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Home My WebLink About14-2330CITY OF DIAMOND BAR DEPARTMENT OFCOMMUNITY&DEVELOPMENT SERVICES 21810 Copley Drive, Diamond Bar, CA 91765 C PR {909} 839-7020 Fax: (909) 861.3117 Building inspection Hotline {909} 839-7027 FIRMLY PERMIT APPLICATION JOB SITE ADDRESS Z1- t S WV O ._4 ARN ?f -Depen _ k-3. TRACT OWNER _S'It"�.-'+i-%1•b vNiC t..et,-e3•B ADDRESS _1-I AIn�A•.rxal ' _.... CITY-Yla.,V IJP a'IA7 FEL APPL)CAN7 _ TEL ^' CONTRACTORR�,� fi f 4 �- ADDRESS .�f L lcle CITY waj K n -f a ZIP a l� l A' Z-78 ..."o ARCWENCAIDESIGNER ADDRESS CITY LP TEL OWNEa-BWLDEO DECLARATION 1 bAmt7 attend utile paABy of Pam and I am emmpt tmm Do Canbadm 9 State urop'a Law W De now et) Ind erred W" by the aheaoonwed, I Hare PIecW Hat to DM 9wia le Agnes) 1"Seclbn 70319, O1Wdo and PM%=Wm Coda Any city a comer Mat requires a Perms to CdoBISA, aft, Impma.demmhk a rat am $bUcWq prW M IM hmma atm mqu De apdk•d IPr too paMD M Me a sirel agement** M ane is Howard pumuantin we pmaabM of One Contactor'sStand Low, Law (CmpW 9) CammenenD *Mfotllm 7000 of DNWM 3 of the Drainage asp PragAar• Corel a DMi fe or a ha is aaaoMM la m on, worW N Word aaMpw Any vlaatlon Of Septan 7031 5 d My apa ea ba pease ar•Iand and "Wonder a Cot pomyry at rot made Dan Aa haWretl ddCm(uss) Ulan ewnaa ttn prwaly a my ompto mwith wap as Mnb mMearmemmkrL.2 do U aD of or U pariWa At Me wa t. aid for aMAW9 M do Intended a offend W cote awe, 70th Cannot, and Roksslo s Cw The Cal6acbm' BA1B 4lcenaq Lax dcee nd eppiy Men dada m aaPoty who Mms� anpoiom' apaamad e1Wi, hrAm a Im(umde Me Prapnty, Pfas'MBd ihal Da aaramrlafMAe M Imamda o�u1 W sale D hvmrer, ma 6Wtlag m aaaor oov to do proceed ane y� d sampktan tY Owner BUR'kr m3 tiara Ma Cfmn d pmNfg the ears nal Mdl W IngeDretlW Da PUMuae d am) L31 also a Me award, •n asaway aaa4m.•y with ftenrea CnnbazWs in vandidect Me andsm IsMean 7044 Mores and Prde9ouu Code The CordMeta• SCM Licarm taw dw5 and aptly m an aemA d awa+tY ram IMM9aft # Mew And 00 onaowls.0akeddedfnmecWa9iNftMpaCmttand9SMm Lomas Lew) U am ptfiaa owcwe OWN tire CmD¢Mr'e SCM Ltrsme lreWDo Wi ong oneadrao By mySlygderyMow l acknowfid the aerator for Mydeimny reeMaKa Inwhaa l mm fare reacted Meat awam yelp A CWCkbM of ft brOMMr4gft M"WMY ties PWWU pammt legally a9 a atucoee We t ham afar nen owrer DDimmtean in dsearedy by CcmgW amaaa0re l uwmmd Mata CM9Me, aPOi Idw Seam 7044 at My Baand Perfaccal. tanda maiMMoMen request when and a coo, it ab CW a at drakwingiaebwa twphrmvleg(Mam DATE SNOT u SDECL4AATMN I hNrePy an" MOM pmWtya may, ppi I am Leaded amor piamofp;m DOOM O {ammenmp wo Eecfp5 TWDj at Dh1#m 3 of ad MAr¢ne and Nord nag Lode, amend My Canada "NO baceand offect ECLAM DATE. l_(_-�[ qcDNTnatrDe ioC A /C'L Wawa's Calreaargim maMAT•N I N9UNAFFWA OWER PnnL YOF PERJURY 014 OF THEFOLLDWIIW DMNW ONS _ I two WM wad M*ftM a 004AMIR Of COMMIN In SW tale WWanco a COMMMMIDo. m provided! by .&cDon 3T00a4a tabes Ikde W UA PaWmaaatl4a walcW wfiN tfA aMAr A (;seen Item AM rA8 mAMeorWtu4MaDaManeatbltrannce, esmMNeuSeptan3700 aDblase CodeW M kyflum omad Ore walk W wtxch 4aspemat b lseuW AQ'Wa9a'd §Canpensatlm hovmma Coder AM Adkyrumtar oo- CPMDN r/ 0 A) JWr FMFCY NONOER _ / IIe65ECinNtSfT NOT Wt44LE1E0 FT6 PERIDa 6RH ONE KAOEO OOI)NLS WOCIj MILES ). 