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11355 SW 95TH AVENUE 11355 SW 95th Ave. ..4 `��./�,rv��.�.a. «y.+�r�`M.s ink• 'kt�r ,��r�,,'�,v♦r� �1 A"�'sF s.pew,� N3'.,y�„a,�����.',N +� �..y�•, •, r 'iq' dq`�^'Rr ��tslt`"�� v '�^ IM OD 00 OD rp + f .� I�' � ; �w ��"'?M�IA�A111M'' �, � �L dIIW,,yt;���,. ?��;� '�T!! "� • i; ps s^ 1 4. to P-4 cq $, ;mac � � � � c� � � � � � �� .�•� ' • �/ � � • b H q #c� �h�4 i� ff hh � N 4.4 Qi I Ln V • �� � ro b � rn � o ° 4 n �►� 1 '.. .Y ,`..''`` r/V'!y �L-. 11{ � s�•{• j•fr`t1�„ ��i .�"� f �'f�� ��� � ��� �'�'N� �y ,��yw���A'"�? 4,;6 'i•+. `C /1'?? -. 'P.` .,• �R,4� ',P ' ar:_ IMF w t �f'?!K <1?Ilr. 4t :i is _ c .:�;•. ro ��IP y A!- WOE J .: � v ? ricin I "AN OF SCRIBED ABOVE INSPECTION NOTICE City of Tigard Building Department P.O. Bo.-, 23397 Tigard, Oregon 97223 Phone ()30-4175 v Type of Inspection ----- Date Requested — Time X._ A.M._ P.M. Address f ^ _ Permit Owner ® Lot # BuilderThe following Building Cadt deficiencies are required to be corrected: Presented to --- ----- LJ Approved Inspector _,i F1 Disapproved Date CALL FOR REINSPECTION 0 YES ❑ NO INSPECTION NOTICE City of Tigard Building Department P O Box 23397 97 Tigard. Oregon 97223 Phone 639-4175 Type of Inspection Date Requested :3 Time __. A.M. P.M. Permit Address _ Lot # - Owner Builder Th oll ing Building Code deficiencies are required to be corrected: Gu [] Approved Presented to � ��s-.------- � pisapp►Quad Inspector Date CALL FOR EINSPECTION ED 1/ES 0 NO ■ 1 INSPECTION NOTICE City of Tigard Building Department n - {(� C, P.O. Box 23397 L� Tigard, Oregon 97223 u Phone: 639-4175 Type of Inspection _--Af of G'�'�-�[ -4 " 4 Date Requested ( I Time A.M. P.M. f C' Address I i, 3 S J Permit # ZJ O Owner- — — Lot # y D Builder - -- - --- The following Building Code deficiencies are regi.fred to be corrected: Ile Presented to _ _ ❑ /lriprrvett Inspector �- A-Mapprored Date _ l — --`' - CALL FOR, SECTION ! YEIs ❑ NO :�?,t+t+s".MukG�"+�r.�-t�;;,ya,y: - �.,; ,..,. '.�r�+... .� ,> v};r'.�,. . ,.,.•,d.Ar'.. .a�� ,..�,�. ,' RECEIVED N 41y�y :1.989" Commonlq Dnnlc;me�# t Mike MJIIs , Ci Ly e 1: Tigard .i W. flail Tigaz,_l, Or E: 2: Gearhart Acres l,�t,�'y ��„nywl[.,• �Y �”' :. ''�1. "W'R1►t, �,I�firS. s` ...`r 2. ..� . �'�'�+ 1. ffiw i.-.�. r ._i+� ' .T Dear Mr. t.i.11s, 1, -,1 ,t l ,_ inLormed that the downspout di,i i_ii a t- ').`�4'i Gd. :' SL1A is ,,, inpleted. j-t bio :,t- inspection and letter of compll a,,-o t ;t .iai t ,l l hat we may obtain a maintenance bonding . Thank YcIl F.G.F.Devt. l ,'_ merif: 'y,r t a., rank Pauszho 04` ', ' � t, �� � '` tic. ✓ ,. it 10-7 fit/ �� �. ,F ' •, ' 1','b4.�� a,'�� r �ti i ' ��'I-`� f�-�' �7i-s,�7.2 `/� �"7^��t►— r,; •� 't 'y. .`" INSPECTION NOTICE v1n City of Tigard Bui'ding Department J� / ► t P.O. Box 23397 Tigard, O-egon 97223 Phone (339-4175 Type of Inspection ___ - ----• Date Requested � L_ Time A.M. Address J -> I— Permit Owner _ Y.