned a eriod or
2
commence
,Jn
Permittee Sign ture
Issued By (.;AL.I... F'OR :ENSVIEUVION 639----4175
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE
P1 UMBI.W., PFAWTA'
CITY OF T'�� RD ,\ PE-JIMI'T N(J . : 1:4-89:1.3/17
cny to l')AI'IL-*. ISSUED 4)/1.?7/09
COMMUNITY DEVELOPMENT DEPART04ENT 01116" PRIM . 1:)M'T' .NO . 091.3V3
13125 S.W.Hall Blvd..P.O.Box 23397.Tigard.Oregon 97223,(503)63r,A175
5CO 7
'11 AX M A P/I IXT 2S:11, /1AI.--4 211.00 SUER : 110PIN11W., HILL. .3 /1 1-::K
LAND USE: : Pq ..o3
1-01, SIZ ' :
NO : NO :
W('.)Pl< CLASS : Nl:::W WATE-A CI (aSE'T 3 '1 NAP
USE *TYI:)I::.* : 51W.11-AL" ;::'AM:l.I..y U1411NAI 0KI::'1...(')W PPVN'T'I:4'
(`-0Nii'1* , '1*Y1:-1I�* : VN L.A.VONA TOPY el 144A. 1)
TUD 51-40WEP
DISHWASHEA
GAPBAGE: DISP'05AL :1.
NO. 1-04311*-11ES : 2 WASHIM.", MACA-111NE: :1.
DWEL.L . UNT'Ni : :1. 1 AUNI)PY 'T'PAY E311...1)(:', . )PA:I:N (I.)1A
FLOOP DRA'T.N
SINK 1. SIEWET4 (F-T)
WA'I'E:I:l HEATEA I 4)'TOPM/PAXN (F:'T' 1.
(JITHE-14
PFEMARKS .
W.11411-41WIF'.5-T (:'L1S1'(')M FlUMEKS PF.:Pm,.I:*I* $1,10 00
0 '5P!3 COUNTRY (A-US 141:11
W
N (')!:iWLG(:) ON F I X'1 U RES
E 5'TA'T+:: 'TAX I. i OO
R
01,11k P
C FAIWLEA P(:)8E:P'T'
o G 0 PLA)MRINC.
N 1.15192 !:i FE 31ST
T
R h J.:1.1.va b ci r,ci (:)r 97:1.2'.3
A
C PHONE 1.503) 640 577 0
T NP . JA,907 101 AL. : $141'7 . 00
0
R
Pl`-.'(.ETP'1' NO . 34/1
..................................
This permit is issued subject to the regulations contained In Title 14 PFQL)1PI*--':0
of the TMC. State of Oregon Specialty Codes, zoning regulation!, PL.".UNDEPSI AB
and all other applicable codes and ordinances, and it Is hereby
agreed that the work will be done in accordance with the plans and l"AOS'T & E)11-'.AM
specifications and in compliance with all applicable codes and WAI*E:',I:l L.INE
ordinances The Issuance of this permit does not waive restrictive PL..9 . 1*01POIL11'
covenants Contractor and subcontractors shall have current city CIAIN DPAINS
business tax permits. This permit will expire and become null and FJ:NAI
void it work is not started within 180 days,or if work is suspended or
abandoned for a period of 180 days any time after work has
commenced, It
shall be s responsibility
bility of the permi!tee to assure
ii r�Zem r requested
and approved.
t 1�t Mittee Signature 4A
(.Al L. VDA :1:N5iPE",*.-T10N 639-117r-3
Issued By. 6. ': —
h
SEPARATE PERMITS REQUIREC FOR WORK OTHER THAN DESCRIBED ABOVE
TWA
RD ,,�,� PLAN CHECK APPLICATION
C' Y ® ,)cnrcxtICAan PLAN CHECK 11
ve.a«
COMMUNITY DEVE=LOPME=NT DEPARTMENT PERMIT 11
i>>nSW.), a131.1 .o.n..21r3r,iw..e o�vrm.{��u+lc�v.�rs � DATE ISSUED
JOB ADDRESS- 15334, -Sw 5c e9Tr* �`�E - --17,7' f -1-AX MAP/LOT .Z-��— t�1� a U
SUB: IVlbp // X11 LOT: 7 --- LAND USF: ------ -
VALUATION:
<-)WNER SPECIAL NOTES
NAME: NO�TFNL'��s'(� CU STOMA t4"C` ', _ REISSUE OF:
ADDRESS: LAST REISSUE: _
FLOOD PLAIN/
SENSITIVE LAND:
PHONE � -
APPROVALS REQUIRED
IRED
CANTRAC7_OR PLANNING:
NAME: 1 _71 w - U - E=NGINEERING:
ADDRESS: L C>c)N�72 y �LUl3 z FIRE DEPT
_ "kU MUC U , rr-* 42049 OTHER
PHONE- T�J, (035- TO (o ITEMS RE UQ IRED
LIST/SUBCONTRACTORS: _
ARWENGINEER BUS TAX:
NAME: _ -.�9(2Ry 7ArT CALCULATIONS:
ADDRESS: TRUSS DETAILS:
PARKING PLAN: —
LANDSCAPE PLAN:
PHONE: / OTIIER:
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COE'MENTS• r� � s' c s, ,� _ / f/
e./ � o - 2
Y1��CM�JnN: p� Skc/ N�/g77I1rFj _ C
PERMIT H ACCT M DESCRIPTION AMOUNT AMOUNT PD. BAL. DUE.
10--432 00 Building Permit Fees _
10-431 00 Plumbing Permit Fees -
f 10-431 01 Mechanical Permit Fees
10-230 Ol State Building Tax (5X)
Building -- --- _-_--
Plumbing
Mech
10--433 W Plans Check fee --- ` �-3�.G
Building
Plumbing
Mech _
r 30-207 00 Sewer Connection -^- _
_ 30--444 00 Sewer Inspection _
51-440 00 Street System Dev Charge (,DC) _ —
52-449 00 Parks System Dev Charge (POC) -
31-450 00 Storer Drainage Syst Dev Chrg (SSUC)
t0-230 09 TRFO
W-411.)
Washington County Fire N1 (95X)
O� Amart/Wedgewood1OTAE-✓
RUC N �
APPIICANT SIGNATURE
Received By : Date Raceived:
cn/358711/10P ----- --- —�__._.