The URL can be used to link to this page

Home My WebLink About14-5031 � �,� .�.. CITY OF DIAMOND BAR �: �. S � �;. � �:�' DEI�!�RTMENT OF C�P.�.�G':�ITY&St�EVEL�PMENT SERVICES - — � 21810 Copley Drive,Diamond Bar,CA 91765 � PRESS \,,,,x W,P,� (909)839-7020 Fax:(909)861-3117 Building Inspection Hotline(909)839-7027 FIRMLY `'e""" BUILDING PERMIT APPLICATION y JOB SITE ADDRESS �la�� • APPLICATION�TE:�� y P/C# I y J D�I z N LOT TRACT ISSUE DATE. 7� J PERMIT# I7 ��a.�i � OWNER �"�A-MMA��S�T� h TYPE CONST. OCC GROUP: n ADDRESS a-��3� D u�'�� t'L � CITY h1Ac1�lON� �� ZIP 1�(� TEL. 31� g6'� (3�� ZONING F ONACKS RW ❑ = APPLICANT N"�'MN�A� A--�SA'� TEL. f3 REAR ❑ � _�� n SIDE/SIDE STREEf RW ❑ Q 'CONTRACTOR C� Y� Y� SIDE ❑ p ADDRES/S L�% � �` �- = CITY L��'�� /� ZIP C•�a6�1 TEL.��- 7S^��1�� PROPOSED USE� I�oM 1LO'b�T+o-. tY:� �� ARCH/ENG/DESIGNER � � ADDRESS #DWEL.UNITS�_ #STORIES �7 #BEDROOMS � z CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION I OWNEH-BUILOEH DECLANATION = I hereby affrm under penalty of perjury that I am ezempt from the Contractor's State License Law for the reason(s) SF D /REM �� , /9 '� I � indicated below by the checkmark(s�,I have placed nezt to the applicable item(s)[Section 7031.5,Business and Garage/Carport — � I � Professions Code:Any city or county that requires a permit to construct,alter,improve,demollsh,or repair,any z structure,prior to ifs issuance,also requires the applicant for the permit to file a signed statemeM that he or she � Patio/Deck _ I i Is licensed pursuant to the provisions af the Contractor's STate License Law(Chapter 9)Cammencing with Sectian w n7000 ot Di�ision 3 of the Business and Professions Cade]or that he or she is ezempt from licensure and the basis for � Pool/Spa — I n the alleged exemption.Any violation ot Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalTy C7 I ,s of not more than five hundred dollars($500). ZQ Re-Roof � (�I,a5 owner oi the property,or my employees with wages as their sole compensation,will do(�all of or O portions � Commercial I y of the work,and the structure is not intended or oifered for sale(Section 7044,Business and Professions Code:The m I � Contractors'State License Law does not apply to an owner of property who,through employees'or personal eftort,builds i or improves the pmperty,provided that the improvements are not intended or ottered for sale.If however,the building or I � improvement is sold within one year of completion,the Owner-Builder will have the burden of proving that it was not built � or improved for the puryose of sale.). I :� (�I,as owner of the property,am exclusively contracting with licensed Contractors to construct the project(Section Z 7044,Business and Professions Code:The Contractors'State License Law does not apply to an owner of property who Valuatio . � �O Adj.Area: I � buildsorimprovesthereon,andwhocontractsforlheprojecLswithalicensedContradorpursuanttotheConhactors'State QUANTITY DESCRIPTION FEE I License Law.). ''j, 0 V� ` \1 I � L)I am exempt Irom licensure under the Cont2ctor's State License law for the following reason(s): � � � �.