__ Lot # Builder The following Building Code deficier,cies are required to be corrected. Presented to _._ .� Approved nspector Disepprowd — — Date CALL FOR R NSPECUON ❑ YEs• ❑ No F INSPECTION NOTICE City of Tigard Building Department P.O. Box 23397 Tigard, Oregon 97223 (Phone: 6{3/9-41f755 _. Type of Inspection _ L ,/ - ' ' ""- , 0, ! Date Requested._:y Time A.M. P.M. Address �f-� ✓ sG f�C ✓4 _ Permit Owner �., ._ Lot # Builder The following Building Code defi c iencies are requir,l to be corrected: �Lr Presented t0 Inspector ❑ Disapproved Date Z? CALL FOR REINSPECTION DYES ❑ NO W W W W +� C17YOF TIGARD OREGON Re: Sag in Ceiling To Whom It May Concern: On March 8, 1990, Mr. Robert Thompson and I made a courtesy inspection at 11355 SW 95th in Tigard, OR, at the request of the homeowner, Mr. John Porter. The second floor, floor joists over the living room and entry area appear to sag approximately 1/2" to 3/4" at the most drastic point. The joist system seems to have been constructed according to plans with 2" x 12" joists at 16" O.C., with a maximum span of 19'8" which is well within permissible span limitations. I advised Mr. Porter to contact the builders to work out the method and the extent of repair_ that would be acceptable. Sincerely, George Steele Building Inspector GS/jlh 13125 SW Hall Blvd.,P.O.Box 23397,Tigard,Oregon 97223 (503)639-4171 ---- .3 AU RF INSPECTION NOTICE Gity i igard Building Department P.O. Box 23397 (lt Tigard. Oregon 97223 Phone: 639-4175 Type of Inspection Date Requested —_� G Time—A.M.—P.M. 7J # Address 1��-t— - --- Permit Owner c--7 Loojt/# Builder - 6— /` 26 The following Building Co.e deficiencies are required to be corrected: Presented to -~"� ❑ Approved Inspector _ ❑ Di-approved Date --- CA L FOR MVWSr`ECTION O YEs E3 NO INSPECTION NOTICE City of Tigard Building :;epdrtment n 7� P.O. Box 23397 OA Tigard, Oregon 97223 Phune: 6//31�9-4175 Type of Inspection jr~[ -y-- Date Requested c::;) C23 S• / Timey A.M. P.M. Address �1 �� /`� Permit #. _Z Owner , Lot # Builder The following Building Code deficiencies are required to be corrected: r , ,yr Presentpd to _.__.�---------_-.-._—�-- ❑ Approved Inspector 4 Olapproved Date CALL FOR REINSPECTION YES 0 NO w CITYOF TIVARD OREGON February 6, 1989 \ Mr. Frank Pausz FCF Development Co. PO Box 1681 Beaverton, OR 97075 Re: Gearhart Subdivision Dear Mr. Pausz, The final order for case No. S 9-86 lists condition, No. 13 which states, "All roof rain-drains, footing drains, shall be tied to a public storm water system or shall be connected to curb weep holes as appropriate". Now that construction of the house on Lot 13 has begun, the roof drains for the house on Lot 12 must be taken care of. This item has appeared on punch lists dated June 24, 1988, and September 28, 1988, and it should be no surprise to you that the building department cannot Issue an occupancy permit for the house on