1 wY Wy tlm t M Vw paAaasKa d s• woMW which th• PaIN1 N ow d, I gnat rat earpo y any perar, many nMaa m m b ton ow SAW W DIB Wuya§ QnAaAWn Lath d Caaadp Aad Bp'm Met A I aaaad bre on1AA n tla Wawa§ Daryx�19D+D'ae dSectlon 9700AMeLob.la08 I�aMw4f sanPNmlp Pme pmdsbm DATE APpUGNT " (F///.{ WAWA '."or M Mom Waal§ Co ft mos" www A InAfoA, and May edged of WoMM b aMnnat demand and Clad Anne up M and Nodded Meant ddMrs LSIOD,000), M wide an to 116 cal a DM CoMpeM1graimn aw,m0 as"Add W M Mow 3748 d On•baODW eAweM. end Wmney§ Nee CM=tCMN LOOM AGENCY 1 Poetry diem amt powy, a pagay thm dam M a Dauautal Lama Agency W Me PalananS of Oa our far wtffihlbapermkuleaadLSa 3097 Lri C) LINDER S NAME. LFNKR SADONEM9. Iwity MdI he* rod MN mopoaAd rade 4M4 Ma Wears fdaAMWt N mecO agree Mcaady vane a My hat eomdybfailaaa6are SM4BEMretaMq MalaAig ayeMKDas ane hagersoMODs mom" ad AfW tqM Me arms Mdowdf aOw, , W 0ipsdbn Pawars �R94TiFi NAt�pNffi{f) L ri r fJSA` 6mE APPLICATION DATE IPICOA / 4- - 2:11" ISSUE DATE TYPE CONST OCCGROUP r 1111111111 ZONING FI!O14 SETBACKS .11REAR 9 • F e • • i ar Y Y11•�}}!� e•A• _ �Y�AiWIY•.� • 9 .. • . �� • iii+:%-aad��ii� IWiiYiYibisi�_— F �Pw ,. . IIIIIIIIIIIIIII��rY .1�i1 = CONSTRUCTION PLAN REVIEW —4w ELECTRIC a a PLUMBING MECHANICAL s INSPECTION FEE ISSUANCE ITZ ': SMIP f J ENERGY P/C ENERGY r RETENTION PRE -ALT FEE BSAF lP TOTALFELS 7�yr� r / /< I�I�■��1 COMMENTS >f WRITE— Copt.YELLOW—Finaca Copy PINK—Assaosor Copy 60LtIFWiDD—Ro Copy GREEN—Appipaa4's Copy CITY OF # 3 BAR INSPECTION#'# INSPECTION DATE INSPECT SETBACK] LETTERTRACT INSPECT16N DAT IN PE T R AND LEDGER FOOTINGS FORMS SWITCH GEAR SLAB COMMERCIAL HOOD UG PLUMBING 'i T -BAR UG ELECTRICAL INTERCEPTER UFER GROUND HOT MOP/SHOWERPAN SEWER LATERAL SEPTIC/CESSPOOL MAIN WATER LINE HERS REPORT RECEIVED SEWER CLEANOUT DEMOLITION ROOF SHEATHING ROOF DRAINS FLOOR SHEATHING ROUGH CONDUIT SHEAR WALLS EXTERIOR POOL/SPA SHEAR WALES INTERIOR '�, ROUGH PLUMBING FRAMINGNENTING Q a ROUGH ELECTRICAL ROUGH MECHANICAL ';ROUGH MECHANICAL ROUGH ELECTRICAL W( ) C { GAS TEST ROUGH PLUMBING PRE GUNITE INSULATION WALL POOL PRE DECK BONDING INSULATION CEILING P -TRAP ,DRYWALL1 -- 'FENCEIGATE?ALARM LATH (PRE) FINAL POOL LATH EXTERIOR .....— '.. WALLS LATH INTERIOR WALL FOOTING/STEEL GAS TEST WALL STEEL I"( ) 2N0( ) LIFT SCRATCH COAT 16 WALL BOND BEAM ELECTRIC METER RELEASE WALL DRAW SEAL GAS METER RELEASE WALL FINAL SPECIAL INSPECTION RO FRAMING PLANNINGAPPROVAL FINAL BUILDING"r`I r1'1A ROUGH FIRE APPROVAL FINAL MECHANICAL FINAL FIRE DEPARTMENT FINAL ELECTRICAL _ FINAL PLANNING FINAL PLUMEING FINAL ENGINEERING/ PW TC Of OCCUPANCY FINAL COMMUNITY SERVICES CERT of OCCUPANCY '�. FINAL HEALTH DEPT _' ra FINAL INDUSTRIAL WASTE * tri t' . 1 • STEPHEN WRIGHT CONSTRUCTION INSPEcn0N 25132 PIZARRO ROAD LAKE FOREST CA 92630-4234 949-533-3326 MOBIL' 949=588-6202 OFFICE Building Permit No —Pit I+{ - 2 3? d Job Indenhfication /Address *z 7 1< General Contractor/ Address AG t Sub - Contractor /Address Structural Engineer/ Address SPECIAL INSPECTION REPORT -•:^---�� Job No V Sa.n«t ! �naS nln DEPT.�ff 8 G.,SgSE7Y CITY iar^•� AoL COUNTY OF lx A. tc Date -7-Z6- I s/ REINFORCED CONCRETE PRESTRESSED CONCRETE— .