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15390 SW KENTON DRIVE �n -15390 SW KDYTY)m DR.I VE ~- s>• R ear .tAr .a7 t i� i� � � CERT:F I CATS: OF CITYOFTIFA OCCUPANCY COMMUNITY DEVELOPMENT DEVARTJIA W �e N� PERMIT N. . . . . . . i M5T90-0274 13126 SW Hell Blvd, P.0 Pox 23397,Tigard,Oregon 97223 (603)M-4176 TATE I SSUE A')0 12/26/90 511 c: API)VESS. . . a 15.390 SW KEN IN DFS PARCEL a 29112C,3--103 1) 91120,3--1030 SUBDIVISION. . . . t ASHFORD OAKS ZONIN©e BLOCK. . . . , . . . . . , LOT. . . . . . . . . . . . . e117 rLASS OF WORK. #NEW TYPE 0= UBL. . . s SF OCCUPFNCY CARP. t R3 OCCUPANCY LUADt220 4 1 E NRNT NAME'. . . R F2Nmarkst TAY M I LI_ER PO BOX ?3291 TIGARD OR 97223 Phone ilk 684- 7543 Contractors .TAY MILLER PO BOX 23291 TIOARD OR 97223 Phone Mt 684•-7543 Req #. . s 30109 0 ,cupaocy of the above refeer,enced building is hereby given, avid certifies the compliance with the State Of Oregon Speci&lty Codes for the group, occupancy, and use kinder wh+.ch Vie rr.fervnnr..ed permit was i snk.ked. F`!RE UEPAkTMENT BUILDINGNBPEC'T R AUILD'ING OFFICIAL POST IN CONSPICUOUS FSI e10E I � w / INSPECTION N2TICE / (� City of Tigard Building DePnrt vwr.*_ 13125 SM Ball Blvd. Tigard, Oregon 97223 Inspect-on Line (Rec-O-Phone): 1,39-4175 Business Phone 639-4171 InnpectLoll: _._ Footing Plbg. Underelab Mech. Rough-in Appr/Sdwlk Found. Plbg. Top Out Gas Line FINAL% Poet/Beam Strurt. San. Sewer Framing "g r Post/Bear Piech. Rain Drain insulationt b. Plbg. Underfloor Water Line Glp. Bd. . Date Requested:,._ �L�Q Times N PM ff/ � `� -T Hddrese:_����1f���.fJ �� Permit I TIIE FOLLOWING CORRECTIONS ARE REQUIRED: Inspect.ort PROVED DIf.APPROM APPROVED ^'1BJRM TO ABOVE .—___Call For Rel-nr,p. ew IBM WN 4L. INSPECTION 10TWE City of Tiiard 'Bu,lt'inq Department 13125 SW Ball Blvd. Tl ;ard, Orogon 97223 Inspection Line (Rec-O-Phonts '16.19-4175 Busineee Phone: 639-4171 Inspection: i 2_1 A_A��_ _ _` / Footing Plbg. Un stelab Mech. Rough-in ,( Appr/Sd�wl)1 Found. Plbg. Top Out Gas Line FINALt Poet/Beam Struct. Sen. Swwei Framing -Bldg. Post/Beam Hoch. Rain Drain Insulation -Plumb. Plbg. Underflc ,t Wades Line Gyp. Bd. -Meeh. Date Requested:_ 1 v �(/ *,1!�/ Time: —AM �__.__PM Addreee:_��� i' 1 Permit 0:� �. Buildert THE FOI.I.OWING MgRECTIONS ARE REQUIRED: oleg Inepector: -- Date1 APPROVED DISAPPROVED APPROVED SUBJECT TO ABOVE Call For Reinsp. I INSPECTION NOTICE City of Tigard Building Department P.O. Box 23397 Tigard, Oregun 97223 Phone: 639-4175 Type of Inspection Date Requested_ ,ez Time. A.M.__,_P.M. Addressr i �"ti CPermit1��: ? Owner Lot # BuilderThe. following Building Code deficiencies are required to be corrected: i Presented to _._� �. Approved Inspector _ _ ❑ Disapproved Date -__ _ _____._— --t U —�.