Lot 13 until Lot 12 drainage system is complete, an stated above. Call me at 639-4171 if you have any questions. ) / Sincerely, 7, Michael Mills Construction Inspector / /r jlh/Pausz / ccr Brad Roast, Building Dept. , City of Tigard �.r 13125 5W Hall Blvd.,P O.Box 23397,Tigard,Oregon 97223 (50'3)639-417-1 — IF: ; ECTION NOTICE City of Tigard Building Department P O. Box 23397 Tigard, Oregon 97223 Phone: 639-4175 Type of Inspection � a':� ' ! Date Requested -2-- Time A.M. P.M- Address -S — Permit Owner Lot # BuilderThe following following Building Code deficiencies are required to be corrected: �►-�a�"–,– S Presented is Approved Inspector C�• – FL` Disapproved Date CALL FOR AF'INSPECTION F1 YEs ❑ NO INSPECTION NOTICE - City of Tigard Building nepartment rf P.O. Box 2'397 \\ Tigard, Oreo:m 97223 Phone 69-4175 Type of Insoection ? Date Requested c'9 �� Time_ Y _A.M. P.M. Address j IS� 15 ;7 Z. r- Permit #�S�2 C C1 0 v' .er_ j 3 5f -------_ Lot The following Buildinq Code deficiencies are required to be corrected: Pres-Rnted to a — "Proved Inspeotor ElDlapprowd Dote T .. .1.___-- CALL FOR .REINSPECTION ❑ YE! L: NO W WA MAMAifs i� INSPECTION NOTICE City of Tigard Building Department P O. Box 23397 Tigard, Oregon 97223 Phone: 6zq-4175 Type of Inspection __ — Date Requested — y—pp Time A.M. P.M. Address Permit #_ T Owner __ Lot Builder The following Building Code deficiencies are required to be corrected: Presented to __. L_,! Approved Inspector _ J v E_I Disapproved Date CALL FOR REINSPECTION 0 YES 0 NO SE:WLA PEAK[ I C'TYOF TSGARDI-')E 'MIT' NO. CITY01' RD 71 5LILW: COMMUNITY DEVELOPMENT DEPARTMENT 01111 0WON 1 5 13125 S.W.Hall Blvd..P.O.Box 23397,Tigard,Oregon 1: -1:M . F'M NO 6W..:?W490 on 97223.1503)6394175 AD1:MEKW5 . 11,555 SW 9,501 AVE'. IP5A NUMIDEP . 0373.6-41 3K i 01100 L I-AND IJ51i A1.2 I-OT STZE ! TIAP : 11a RN('.-'— I.-A 1AX,TION: 35 WORK CLASS : NEW 0!5E 'rYl.-.,F*.* : 151NGL.E FAMII.-Y 111*! at.pP:IAc.'mrv1' i"'1:11"llivem tcl wit'l-I ;43.1. 1-'Wlkn+w taricl A(J*-rlcy Fh(.-4laetrr mi. t. elxpirlrnth U.'20 (Jayla f I"c)in 1.h*I (J a t a 1.0;1(1 t.t 4rR ri h& 1,ca rata I IlLinut.11,11, pa:i.(J wil.1 bti- 4`111—plai-wacl A.41 tllff�' pernli.t All'T'll-1c:4 cimes I-)cI 1, g I I III I at-ecl (11, -t'he� lofft)10 hit.& t gj.Vel') , 1.1-1w -Fwaiwj, 11, is 1.1. -Fi,oin oicz ci:on ont.m.m.-e givel-1 . r. r. I-Imt ii;(j liac�iata(J , the intat.no.l.c-i, fol: 111 1, 'T. 1 PLIC't4lume at " Imp al.1-1cl !:).1.(:I*) tivaWliIi.." Pmlrmit JW11(i ti-Irl WJAI irtiot'llkil. as llill'(or-m] --TWiTAL.L . IYPE P L)T I DiNG SE. IE: ANEA: 1;:L 1XTUPE UNITS, -. TENANY' IMPROVEMENI OWEN-LING UN:E'T'!'i 'I. NO . nr-:* RLMNS 1. 0 ANOLPSON DAN E PEAMIT w Y363 Slkl 8Ee-1Vh:-'PT0N 1.11:1 LSDALE (U)NNECTION CHAWAH $1. 1100 . 00 N VC E C)F, L THE TAP INSTAI L. . R OTHER C ANI:A-'JVM')N DAN E 0 N MI-A1X'.)W8PO(:)I< DEVE-1-OPMEM r T W563 SW H17.