� •1( uYc�i I � Z By my signature below I acknowledge that,except for my personal residence in which I must have resided tor at least one W I � year prior to completion of the improvements covered by this permit,l cannot legally sell a structure that I have built as an w owner-builder if it has not been constructed in its entirety by licensed contractors.I understand that a copy of the applicable I � law,Section 7044 of the Business and Professions Code is available upon request when this application is submitted or at .L 0, L- I K the following Web site:http/www.leginfo.ca.gov/calaw.html. Z . � DATE: SIGN: � ?J S�`'� � � — LICENSED CONTHACTOH'S DECLAHATION � � O W� I a I ' I hereby affrm under penalty of perjury that I am licensed under provisions of Chapter 9(commencing with Section 7000) � of Division 3 of the Business and Professions Code,and my license is in full force and ettect. J ♦ � ,y O n . I /��q �y f1 � LICENSE CLASS: LIC.NO.:_ L�JCJ��!C' z � � I � DATE:��"" �`^ � CONTRACTOR: ��M ��1'�Q/I� � I Q w WOHI�B�S COMPENSATION DECLAHATION � I y I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS: ) `� � �I have and will mainTain a Certificate of Consent to Self-Insure for Worker's Compensation,as provided by CONSTRUCTION: A �/� � Sec[ion 3700 of the Labor Code,tor the performance of the work for which this permit is issued. p�p,N REVI EW: �7. �� I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for / ^� � the pertormance of the work for which this permit is issued.My Worker's Compensation Insurance Carrier and ELECTRIC: ,�Vr,b z ¢ PolicyNumberare: PLUMBING: Z CnRRIER ��yl /� � �� r MECHANICAL: %�(�` S/, � POLICY NUMBER� ��I� .n INSPECTION FEE: (THIS SEC110N NEED NOT BE COMPLETED IF1HE PFAMfT IS FOR ONE HUNDRED DOLLARS($100)OR LESS�. ISSUANCE: �' � I certify that in The per(ormance of the work for which ihis permit is issued,I shall not employ any person in any manner so as fi � become subject to the Workei's Compensation Laws of Califomia.And agree that if I should become subjed tn the Worker's SMIP: J Compensation pmvisions of Section 3700 of the r Code,I shall fo m com,,pY'with thg�p�yisJ�s. ENERGY P/C: i DATE:1--,/S APPUCANT: I. �/C�/Y�1�7�t% �l.1��S ENERGY PERMIT: I/ � WARNING:Failure to secure Worker's Compensation coverage is unlawful,and shall subject an employer to criminal � D ipenalties and civil fines up to one hundred thousand dollars($100,000),in addition�the cost of the compensation, RETENTION FEE: p � damages as provided for in sedion 3708 of the labor code,interest,and attorney's fees. PRE-ALT FEE: � i CONSTRUCTION LENDING AGENCY BS F: � y I hereby affirm under penalty of perjury that there is a Construdion Lending Agency for the performance of the work for ��1� �/'� d � � which this permit is issued(Sec.3097,Civ.C.). I — LENDER'SNAME: ��D ' I Y LENDER'SADDRESS: i I certify that I have read this application and state that the above infarmation is correct.I agree to comply with all city and TOTAL FEES � � / (�J Z county ordinances and state laws relating to building construction,and hereby authorize representatives of this county to COMMENTS: � enter upon the above-mentioned property for inspection purposes. J � � I ¢ PERMITTEE NAME(PRINn � � �� 'n n PAID BY: VALIDATION: I = SIGNATURE OF PERMITTEE , DATE RECEIPT# �� , i��s WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy CITY O'F DIaMOND BAR . ` . INSPECrTiOf�E• REC�:Rn., • � •_-. �.