-. MASONRY �` WELDING ;.r. • _i i HI -TENSILE BOLTING GYPSUM CONCRETE CHEMICAL ANCHORS__ OTHER WELDER RECEIPT NUMBIPFL, WELDER RECEIPT14UMBEFI DATE Or VIVECfantr DESCRIPTION OF WORK INSPECTED ?'7ts-I�f ptSC.V/�r4 I�CEN"� o pct Ct fr {/41 �o ta1 F P 'I1`0/ Y 4A rrpe rr /• U /.yt F! Jau 46q., f4J40 e ,s:o r", f, px w Crit/ ('I /aq f"' SG%•r epaar JI rY Q�L-/i^ t .. ♦ 5 In Time Out grout . Mortar ConcreteI Stock Onerni F077"T "it . ` Ait Inapadtlona basad on a minimum oft hours A over 4 hours - 8 tours minimum Any unspaelbn exrtantllrgl past am noon hour wni be billed as ' two minimum In addition, any 49epection extending past an 8 how pe - rid, or Saturday mapection win ba bisect et time and a halt ATTORNEY'S FEES - If any action at law or in equity is brought to anforf a of alterupt the terms of this Contract, the prevailing party shall be entitled to reasonable attorney's fees, costand necessary disbursements in addition to any other relief to which such party maybe entitled , t PECIAL INSPECTION REPORT Inspector's Name. f ✓� �" r14 Inspector's Stgriature. I.D. No. MIT, % ' 9 has been filet, and It states that the above wok to the best hi her knowledge complies with the provisions of the Uniform Building Code and meets approved pians and specificafions Respectfully Submitted, Approved by Project supenMsndoM By Av V CERTIFICATE OF LIABILITY INSURANCE 06/212013DDmrrt THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER IMPORTANT If the certificate holder Is an ADDITIONAL INSURED, the pollcy(Ies) must be endorsed If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements) PRODUCER Business Owners Ins Agency 3914 Murphy Canyon Rd #A239 San Diego, CA 92123 CONIC'NAME Jesus Rojas PHONEFAX 656"674-0101 ac Na 858"874"3801 EMAIL ADDRESS jesus@bola net PRODUCER �IERID a. INSURER(SI AFFORDING COVERAGE NAICM INSURED PEN CHENG CHIEN , DBA PEN CHENG CHIEN 512 CAMINO DE TEODORO INSURER AmTrUSt Intemallonal Underwriters Ltd AA -1780074 INSURER B State Compensation Insurance Fund 35076 ❑ ❑ WALNUT, CA 91788 1INSURER C 61132014 INSURER D MED EXP (Any one Person) s 5,000 PERSONAL S ADV INJURY E 1,000,000 INSURER E ❑ INSURER F COVERAGES CERTIFICATE NUMBER REVISION NUMBER THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR LTR TYPE OF INSURANCE AWLUBR POLICY NUMBER MMM,DDIYYEYPOLIW I IMPWDDOLICYEXPIYYYYIUMITS GENERAL LIABILITY EACH OCCURRENCE E 1,000,000 A 0 COMMERCIAL GENERAL LIABILITY ❑ ❑ CLAIMS MADE ❑� OCCUR ❑ ❑ CN102470100 6/13/2013 61132014 PREMISES Me occIsreari E 100,000 MED EXP (Any one Person) s 5,000 PERSONAL S ADV INJURY E 1,000,000 ❑ GENERAL AGGREGATE s 2,000,000 GEN L AGGREGATE LIMIT APPLIES PER PRODUCTS COMPAOPAGG s 2,000,000 ❑� POLICV PRO JECTLOC S AUTOMOBILE ❑ LIABILITY ANY AUTO COMBINED SINGLE LIMIT E (Ea arndent) BODILY INJURY (Per person) E ❑ ❑ ALL OWNED AUTOS SCHEDULED AUTOS VIREO AUTOS ❑ ❑ (Per accident) E PROPERTYILY DA PROPERTY DAMAGE E (Per accident) cool] NON -OWNED AUTOS E ❑ E ❑ UMBRELLA LULB ❑ OCCUR EACH OCCURRENCE S ❑ EXCESS UAa ❑ CLAIMS MADE ❑ ❑ AGGREGATE E ❑ DEDUCTIBLE S Is RETENTION E B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICERIMEM ERIEXCLUDEIW ECUTIVE Y N (Mandatory In NNl NIA ❑ 9061195-2013 6/15/2013 6/15/2014 wC STATU-ANY OTH- E L EACH ACCIDENT E 1 000 000 EL DISEASE - EA EMPLOYEd E 1000,000 it yes desmhe under DESCRIPTION OF OPERATIONS below E L DISEASE -POLICY LIMIT I S 1 000 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, A0UNonal Reminds SeMduls, if more epaca Is requireal SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS '7""k " ©1988-2009 ACORD CORPORATION All rights reserved ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD POMONA UNIFIED SCHOOL DISTRICT CAPITAL FACR TTTES PROGRAM MANAGEMENT Form Number $04 SOUTH GAREY AVENUE • POMONA • CALIFORNIA 91766 Cerfificadon of Compliance X :;r wfv CID9 -5`09Applicant s Phone No $ire ppTwont executing this declaration certfies under penalty ofperlury that (1) they are the Owner and/or Developer or they are authorized to sign an behalf of the Owner andior Developer, (2) that the mformanon prowled a true and =were to the best of the Owner s andar Developer s knowledge, (3) the Owner andlor Developer will file an amended ccritjeatmn of compliance and pay the addutonat amounts due if Owner and/or Developer increases the number of dwelling unit$ andlor squarefootage after the budding permit is issued or if the initial determination of wits and/or square footage is found to be incorrect, and (4) they have read and fully understand this side and the reverse side of this document tnaluding the 90day protest period posted on the reverse side of torts document Oyarses/Deveioper's Name Ownets'Developer's Phone No Chimeea@eveloper's Mading Address Development Type and Fee Schedule, Chock appraprwta bax(rs) fdl in the jee per sq ft and circle Major, lave! mffect `7 e 0 Residential $ � 9 1s ft (Level t - Leve! 2 - Levet 3) Maw Addition_X t Single Family f Single Family attached_ t Mule Family_ J Other 0 ManufacturediMobile Homes $ fsq It (Level t - Level 2 - Level 3) 0 CammermaVtndustnai $ fsq ft in tstatus just1ficationInotes 13 Senior Citizen Horsing $ fsq ft, (See roverw side of sheet) 0 Exempt $ -0- fag R (Pmvdo justification.) _ Fee Calculations Each CertrftcationofComphanceformtsfwfive(S) projects mnrumum. Use addriumaljornufor additional protects 49 SkrtSc4 CxuiS►M �imtn �' w�i 3_ $ ��" 5 _ $ {o ff Tact No 1 Lot No / Address n Check No Fee par sq it Area Foe 2 $ sq it $ Tract No 1 Lot No t Address Phan Chalk No Fee per eq ft Arm Fee 3 $ sq it $ Tad No 1 Loi No 1 Address Plan Check No Fais per sq ft Arse Fare 4 $ sq it $ Trail No t Lot No 1 Address Pians Check No Fee par sq it Area Fee 5 $ net it $ Tres No / Lot No t Address Plan Cirerk No Fee per sq R Ads Fee ME Recelpt of Fees TOTAL FEES DUE $ (This fors only) �.. flus u m cors fy that all fees dun m rhe Pomaw Unified School District under applicable pmvismns ojthe Government Code and the Education Code, as prerwitude to the ternaries of a Building Permit by the Cul/Cowry have been received Baird an the mformatrmt n•�� Ito ~OclDate - See reverse side for Gefterat Informsetton. Senior Chitin Housiloj& Payment of Pees, Notice - Protest Period and Appeals Process. D mbutanof Whx1a-GYfCM ty YeWW-DlsbrctlCFPM Pink-DistdrdfFiscal lienees, Goidenmd-OvmenDeveloper Revised 4105 GENERAL INFORMATION On November 4, 1998, SB 50 became effective This bill grunts California school districts the authority to levy fees in excess of those Puthonzed by Government Code Section 65995 (Level i Fees), if the district meets certain specified tests and approves a School Facilities Nexis Analysis Alternative Level 2 fees may be levied when state bond funds are available for school construction projects, and Alternative Level 3 fees may only be levied when the State allocation Board certifies