—a CALL FOR REINSP .TI() 1-1 YES 1-1 NO t v, s! ■w w. ier w ae wr s +ger a.a INSPECTION NOTICE City of Tigard Building Department + P.O. Box 23397 'Tigard, Oregon 97223 Phone: 639-4175 Type of Inspection _ Date Requested � ���= � Time..-//--' ime..- A.M. P.M. Address Permit # � Owner _ �r---- ---- _�. Lot #----- Builder ��'-s �zc—� — ----- —_ ----- —The following Building Code deficiencies are required to ba corrected: r Presented to Approved Inspector Disapproved Date CA L Po' k UINSIECTION_ C7 YES M No arer aar ass wss ae aar aer ear aai arr INSPECTION NOTICE City of Tigard Building Departm P.O. Box 23307 Tigard, Oregon 47223 Phone: 639-4175 Type of Inspection Date Requested_ ,LLQ_ _ Time_ __ A.M._ P.M. Address Permit Owner — Lot 4 Builder The following Building Code deficiencies are retiuired to be corrected: ........-._.. . Presented to �4 Approved Inspector 71J& I Disapproved Date CALL FOR REIN�CTION 0 YES [A NO INSPECTION NOTICE City of Tigar(I Bt --ing 1',epartment P k2 Bo 23397 Tigard, Oregon 97223 Phone: 639-4175 'rype of Inspection /— Date Requested Time A.M. P.M. Address Permit Owner Lot Builder The following Building Code deficiencies are required to be corrected: r (X ale- Afp-7Z Presented to d-1 Approved Inspector Disapproved Date CALL FORR'REINSPFCTION �rJYES 0 NO INSPECTION NOTICE City of Tigard Building Department P.O. Box 23397 Tigprd, Oregon 9722'31 e Phone: 639-4175 Type of Inspection "/ Date Requested A, ------ A M. P.M. Address Permit Owner Lot Buildr The )wing Building Code deficiencies are required to be corrected: A-z 4z c 74- 7 5,7cT-- -e- Presented to U Approved Inspector [9--Di-mpproved Date CALL POR RFI � Ela El No ■ar aw aww w art rr rt rale w INSPECTION NOTICE City of Tigard Building Department P O. Box 23397 Tigard, Oregon 97223 pp Phone: 639-4175 Type of Inspection ._..est =-= ------__- __— -__--- Date Requested -._- _ Time___x___ A.M. P M. Address _lS_ ._9 G+ �` �L.n '✓` __ _ Permit #_�_� ' Owner - -- ---- �. Lot -- Builder --- The following Building Code �_ficiencies are required to he corrected: —1ZI&V—4r Presented to � Approved Inspector , U Disapproved Date CALL FOR REINSPECTION ❑ YES L] NO INSPECTION NOTICE City of Tigard Building Department I,�1 P.O Box 233£7 Tigard, Oregon 97223 Phone 639-4175 Type of Inspection !=4 l�zs - ------ Date Requested __�i��" �l Time / - ' Address _�G� _ - ��--� _ Permit #' 7 Owner .. ,y_ Lot # BuilderThe following Building Code deficiencies are required to be corrected: Prevented to -- /_ _.._ - ,- pproved Inspectnr Disapproved Date �- CALL FOR RFI F.C770N U7 YES C.] NO uusi 1� Aw sis � wr ar st r INSPECTION NOTICE ` City of Tigard Building Department r t` P.O. Box 23397 Tigard, Oregon 97223 Phone. 