� + , . -� --- . • • r � . � . . � � , . � . .._ SETBACKI LETTER �� TRACT AND LEDGER F�OOTINGS'FORMS � �� ` �n';�'I S�: � "� �' '� SWITCH GEAR � - ;,S,t..�B,f�_. �. ��, �_ � � COMMERCIALHOOD f .. - �. .,., y 3lJG.PLOMBING §;�k l'—Ja�'—� �� T-BAR (1G�:-ELECTRIGAL . � � ;� ,� ,;��,w ,,M,.� .,� � �� INTEACEPTER ��. , ; — w" — � p° � UFER GROUNp M �r k, �, � � HOT MOP/SHOWERPAN SEWER LATERAL � SEPTIC/CESSPOOL MAIN WATER LINE ' HERS REPORT RECEIVED SEWER CLEANOUT � DEMOLITION RQOF SHEATHING � ROOF DRAINS FLOdR SHEATHING ROUGH CONDUIT �SHEAR WALLS°EX7ERIOR - `�; i� °` : POOUSPA i� r �,;„ , ,;�. �': �r_ 'SHEAR�WALLS INTERIOR '� �„p� < ROUGH PLUMBING . � �� - - ,� � �; , � '.FRAMINGNENTING '� ` ;2�5'�'� �� ,�, �,� ��' ROUGH'ELECTRICAL"� � °� �R�tJGH;MEC�HANICAL �;�� s,� ,p., �� ,�� -_ ROUGH MECHANICAL � ; � � ROUGH ELECTRICAL W( }C( 1 2 1 GAS TEST s,�r ROUGH'PLUMBING� � '` � �' P,RE GUNITE � �. INSULATION WALL i POOL PRE DECK BONDING INSULATION CEILING P-TRAP' � �' e� �� DRYWALL ,�.. Z��y FENCE/GATE/ALARM LATH(PRE) FINAL POOL � � � tATH EriTERIOR iZ b � WALLS: IATH INTERIOR � WALL FOOTING/STEEL 6AS TEST '`��/ J.1 '�- WALL STEEL 1sT(.)2Ne( )LIFT + 1 SCRATCH COAT WALI BOND BEAM ELEC i RIC METER RELEASE WALL DRAIN/SEAL GAS METER RELEASE WALL FINAL SPECIALINSPECTION i . " ' RO.FRAMINGPLANNINGAPPROVAL — _ _ _ FINAL'BUILOIN6 � �� „ �� n ROUGH FIRE APPROVAL s �INAi:,MECH�#NICAl,:,,..°�� ,.. u� _•-F;,, ff. FINAL FIRE DEPARTMENT � � . , .. - ,. �FINAC EIECTRICAL �; � '.� �� FINAL PLANNING � � � • " :,��. FINALSPLUM8ING"� � � �' � �'" �� INAL:ENGINEERING/PW �"I , " Y x FINAL COMMUNITY SERYICES �T.C:,ofOCGUPANCY. �' � � � �,. _ , �,wr. � , ;CERT.oi O�CCUPA1dCY�� 'FINAL NEALTH DEP7. � FINAL INDUST IAL ASTE COMMENTS:�- t�3�LL �"�iNC- �' i- !� � . w��. ��p�� `� ,i.� . , I �3. . . . _ ,•�.J� . -. � ti'�` . , � � _ ` ' • �i- �' �. . . . . d �-�,,j` �» <.�. 'V � ,�_ � •,o, �. �.,i: .- , . � �.� • ,�� . '" . . .},3.. _ . � � . COMMERFORD I�NSPECTION I.NC.:.-.- ' DE�PT.OF BLDG.&SAFETY 2269 PAPAYA DRIVE " � � LA HABRA HEIGHTS, CA 90631 CITY�OF � �� o, �v n � .�� (562) 690=3198 or (562}690-2883 � �l FAX(562)690-4887 COUNTY OF ��1; �i✓��P S . SPECIAL INSPECTION REPORT � _ + b ,l U.. Building.Permit No. 1 �� Job No. � � Date d �' � /�,.� _. Job Identification/Address �I �� C7 dl rx �o, ��ia�� 11'�� i o✓�"a• ��+r ,�'� /��,� General Contractor/Address �C�oi vb. �ci rG� ` � �� f`�� i�'w � �'ra - , - • , v ' ' � Sub-Contractor/Address - ' Structurai Engineer/Address .�• �a- �V��`�� e c'+ � ��/� S�! � tft(��.`��: n C;`�u-�.: ��a r � �u "��&'� . TYPE OF WORK: REINFORCED CONCRETE��i MASONRY HI-TENSII.E BOLTING DRII,LED IN.ANCHORS�� , PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE FIREPROOFING ' � ;E��'��' , � WELDER. :' RECEIPT NUMBER WELDER RECEIPT'NUMBER � . -, , , ;' •DATE OE INSPECTION DESCRIPTION OF WORK INSPECTED: ' - ' �- �l-/,S" � �1n ��,,��1 ��A�t�; � �. �� 8 .