that it is no longer approving apportionments for new construction due to lack of available funding The Board of Education approved the School Facilities Needs Analysis and adopted a resolution levying the alternative fees under SB 50 and has approved the fees on coruercialhndusmal development by separate resolution Copies of the resolutions and the School Facilities Needs Analysts are available for viewing in the Capital Facilities Program Management office SENIOR CITIZEN HOUSING Per Government Code Section 65995 1(c), if a senior citizen housing project is later converted to non -restricted use, the applicant/developer who is seeking the change in use will have to pay the difference between the current residential fee and what was paid for the senior citizen housing PAYMENT OF FEES State law prohibits a city or county from issuing a building permit unless the local school district has certified that the application is in compliance with the District's collection program for fees assessed developers The procedure for obtaining the required certification follows Project Plans - A set of project plans stamped by the governing city or county building department, and valuation receipt indicating calculated square footage and plan check number, must be reviewed by the District The address follows Capual Fadhow Program Management, Pomona Unified School Dxsirtct, 800 South Garsy Avenue, Pomona, CA 91766. Calculating Area for Residential Protects - The District levies fees on existing residential construction only if the resulting increase in assessable space exceeds 500 square feet after deducting any loss of assessable space in the same residential structure as a result of the same reconstruction All assessable square footage in new residential structures is subject to the fee levy "Assessable space" means all square footage within the perimeter of a residential structure, not including any carport, walkway, garage, overhang, patty, enclosed patio, detached accessory structure, or similar area, Residential projects also include the initial location, installation or occupancy of a manufactured home or mobile home Calculating Arm for CommerciaUlndustnal Protects - The chargeable covered and enclosed space of commercial or industrial construction shall not be deemed to include the square footage of any structure existing on the site of that construction as of the date the first building permit is issued for any portion of that construction "Chargeable covered and enclosed space" means the covered and enclosed space determined to be within the perimeter of a commercial or industrial structure, not including any storage areas incidental to the principal use of the construction, garage, parking structure, unenclosed walkway, or utility or disposal area Available Hours for Verification - CFPM staff will verify project development type and square footage and complete the Certification of Compliance n during available hours Available hours are from 9:30 A.M - 12 00 P M. and 1.00 P.M. - 4:00 P.M., Monday through Friday, except District holidays. Other times are available by appointment by calling (909) 3971800, ext 3920 r t Available Hours for Payment - Fees due are paid to the District during available boors Available hours are from 9 30 A.M. - 12 00 P.M. and 1:00 P M. - 4:00 