639-4175 Type of Inspection Date Requested Time .._— _ A.M. eta .IIA, Address Permit # Owner Lot # Builder The following Building Code deficiencies are requk ed to be corrected: Presented to — _ - `1 Approved Inspector Disapproved — -- Disapproved Date 151 CALL FOR REINSPECTION 0 YES 0 NO INSPECTION NOTICE City of Tigard Building Department P.O. Box 23397 Tigard, Oregon 97223 Phone: 639-4175 Type of Inspection L Date Requested.. �i �._._ Time A.M. ._ P.M. Address ---, -s ��Gs1__,I—►*o /1 t"' Permit # c, Owner _ Lot # Builder The following Building Code deficiencies are required to be corrected: Presented to r-- Inspector _ _ _ H Disapproved DAtP. CALi, FOR REINSPECTION ❑ YES 0 NO INSPECTION NOTICE City of Tigard Building Department P.O. Box 23397 Tigard, Oregon 47223 Phone: 639-4175 � .� Type of Inspection l Date Requested_—�� Time -_ A.M._21 — P.M. Address ---_l l/J - ;"Sa•�- �i�i Permit Owner-._ _. - Lot Builder The following Building Code deficiencies are required to be corrected: Presented to _ C.7 Approved Inspector _ ❑ Disapproved 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 Date Requestedi e, me A.M. e�� P.M. -5 Address / 55 2(:5 Permit Owner Lot Builder The following Building Code deficiencies are required to be corrected: Presented to Approved Inspector [j Disapproved Date CALL POR REINSPECTION Cl YES 11 IYO INSPECTION NOT ICE City of Tigard Building Department P O. Box 23397 Tigard, Oregon 9722.3 Phone 639-4175 or Type of Inspection Date Requested__ =1�c_!d Time-_ A.M. P.M. Address Permit _. M Owner— ---- ----— --------- Lot The following Building Code deficiencies are required to be corrected: I 4 Presented to __._.. _.� �+ Approved Inspector _ Q __ _ --___ _._____ Disapproved Date 6ALL O RF,INSPf CT'ION YES L=l NO CITYOFTIGARDJJASJ E. %, 1"1w RIrI a 'T CITY I:IE'RMIT' !t. . . .. » » .. :: MST90 0274 COMMUNITY DEVELOPMENT DEPARTMENT oMa►ow PR I r1. PE::RM 17 a. MST"30- -Or'74 13125 SW Hrl Blvd, P.O.Boz 23397,Tipad,OreWn 97223(503)939-4175 DATE I;3 S lJ II1): (48/07/90 SITE ADDRESS. . . .- J.5390 SW Kk::N'T'ON DR PARCELI 2S112CB_-10:300 SUBDIVItiION. . . . 9 ASF•If'ORD OAKS ZONINCia BL.U11K. . 1. .. . .. . . . . I L04.. . . . . . . . . . . , . tt 117 .............................................. _.._...._..................._._..,.............. ..._.._.... BUILDING REISSUE: DWELLING UNITS11 BASEMENT. . . . . .. . . 20 sf ('!_OSS OF' WORK. KNEW DI:".DR11 S 14 PATH :.3 GARAGE::. . . . — . .. . . tt 420 S f 'T'YPIE OF USE.. . . ISF FLOOR AREAS-------- .w__- - REQUIRED SE::'Tl4AC:l'.S-•--••--••-----_._. TYP OF CONST. c514 FIRST. . . . a105 Sf L E1::1'. . :`:) ft RTGHT. -.5 f(: O(XUPANCY GRP. :k;;:s 56COND. . . :972 S FRONT. c20 ft r1FWAR. . 1:38 ft S'T0R.1:I.-%S1. . . . . . . r.2 THIRD. ., ,, . a0 Sf REQU1:Rf:b_.._.__...___._.__..........___._, w._.._.._. HET OH T. . . . . . . . 1 20 f t 'TOTAL_ - 12 0 2 2 $f SMOKE DETECTORS. e Y P-1-(IOR LOAD. .. .. . ^40 pts f V01._UC::. . . » . 