� nu,��.� _ �a�,��.k S,�`` ul��F��'�:�� r' � � . ' � t/!t�b (�l• � �uJ n f �U d �+��.��u n n �. �ct�.}f 4E� �U�t.S� .. ({�� a -a�L�c � �.o�.Y r -. . Q . . ' ;�./�A 1{ UPd+ i d��0 LD1i�:�l (A�1 �Uu- n.��aL�.Dice•. . . �, � � b��1.�..�`�� 5 � ,�:5 — 01 `'� l�[ � �S—� � ;.,� ►�n�� . � ' � �j , � �,� ��.�� Q�'� �1 �,7 u�al e�S �c.� 51 a L, �c � @�n�-r c�• ��`�� C'��p�f�r.�l.-� C� �1�C�i� � � f S b� qW �G� � . ��d a ��` ��`� � � e�v :�i ��c1�,;,n- � ',c� ��c�a To�� (�� /, (� ,� 1� , �, t��,-}(�e �/ ��C � � C� �/ � �`'2 I� �1��Q��i � G t�f'v�b J S� � l: ✓i�Y�P�'„ �� a� 'E'- �O b`V('-;� , �t�L�c�� 0� ��(c��d-S �AO \ 1nul�� 4.�4�,��i c,v:.� e l�ru�ti. .� o�',� - � � �-,� l�v�:,.��:a ..�; �=�t�: � �� - y�,�4. . � � �l��- �c��_� _.._ � , - � , . HOURS Date Re . O.T. TIME IN TIME OUT,_ � — 9—/,S `'`� `�,'cJ� �� :� ,�� v� • ��" SAMPLES . Grout Mortar Concrete Block Prisms Densit ; All inspections based on.a minimum of 4 hours&over 4 hours-8 hour minimum. In addition,over 8 hours and Saturday will be , . billed at time and a half. - " . v ATTORNEY'S FEES-If any action at law or in equity is brought to enforce or interpret the terms of this Contract,the prevailing.party, shall be�entitled to reasonable attorney's fees,costs and necessary disbursements in addition to any other relief to which such party� may`be entitled. • ' . � _ j r �� SPECIAL INSPECTION REPORT �4 � � � .� o Ins ector s Name: �Q v.�e VVO,U c� Ins ector s Si nature. � � � P P g I.D.Na�`�a� Z�SC) .�has been filed and it states that the above work to the best of his/her knowledge�m'plies with the provisions of the International Building,Code and meets Approved Plans and Specification. - Respectfully Submitted '� ��f� �� , Approved by: �,'d 1 By . Project Superintendent ' Commerford Inspection,Inc. � � � . , , 't �.. 1 �` .. ` � � �` I� . _ . � _� _ ` - 4 � . - _� � . f r y n`' . S' . . .. ; .�. � . ' ' _ "�+a„�` \'h"' - .. � .3 ., at° w "-;. .a z t 41y l. +. �� - -. _ .�, ' _ . .• �/y}y . a t i� ' . '`'� ' m ..ce`�, ..'T,�►a a �i' \ . COMMERFORD INBPECTION-INC.,; � � DEPT•.OF BLDG.&SAFETY 2269 PAPAYA DRIVE,:`� '' � ;r,l'-- .. _ -�`; r . LA HABRA HEIGHTS,CA 90631 .` . CITY OF' �, � = � ��.�� '�� (562) 690-3198 or (562) 690-2883 ` , _ ' - FAX(562)690-4887 ,�� . � COUNTY OF � L: � "� i l� 1; _ , . . � .. . . . , �J ; -. SPECIAL INSPECTION REPORT , p-r - �i , Building Permit No. ',� �.� "� �'� � 7ob No. � � Date ! V' �� Job Identification/Address � �.'>i *.�� . :.y " � l�, �=� � ' ' � � �•� - Y 3 '� 4 �,/.. ., r-• / ! � Y �.�.0'4-i ��i �.c iJ!" :�"�yfL 0 eC :�. 7 � � "s�`�. 1 � � General Contractor/Address �•-'�i y�. .} • �:� a '� c>-:i ''i� ��%� - ��='� '� � � , � . , Sub-Contractor/Address Structural Engineer/Address �'�• `� • `��`I�`�`` `� �` � > �;�'�� t� - tfY'a_�ch b'�4. � ;;�,� c • ; ,,y ,.� 1. �st. `u� 1 f�f"-. ; ' ' � , 1 TYPE OF WORK: REINFORCED CONCRETE�. �r MASONRY HI-TENSILE BOLTING DRILLED IN ANCHORS:` ��/ ' PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE FIREPROOFING � ,_ �� " _ , . WELDER RECEIPT NUMBER WELDER RECEIPT NUMBER DATE OF INSPECTION . DESCRIPTION OF WORK INSPECTED: ^° ' �, � • f �. 