P.M., Monday through Friday, except District holidays Copies of the completed Certification of Compliance will be given to the applicant for use in obtaining the building pernm(s) and for the applicant's records NOTICE - PROTEST PERIOD Section 6620 of the Government Code requires that Pomona Unified School District provide a written nonce to the project applicant, at the tune of payment of school development fees, truttgation payments or other exactions ("Fees'), of the 90 -day period to protest the imposition of these Fees Therefore, to accordance with Section 66020 of the Government Code and other applicable law, this Nonce shall serve to advise the applicant that the 90 -day protest period in regard to such Fees or the validity thereof, commences with such payment or performance of any other requirement as described an Section 66020 of the Government Cate APPEALS PROCESS Any claim by an applicant that their project should be exempt from assessment of fees, or that the fees levied are incorrect, must be made in writing and filed with the Pomona Unified School District The claim roust specify the factual and legal grounds supporting the claim In addition, the claim must contain a statement specifying the nature of the project and the date the project building permit application was filed The District's Superintendent, or his designee, shall respond in writing to a claim within fourteen (14) days from receipt of the claim The response Mall contain the Supermtencl art's decision on the ch n and a statement of the reasons supporting the dectsion. Any claimant who is dissatisfied with the decision may request review by the District's Board of Education A request for review must be written and filed with the Supertntetdent's or designee's office not later than tat (10) days from the date of the decision The request must contain a statement of all factual and legal grounds in support of the continuing claim The Board of Education shall consider and act upon a request for review at a public meeting not later than thirty (30) days from the date of filing of die request A claimant may appear and address the Board to regard to the claim The Board shall provide written notice of its decision, to be mailed to the ch meant, within fourteen (14) days after public meeting at which the Board acted upon the claim Correspondence shall be addressed to Assistant to the Superintendent, Business Services -Fatalities, Pomona Unified School District, 900 South Gorey Avenue, Pomona, CA 91766 x0'91000019* %j 06/16/2014 3351949742 Th I s i s a LEGAL OeFT O* of your check You can use I t the same way you would use the orlginalcheck RETURN REASON -A NOT SUFFICIENT FUNDS I Ul nu 3193 Dato Pay to the L ' r F Ie ' M C3 ,. sC3 Er C3 r-4 rC3 C3CO3 MC3 C3 y _ Cr M� �t YOUR ACCOUNT HAS BEEN CHARGED FOR THE FOLLOWING ITEMCSI RETURNED UNPAID. REASON FOR NON-PAYMENT SEQUENCE # AMOUNT DEPOSITORY ACCOUNT NUMBER- XXXXXX2094 CHARGES FOR PAPER RETURNS NSF-Insuf Funds 3351944742 1,518.74 TOTAL CHARGES FOR PAPER RETURNS 1,518 74 Q'F2 1A-- �33xa .3+d �to4- �n5+�r C".�r•,..�t6.:trlg• P'�..ylc� 1•'�^i Fac � � S • "� -� �F i'� � � = drl'�,� -? 9 G'(--xt,, TOTAL CHARGES FOR PAPER RETURNS 1,518 79 SHOULD YOU HAVE ANY QUESTIONS OR REQUIRE ADDITIONAL INFORMATION, PLEASE CALL THE PHONE NUMBER THAT IS LISTED ON YOUR BANK STATEMENT.