*AVE;.F4'Y'UN--Fi:r.1-L.Sr.)AI...E R b A t-ut v t;-,t I--t a n r 97006 C PHLME: ("50,311 V97-7666 T 0 TOTAL 1. 135 00 VTON NO . 463,114 R II r*'C.L':IJ*t1' NO. ............ This permit is(:;sued subject to the regulations contained in Title 14 of the TMC Stete of Oregon Specialty Codes.zoning regulations PEQ(.IIRFA) 1NSPECIA'ONS and all other applicable codes and ordinances, and it Is hereby ROUGH--:LN 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 Contractor 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 It work Is suspended or abandoned for a period of 180 days any time after work has commenced It shall be the responsibility of the permittee to assure all required'jpa7ctions ips-mquestpel and apprpted. Permittee igrinture Issued Bi. F OR INSPECTION 6XV-Al. 1.5 y SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE C'TY OF T'GA RD MllNO , : PL88P500 wyommo COMMUNITY DEVELOPMENT DEPARTMENT o1n,JN LAII' llwSUED: :1./2,3/89 13125 S.W.Hall Blvd..P.O.Box 23397.Tigard.Oregon 97223.(503)6394175 PPIM. PM'T* .NO. 802A190 1117171 :::!55 5W 95TIA I)VI: TAX MAP/1-0'r 1.S:1. 35CA /13.00 Gli.,1PHART AC R1*-: BK I.-AND I 0I tal.ZUK WORK f.-L-ASS : NEW UrEM NO Nt W A Tr;:':P CI 05ET 3 144AP !A:N(;LE FAM11 Y (.1PINAI 11-310A.-OW PRIVNI'R CON!VT . 'I'YF)I;:' VN I owoprat'.44y 3 1:44114EA P . UPF", P3 TAM G110WEP 2 GIAH'ASti-i: DISIAWASHE'P I GAPDAGE DISPOSsAl 1. NO . WASHING MA('.: INE DWIE.I.-L. . UNI'T*S : 1. 1 AUNDAY MAY 81 DG - DPA IN t D.0 A FLOOP DRA.1:19 SINK (F-T) (YTHEP 0 (114DI..PSLIN DAN E PEPMT1* W '?36*.3 !:iW OLAVEAT'ON H I L L 15 D A L .'1;: $132 1-5 0 N E I AX $6 e)3 (111,11FA C 0 W01 N W(M.A.1011 Pt.umn.NG T R I.-)cI BOX RIP A c)r,C? !ii I I tit.in 1.11., 97030 C 1.6 T !)03) 667— 1181. 01 l:4r(':l-t"I'PAI T('.)N NO . 'r.*-!3611'1 I VT NO This permit is issued subject to the regulations contained In Title 14 .......................... of the TMC. Stews of Ciregoi. Specialty Codes.zoning ret,-ilatlons and all other applicable codes and ordinances and It Is hereby agreed that the work will be done in accordance with the plans and PL 1*1 1.JNDEW!:iL.A0 specifications and in compliance with all applicable codes and P 0 1:i I' & P r-*.'A M ordinances The issuance of this permit does not waive restrictive Wn'l LINE covenants Contractor and subcontractors shall have current city business tax permits This permit will expire and become null and void it work Is not started within 180 days.or it work is suspended or 11"'AIA DPAIN!l abandoned for a period of 180 days any time after work has I 'I NMI— commenced It shall be the responsibility of the permittee to assure all required in!p ons are requested and approved Perrnittce Signature C-1 2 .5supri BV I ZO I iAIW SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE N MI C',I-IANJ'CAl.. PE.:14IM1T riii-r-Mrr NO . : ME:'811:112.501 CITY OFTIFARD Ct7Y0ZFTfGFA1Rt0 I. COMMUNITY DEVELOPMENT DEPARTMENT 00100H 15SUED: .1./2.3/B9 13125 S.W.Hall Blvd-P.O.Box 23397,Tigard,Oregon 97223.