8. �t i� / .! , f � 1 - i ��'� J�� at-'d�1�'�� .-�r)1� V� � ,`�} rv � ,�i .,L �? '� Edv� 1 �0!� � Cife� • � . � , � f a! . .. � "t . ' -� _ �,�1.� � ��; � ''E t' - '� v ��, a � �t��' G•a. �.:,,,t 5 Q �� _. � � �� ' ' . ,� �i- '4 S aa� �l�. �V t V�t!.� s a�t� i��J i� - y • �11 .Y�;j- � :�. ��,-��`yC ��-i �s'� '�� • � �`� � �'� � ,`t � a..) - - � - l,�' bi,? V P�,9�,:Yi , \ i r' 'i �: a " � j v :i � � �. � ;'e,: f �� -'1 � a. „�,, . � _ �.�,� �' L�L,�� i� +�� i'� L4 :�' . .�„ �J �"-¢ -4 ::i�p f. C.� F . ,�r' le �..� � +�� )�: ;'�' � �•� �4 � f`' ,` � ,- . ` t .1 .* + - . C` >. � �,:;�.3k 'J �- �.�/'l �� t t�-�. . .. �ti ,1 ! � :i C� .;J�'.1� `; �� ..y ��', l: � i . � . Ls1`C.. +1. � .. f .�;��` ; .� � :�^`� e,, �. � Q� '�' �1 ' �I.s,-n.i�r.. �� -� f � i � rl !^ "-a� � � M ' � f!' •� � � l�„ � � _,�!�� `r � � � , i . . i" e i•..._ HOURS � - : - ` , Date Re . O.T. TIME IN TIME OUT . � '. � � ;.., -`� �� , i1�;: '��L'vi C+�:�.1�: d'1 1`L'.` "' � SAMPLES � f Grout - Mortar Concrete Block Prisms Densit 4 . All inspections based on a minimum of 4 hours&over 4 hours-8 hour minimum.In addition,over 8 hours and Saturday will be billed at time and a half. • • • ATTORNEY'S F'EES-If any action at law or in equity is brought to enforce or interpret the terms of this Contract;the prevailing party shall be entitled to reasonable attorney's fees,costs and necessai�y disbursements in addition to any other relief.to which such party may be entitled. �.'' ' � .Y- .'. 1 SPECIAL INSPECTION REPORT �1 � f � - t r Inspector's Name: ,._.T l� :.�� 'a Y'�.`� �� Inspector's Signature:. ' ' `� ''. � i I.D.No.��%.�. :�::=� ��"has been filed and it states that the above work to the best of his/her knowledge co`mplies with the provisions of the International Building Code and meets Approved Plans and Specification. � _ .__. . , �. - Re.spectfully Submitted , . � n � . •r .--' _ APProved 6y: � ' ' 1 ''Q� '�� By Project Superintendent Commerford Inspection,Inc. � �� .�.. � . � . _ _ _ __ _ 1 �l-'�� . - . , . � �� - � . . .��, : . CITY OF DiAM�ND BAR ;�; � � � ; � "' I Department of Building and Safety -;`., _ � R E Q U E S T F O R A P P R O V A L O� S P E C I�,L I R I S P E C T O R �� ->, , �'�Ni�� v��.%� �.,I�Jlly j' �� SpeciallnspectorsName �a �; P. \ rn �`�u� Phone No. ��-7SS-O�jO�; I 3S�c� Y+'1 e�e r � Address ��• City �� Q� Zip 96�6.� Type of Inspection ❑ Continuous �eriodic JobSiteAddress � � $3� v n� � � �14 �-�. Job Name Type of ProjeCt �.UO �,•� a�d�; ��vr P2a r �� c�LIS � Attach work experience and educational qualifications to this application. The above named person will be employed to inspect and/or test and will be responsible for the following inspections (Please circle numbe� and provide description of work): 1. Concrete Placement 2. Reinforcing and/or prestressed steel 3. Structural Wetding ' 4. High-Strength Bolting 5. Structural Masonry �� . `r , 6, � b � dtR/P s '�`nrea� 0. �.eY' /� J -e1C� 'tr✓l 7, �a`4^ .. � Duties and responsibilities of the Special Inspector: 1. The special inspector shall observe the work assigned for conformance with the approved design drawings and specifications. 