9r: 92484 PARK T NG SPACES. .. tt 0 Rema•rP,S 1 __....____..__...._.. ._._._.._........_.._...._..__._....._..._ ._.._.._._._.._ PLUMBING _............_�... S:i1.I�IKS. „ . . . . . . . ,. I FLOOR DRAINS. . . . -0 SACKFI...OW i='REVNTRS. . 0 LAVA'TORIE S:,. . . . . -4 WATER HEATURS. . . 11. TRAPS. . . . . . . . . . .. . . . .0 TUB/51-10WERS. . . . ..2 LAUNDRY TRAYS. . . :0 CAT(:H WATER (:I...OSiE_TS. . a3 SEWER LINE (ft) . 10 GREASES 'TRAPS. ., . » . . ., :0 1)1 S H W A 8 H I':.R i. . . . r 1. WATER LINE (ft) . 1 I(a0 OTHER F"IXTURE::S. (:i0RBAGE D1:8P. . . 11 RAIN DRAIN (ft) . tt0 WA'.31AING MA(:H. . .. tt 1 SF RO IN DRAI.NS.. . : :1. _.._._ „......._ .w_..- MEC.HANICAL. ........._......_.._w.._......__......._._. _.... ....__ ._..___ FEES FUEL T'Y1='I:S--µ- - - UNIT HTRS. . ;:0 type ania.cnb t y date reC,pt. /GAS/ / / VEN'T'S . . . . . :0 PAYIII $ 100. 00 JLH 08/07/90 203452 HAX INPU'T:0 BTU VENT F:ONS. . 14 BPRT $ 412.00 1 / 1 URN ( 100K . . ".0 HOODS. . . . . . : :L PPI-C, $ 2('17. 80 F URN )!:1.00K . .. :; 1. W(:IODS'TOVES. :0 PST'(; $ 20. 60 J / FLOOR F URN. . . » 0 CLO DRYERS. 1 :L STDC g; 600. 00 I:t0IL../(:MP ( .3HP H OTHER Ull.'[ T'Sx0 SSD(; $ 375. 00 GAS OUTLETS I 1 V"ARK $ 2301. 00 (:1 w 1.1 a•r r _......__......._............__._.............,..,......_._..,......_........ 11 P R T `; 40. 50 ,TAY MILLER MPLC: $ :I.0. 13 1 / NCO I!(.)X 23291 115P(I. $ 2. 03 ! / F•PRT $ :140. 00 'T JA3)ARD OR 97223 1 5I."'(:: g, 7. 00 F rtc>'rte N 1 684---754 3 PAYM !G 2025. 06 JLJ-I 08/07/90 1'(:'r a c:'t o r•" -.._.._,._........_........_......._...._...._..........................................._...._...... Jof MILLER ('() BOX 23291. r'h carte tt^ 684--754' #. . 1 3010 _..........._.._..._............_................._........._....._.....-..---.._...... .._.._.._...._..... 9> 21.25. 06 TOTAL This permit is issued subiect to the regulations contained in the - - REQUIRED INSPE.C:T IONS Tigard Municipal Code, State of Ore. Specialty Codes and all other Foot/fcn.tnd Insp I`ler_hartieal Insp applicable iaws. All work will be done 1n accordance with approved Wtr Proof ing Psnt F•iUmb 'Top OUt plans. This permit will expire if work is lot started within 188 Pc)st/Beam Strt.tct Framinq Insp days of issuance, or if work is suspended for more than 189 days. Frost/Beam Meehan Fireplace Insp Crawl Drain Gas Line J:r►4ip � . i.t:ter• Signatt.tre Ir1sp lr;sc.tlaticoll :E r1� p FILM/Underfloor Gyp Board Insp a;ued By-, Ft-q Drain Bsm9 t Raindradrain Ir1sp 1.;,�11 (or :Ln<sraec 1;ior1 639---4 175 i. w oo�r w w w = w Fm CITYOF TKARD SEWER E7R111Ef:TIgN PIw!i M I'1' C r1W1D i�,E R11:C T N. . . . . . . .. S W Ft".i 0•-0:3 2 rJ COMMUNMY DEVELOPMENT DEPARTMENT Mme+ I:��IM. I�E:FtMIT N. ^ hlli'T''3uI 0�?7�e 13126 SW Hall Blvd. P.O.Boot 23397,Tipard,Oregon•!72x3 46p31,S�"l 76 DATE ISSUED: 08/07/90 aITE: (11)1)R1!