(503)6394175 1'1411141. WT .NO. 682/490 ADINA jl� . 1.13,156 ""'.1 AVE,. -- I AX MOP/L.01' I-ST 35(',A 1:1.00 SUI:.4: LT : 13 Bl< : L r1ND I..J SG:: : 111 E? 1,111m : NO: NO: W01PI1< C'LASS : NEW I.-I.MNACE 0.00K J. A11-4 HANDI—P 0.0 11'J 'TYPE . 5XN(.';L,E F'0PNA(*.1'E 1.00K+ All*-I FIANIX-11 10K 'I YPF : VN 1:1.00P I!1JRNAGE E:VAP . C1001 I-J4 IM 11E.ATE 1:1 Vl;.::N'T FAN VENT VE'N'T . SYSTEM 1.4 15*10 PT 1:;: P 1:11—PlIG010111%, .3 1 15 H P 11NICANEEPA1134(DOM 1'.)Wl::'.1 L. .IJNT T'S 1. 0 1 A/C(:)Mi:-' 15 301-1P 1 t4C:l:Nl'-:P(-)*T*()P(C(:)M I 11F.1 TYPE: GAS F31 P/C(:)Ml:) 30 501-IP PEPAIJI L)INITTS NI-)X . 1,14PUT F1L.P/CX)Ml*-1 15044-11-' UTIAIE'k I 11.11%. DMI"11:14bl? 11:11P114.1,; (3131LEAS) 0 DAN E' $1.0 . 00 W '7.'563 SW 1.)A.L.E: 1-1160 WE .1. 1. $a.0 . 1. 3 N Ij(?M V I L 13 1,1 E R l (YIE 'TAX %J I I-RA1 C 0 IA'11114 Sli-ASONF) I-IFAIJAU; A1.14 GUND . N T 1.-,,0 1:.1ci x e)610 9 R 1:1 r)1,1, 1 iii I I cl P 6 6 A C ( !1503) fftll :5191.9 T I'Iffj 4;.11!:1 111 r.()iI 0 .I.A.)IN NO , 111PAPE11*3 101'AL. : $5 Z! . e,el R PIECE:C 1::,1' NO Id v ............. ........... ............. ........ ..... This permit is issued subject to the regulations contained In Title 14 of the TMC. State of Oregon Specialty Codes.zoning regulations 111W)TRUD :LWIPEECTIONS and all other applicable codes and ordinances. and It is hereby CLAS I...1.N E agreed that the work will be done in accordance with the plans and 1.105 1 rb PEAM specifications and in compliance with all applicable codes and 1.4111 11A I N ordinances The issua,ice of this perm does not waive restrictive covenants. Contractor and subcontractors shall have current city business tax permits This permit will expire and become null and void if work is net started within 180 days,or If work 19 suspended or abandc.,ed for a period of 180 days any time after work has commenced It II he the responsibility of the Permittee to assure all required s r a reque ed and Fipiilleed Permittee Signature 1 (Arl 11NISPVC-7 TUN h 49 Issued By SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE NO. Buee2Aigo "NOFTIGARD CIT�^ Cl CITY OF TWARD COMMUNITY DEVELOPMENT DEPARTMENT 09100N 1)(YTE: /2.3/f:9 13125 S.W.Hall Blvd-P.O Box 23397,Tigard,Oregon 97223.(503)639.7175 PAJ:M , PMT .NO. (382A9 J 0 -A)EADDRF-515 : 11*3:515 'aW 9511-1 AVE I AX M A P I,(TT 3.53. '35CA 11-00 EiUb: GEEANHAl"."T ACI*-4E 5 "00 1 IQ 1. VALA-AT10N. 111 6--1- ,006 513:11RACKS F'RUNT : 20 PFAW 1!5 WORK CLASS : NEW DWEL I.—I IN ITS : I LI:A;:'T : 5 I;1V3HT: :1. S114(:LIT FAMTLA NO. DEEDOOMS '. 3 WALL C'C.)NtS'T : i)Wi V . I*YPE.: VN NO , IDATI-IS : I'S N: S : F:: : W PRO T .OPENINGS : "ITY1 Al A P E:04 1.41-110 NO . STOAJA-"S : 6Z40 POOFUINST . C F."I Fir-K PE'? ?NO 20 r. : 6A0 AREA Sir-ii'PAP? : : 47 3PD : PATED : DAGE.M 1, 4100 F-134-K W'-lPKI.A"? ALAPIVII? C)D F I OAD: 4 0 1:1 OW(GPM) 17EA'FA-1 17 yl:::1-) 1.11. r11' VYVIF : C.;A i COPI:'cl,' PI. AN CA-IL-1 J% I-:Y RElSSUE L]IF NO. 88:11.708 I AST 0 i1NI.A.::Pl!50N 17A N 1-.. $337 .00 f.