2. The special inspector shall furnish inspection reports to the building official,the engineer or architect of record, and other designated persons. All discrepancies shall be brought to the immediate attention of , the contractor for correction; then, if uncorrected, to the proper design authority and to the building official. 3. The special inspector shall submit a final signed report stating whether the work requiring special inspection was, to the best of his knowledge, in conforrnance with the approved plans and specifications and the applicable workmanship provision of the codes. �- �-/.� �� / Date wner's Signature Contractor's Signatu�e Fee$ Approved: _ Buifding OIlicial Receipt No. Date DISTRIBUTION: White—File '�12 BD Canary— Inspector Pink—Specia!Inspector i . , , ; . , . �. :� � ^.; � �... . . M . , _ - ' WALNUT VALLEY UNJ:FLE" D SCH4C}L DISTRTCT 880 SQUTH LEM4N AVE3�fUE WALNIIT GA `91789 � CERTLFICATE OF COMPLIANCE ' With Fee Pravisions of Government Code Sectian 65996 DEVELOPER/OWNER �� "�� ADDRESS a'1 $3 S b N A-U��F Signature o icant CITY/ZII' T�1�ta N i,� 13 A-q �` t�7b� The person signing represents that �ie/she is authorized TELEPHt�NE ��t> g�-� q � �7 to sign on behalf of the ownerldeveloper and that the �. information provided is irue and accurate to the best of hislher knawledge. NEW LOT ADDRESS USE OF BUILDING TOTAL SQ.FT. • ResidentiaUCommerciaU�ndnstriai Ciry HOME IIv1PROVEMENT�QR REMODELING PRQJECT ADDRESS - LIESCRIPTION , TQTAL SQ.FT. ��.�' o�� w' �►l� n�a�, i��f,'G�, - `�—��,�-s Diamond Bar�.__Walnut (Bedroom,Pamily Rm.,Kitchen,etc.) Signature of.Superintendenf of Buiidings �r Date j�-�' /N-��—+- TO BE COMPLETED BY SCHOOL DISTRICT �EE SCHEDULB: The develapment fees levied by the Walnut Valley Unified TOTAL FEES D�� School District under pravision of Government Code§65995 $��,,� _�j '��-� ---" are: {EFF. 12t1108} Reszdential Develapmsnt 2.971s . . Receipt # �O�� CommerciallIndustrial $0.471sq.ft. Date 1��3`�� l�j ' �ess are assessed on TOTAL square footage "living space" of ALL new �r remodeling canstruction projects OVER S00 sq. feet (e}iminating garage or uncovered patio). _� This is to certify that all fees due to the Walnut Valley Unified School District ander pravisian of Government Cade Sectian 65995 have been received and a building pernzit may be issued. This is to certify that the above described develapment has been determined to be EXEMPT from.tfie development fees of Govemment Code Section bS99S and a building permit may be issued. '� Exemption Jusfification: PR4JECT I5 5q0 OR LESS SQUARE FEET � OTHER � �� ! � ! C�� . C,elia Moynihan � Directar, Fiscal Services � 1/87 Rev.2188;6/88;8/89; 1l90; 8l90; 10/90;8l92;6/93; 11193;8194;fi196; 1!9'7; 8t98;71Q4;6106;2/08; 12I0$; 2113 . 1 RECEIPT DATE �� i ��- 5082 m Q RECEIVED FROM �`k � c_►n A r� A�S�.� I m Nw� � a �c:: ADDRESS � ¢ �"� ��.{} �9'Nn.��t�ti,n.� -�'�vl�4Lu►�c�v�P�--.��i�N'� DOLL,aRS $ "rjrJ�.� 0 J.�U LL ¢� _�� FOR ��IP-�D�'2� �p� ��-� G�' � ��y ��} � ACCOUNT HOW PAID AMT.OF CASH fI ��II�p ACCOUNT ri II , AMT.pAI�J CHEC Y� �� /f/ ' BALANCE DUE MONEY ORDER ,,,, /� � BY a��=�;, � 1 -