-:'(5 i« . : 1,5:3` 0 SW i:l NT01�1 1)R 144RCE:L: 2S1.12CD 1.0:3W0 GUBDIVJ S1:(JN. . . . : ASHFORD OAKS ZONINGs 1-4L 0C K. . . . . . . . . . .. I._c:►T. . . . . . .. . . . . . . .. 11 11PN'T' NAME::. . . . . . 1.1f:+A NO. . . . . . . . . . ..42351 FIXTURE UNI T•5. . . : CI._OSS OF WORK. . . :NEW DWELLING UNITS. . s1 'IYI'E GF:* USE. . . . . :SF* NO. (JF BUILDINGSs1 I.NSTAI...L TYPE. . . . s PUSWR' 1:11PE RV SURFACE. . s :t:; I tawrler s __......_._._.__...._.._...._........._....._.__....._....__............___.. _........._._.. _._._... ___.....__..._.._ FEES ..__.__.__........__...._..... JAY MILLER type amot.kilt by date 'rec pt; PO D 0 X 2132 9 1 PRM'T' 1500. 00 I NSP ', ;:3'5. 00 TIGARD OR 97223 i:'AYM 153;'3. 00 J1 1.1 00/07/90 E 1101.1e 0: 684-•-754:.3 Cont-racto.r» —_._...__._.____....___..__.....___._........�_,.._. __.._.._._._. CONTRACTOR 140T ON FILE c1ne 1535. 0O�TOTAL �_�_._._...._.....�...__,_...._ _.._._._......._._. REQUIRED INSPECTIONS _.._.__._._...._. This Applicant agrees to comply with all the rules and reg.ilation,i Sewer Inspection of the Unified Sewage Agency. The permit expires i2e days from the date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee the accuracy of the side sewer latc,,als. 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 located, the installer shall purchase e. "Tap and Srde Sewer" Permit and the Agency will install a lateral. I'e-r m i{:{;ere f:i i.C1►'1 rx{;►.►•r e: iap.— ��_� � ........_-_.___.._...__..._.... L Id Dy^ ._.. Ca 1 .1 fr:)'r irlsil:►ection 639 -4175 ',TTY OF TIGARD RECEIPT 13F PAYMENT RECEIFT MO. s IC),-20 4 CHECU AMOUNT a 100- 1 NAME t JAY MIL.Lr_'F%' (.-ASH AMOUNT t 0. ADDRESS o PAYMENT DATE o x:113/1'I'7., SUPD I V I S I ON TISARD. OR 9-7223— 15•�Pt) SW f-;:.CNTON Dr-, PURPOS17. OF PAYMC7.N'T AMOUNT PAID rupruw nF PAYMENT AMOUNT PAIC, Pl-i:AN CHM1'. FEE 16P 701'At- AMOUNT PAID ':ItY OF TIC7APP PFCEIPT OF r,:,Ayiir t.rr RECEIPT NO. e90--'20 14 Cj.JCj(">' AMOtjjq'T '?'560 J(tY MILLEP E4L.L)); CASH APIC)LINT PAYMENT Dv"qTE SI-JEAL)I V I S I ON TIOARD. OR A.A. r"USPOSE (DF PF.oIIENT AMOUNT PAID PLIPPOSE OF` F"AYMENT AMOUNT PAID 1-1—lt-40- 7 —) - Q PI-liviEll"NCII PERM MFC HAP PC 4 50 ST. BUILD PEP CHECK FE 1 77."r'_ SE VIEP USA S E W I` R, J N R FTC T SIREFT SDC 00 STORM DrIlAiN SDC 75.f"o) 5W i? r-AjT(.')tA en CITYOF T- 14FARD PLAN 0Ea WLICATIOM COMMUMM D!IVELOPMEMT DEPM, MT (7!""' PLAN CHECI / "Maw.HOW LPAQMali1�1;?��OwfwR��Mf. 7) PERMIT / _r115 �' MOT1c ISSUES 308 ADDRESS: 153 p S,�✓ e�,��-, d ,� TAX MAP/Lor ,2,5i 1a C-b -ice 3c) O Lon LARD USE: VALUATION: �. O1ARER B NAME: PEI�K BOTEM - -- REISSUE OF: ADDRESS: LAif REISSUE: -- FLOOD PLAIN/ MEMSITIVE LARD: PHONE: OONRRAPPROVALS REOIlIRED PLANNING: NAME: Jay iller Builder, Inc. ENGINEERM: ADDRESS PO Box 23291 FIRE DEPT Tigard. OR 97221 OTHER: PHONE: 641-1992 ZTM REQUIRED BUILDERS BOARD /: 59667 Ev DATE: 3/3I /q t LIST/sUl COMACTiORL: BIM TAX: ARCH/ENGINEER CAL.CULATIM: NAME: TRUISM DETAILS: ADDRESS: _ OTHER: PHONE: COMMENTS: SUBrONTRACTORS: PLUMB: z,, w,.*t-- sna.7a IECH: Rel l wpwtin9 nnAA7 PERMIT / ACCT I DESCRIPTION MOUNT NOW PD. RAL. OIE 10-432 00 Building Pwiit Fees 10-451 00 Plumbing Permit Fees —0, -, 10•-431 01 Mschmnical Prruit F«. 10-22001 Stat. OuIIding Tait (51) � �. r�� Buildingo G� Plumbing 1 Mach p 10-433 00 Plans Chad Fes wilding Plumbing Mach / y 30-202 00 Mawr Connoctlor+ M"44 00 Saw Inspection 51-440 00 Str*et S stem Deo y Ow" (SOC) 52-449 00 pests Systsm Day C UWW (PDC) 21-45000 Storm Orainsps Syst On Chr7 (SWC) 10-22006 M.,. TOTAL. �� t(,�� r' ROC 0 APPLICANT sI Reeelved%: Bente Received: GRADIN ./EROSION CONTROL INFORMATION . GENERAL CONTRACTOR NAME&ADDRESS: CASEFILE NO.: �TTaav� Mi l lkr Builder. Inc. PERMIT NO.: P0R 23 7 9 1 �1�- . Oregnn 97923 APPLICANT NAME AND ADDRESS: EXCAVATION CONTRACTOR NAME&ADDRESS: J 1 _ Jim Paulson Excavating Tigard Or 97223 Route 1 Box 1062 OWNER NAME AND ADDRESS: Hillsboro, Oregon 97124 a _ TELEPHONE NUMBERS: APPLICANT: 6 8 4 7 5 4 3 PROPERTY DESCRIPTION: OWNER: 684 7543 __---- STREET ADDRESS AND CROSS / TED GENERAL CONTRACTOR: 8 4 7 5 4 3 EXCAVATION CONTRACTOR:6 4 5-1011 o-6S SITE/JOB: LEGAL DESC-PUMON: 24 HR/AFTER HOURS EMERGENCY TAX LOT NO.: L o7 10 9S ftrdyt COISTA,Cr PERSON,TITLE,TELEPHONE: 1/4 SECTION__ a. e Eickhoff SITE SL:E,ACRES: S.i.O O Jon supgrintendant 639-7798 DISTURBED/WORK AREA,ACRES: 3000 i-OCATION&ADDRESS WHERE SPOILS LTiAVING SITE'NII.L BE TAKrN SITE RUNOFF DRAINS TO:(CIRCLE ONE) (NOTE:PERMS MAY BE REQUIRED) CATCH-BASIN I DITCH PIPE CREEK Stumps b brush to 1igrenngd fill area . Dirt Y_o licensed dump site. (CIRCLE ONE) PRIVATE PROPERTY PUBLIC RIGHT OF WAY) EROSTOMEDIMENTATION CONTROLSQ MEASURES MINIMUM ESC REQUIREMENTS MINIMUM ESC REQUIREMENTS DURING CONSTRUCTION: FOLLOWING CONSTRUCTION: SEDIMENTATION FACILITIES STABILIZE EXPOSED SURFACE STABILIZED CONSTRUCTION ENTRANCE REMOVE AND RESTORE TEMPORARY ESC PERIMETER RUNOFF CONTROL FACILITIES CLEARING AND GRADING RESTRICTIONS CLEAN AND REMOVE f.LL SILT AND DEBRIS COVER PRACTICES ENSURE OPERATION OF PERMANT FACILITIES CONSTRUCTION SEQUENCE OTHER OTHER PLAN FOR EROSION CONTROL r^.EPARED AND SUBMITTED IN ACCORDANCE WITH'TECHNICAL GUIDANCE HANDBOOK-. EROSION CONTROL PLAN DRAWING,AS REQUIRED,HAS PLAN CONSTRUCTION NOTES COMPLETE,INCUIDING EMEkOENCY PHONE NUMBER, SCHEDULFISTAGING FOR INSTAII.ATION AND REMOVAL OF EROSION CONTROL MEASORES,AND APPLICABLE STANDARD NOTES. 1 HAVE READ AND WDLL COMPLY%TM THE ABOVE AND WILL CONSTRUCT AND MAINTAIN ESC MEASURES AS NECESSARY 10 CONTAIN SEDIMENT ON THE CONS'IRUCTIO SITE. • SIGNAi'.E OFFICIAL USE ONLY. RECEIPT DATE ACCEPTED FEE NUMBER RECEIVED BY