^)N r4I'-.i:V1r.:'.W $10 , 00 W �iW N E 1:1v Pit V ex I" t;(:l U) C)1*1 R (AX 1.6.W.P.5 Ill ''I I 0'MENT CIAAACAKS : Cf 11111EN50 . 00 0 DAN E:: N ML;(.):)1.)WF4I40(JK DEYLA (.)I::,Ml-.N 1 $600 , 00 T 9363 !A4 C250 00 A 1.1 lik v c.,,I, I.1'1 1-1 ()1- 9,1,006 PPF:PA 1.D < $40 00> C T 1:11ONEo' (30'.3) 29-1-1666 1 01AI, 411. /153.E15 0 nrol"GIVA'VTON NO 1631111 r-*--VXJPT* NO . This permit is Issued subject to the regulations contained in Title 14 ............. of the TMC. State of Oregon Specialty Codes,zoning regulations PL(A I I 111i•A7 lWiFIEC I'lON45 and all other applicable codes and ordinances, and it is hereby t)f i 1 1 NC.-, agreed that the work will he done in accordance with the plansnd III ff4L)A*I T ON WALL. I-'1A1N IIPr3 A:[N specifications and in compliance with all applicable codes :nd ordinances The issuance of this permit does not waive restrictive It If & KAKAM WAJ F:P L.I NE: covenants Contractor and subcontractors shall have current city I It.1*:.'i UNDE.1151..AL) Elly business tax permits This permit will expire and become null and cit n U! FA*NAL void if work is not started within 180 days,or If work is suspended or I'l I.! F0P(71J1 abandoned for a period of 180 days any time after work has I W, commenced. It shall be the responsibility of the permittee to assttrr all required inspections are requested and approved 1. o- TJ ON Permittee Signature Issund By ou 11 I hl"11�1111 ir I SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE 6 3a W CITY OF VGA RD 4' IV' "A"'� WUNID, PLAN GHLCK APPLICAII COMMUNrTY DEVELOPMENT DEPARTMENT-l'i' k Cf1YonooN 0 PLAN C11F CK 0 13125 SW Hal Bad. P.O.sa�2=7.Ttwd.Oregon (SM)63041�n P1 F?M 1.1 ly DATF fSUED JOB ADDRI I rix MAI)/I ()I .51 ',Elft4 v 0,1 : ANI) Ll,4it- Z- VALUA I [ON: OWNL R :01CCJAL NOIES 00DRESi;—, REISSUE OF: LAST REISSUE: FLOOD PLAIN/ SENSITIVE LAND: T146NE; GONIRACTOR APPROVALS R�.qgIAIJD PI.ANN[NG: NAME . E NG 1.N F I P.1 NF, ADDRESS: FIRE DEPT 0-1 HER: i)H6NE ITEMS REQUIRED ARCH/ENGINEER I. 1ST/SUBCONTRACTORS: ...... NAME: BUS TAX: CALCU(,.ATlE)N,,' ADWESS: TRUSS DETAILS: PARKING PLAN: LANDSCAPE PLAN: PHONE OTHER: COMMENTS: PERMIT # ACCT # DESCRIPTION AMOUN"I AMOUNT PD. HAL. DUE 10 -432 00 Building Permit Fees 10-431 00 Plumbing Permit Fees 10-431 01 Mechanical Permit Fees 10-230 01 State Building Tax (5%) Building414� . )- --/ 9-,�— Plumbing -3 Mech 10-433 00 Plans Check Fop. Building ?o ocn ujI(OL4 Plumbing 30- 702 00 Mpc-h Sewer Connection 30---444 00 Sewer Inspection bl- 440 0() Street System E)ev chsr*qp (,sDq S2 -449 00 Parks SysL(!m Dov Chars e (PD(,) 31-450 00 Storm fwainAgo syst r)vv Cl,jrq ([j, V 10-230 09 fRFD 10- 230 06 W-ishinqtLin CtlunLy Fir,o #1 (913%) 10--L20 UO A moi r-t. Wt d q o wo od 101m _jY -"t # 0' A PiP 1. C7A -i-',IGNATUR1- c . Rpcoivod fly : Date Received: