HomeMy WebLinkAbout2014-00834 addition • � CITY OF ORONO * Z 0 1 4 — 0 0 8 3 4 *
2750 KELLEY PARKWAV DATE ISSUED: 08/13/2014
ORONO, MN 553_56-
(952) 249-4600 FAX: (952) 249-4616
ADDRESS : 1925 COUNTRY CLUB RD
PIN : 27-118-23-43-0002
LECAL DESC : LONG LAKE COUNTRY CLUB ADDN
: LO"I' 003 BLOCK 003
PF,RMIT TYPE : ADDITION / REMODEL/ REPAIR
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : ADDN/REMODEL/ REPAIR
ACTIVITY : 434-RESIDENTIAL
VALUATION : $ 4,000.00
'��O"l�l�:: SH�D
APPLICANT PERMIT FEE SCHEDULE 103.25
STATE SURCHARGE(VALUATION) 2.00
FREDENN, GLENN & LOIS TOTAL 105.25
1925 COUNTRY CLUB RD Payment(s)
LONG LAKE, MN 55356- CREDI"I'CARD 8613 105.25
OWNER
FREDEEN, GLENN & LO(S
1925 COUNTRY CLUB RD
LONG LAKE, MN 55356-
AGNEEMF,NT AND SWORN STATEMENT
l�hc work for���hich this permit is issued shall be perlormed according to
the approvcd plans and specifications,applicable City approvals,and the
State Building Code. 'fhis pennit is for only the work dcscribed and does
not grant pennission for additional or related�vork N�hich requires separate
permits. All provisions of laws and ordinances governing this type of work
shall be compied with whether or not specified hcrein."t�his permit will
expire and become null and void if construction authorized is not
commenced within 180 da�s oY the date of issuance,or iC construction is
suspcnded for a period of 180 days at any time after work has commenced.
The applicant is responsible for assuring all required inspections are
requesled in con�i�rmance vith[he State E3uildin,Code.This permit may bc
revoked at a � time f r d c cause.
/' �i
/, ���}.-,,-iC-�'J---_- � �
Applicant Permitce. ignature Date Issued [ Signaturc Date
CITY OF ORONO Z�
BUILDING PERMIT APPLICATION ( D S,-
FOR NEW STRUCTURES OR ADDITIONS �`�-�"
�O�O Mailing Address: Permit number: C�O��j�— ��J
PO Box 66
Crystal Bay, MN 55323-0066 Date received: �- —�
StreetAddress:' Received by:
y G� 2750 Kelley Parkway Plan review fee: �� ��
`� Orono, MN 55356
`qkFSHo'�`` ��7 l/
Total Fee:
Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
This application form must be completed in full and all required information must be submitted.
Incomplete applications will be returned. (P/ease print)
GENERAL INFORMATION:
�.
Job Site Address: / �y,�.; .tr , .���� � �', " �� ��-= � .< ���= ,��� � .
Will this be a Parade of Homes, Remodelers S�tiowcase Home or other Disp y Home? ❑ Yes � No
If yes, a specia/event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be
required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will nof be allowed.
CONTRACTOR/APPLICANT INFORMATION:
Name: � _ t -
L Y 1. .� ��1�_,.
._ �-.._.t. �'.. �.� . .. �....... .�� i
State License# Expiration Date:
Phone: (cell) �'; /.� - ,`—�i - 7,3 7 7 (n##��e) �'�.�, ,. �:-�.�i �7.� - �� �'t;�
Mailing Address: i ?_; � �,�> "' Z Cit ' "�-�. ZIP: :,�,_;- ?-
Contact Person: �z�k...,� Applicant is: Contra �r / Homeowner (Circle One)
Email and/or Fax: <:�/-=;-� �;_ � ;� .,1;;�,r.% i -r-�,
PROPERTY OWNER INFORMATION:
Name: � '
k �c,� �z�;.. •—,:�r� ��
Phone (day): . � �- /� -,��/- �_3 7 7 .
. .
— �� x v�-cL_ . J�c � .c":_ � �-
Address: ��•�� ��, % _ Cit '�"-- ZIP: ��`---� �
Email and/or Fax ;�j✓�� ��<<��F-F-, , � ; <?i� �r� ; /. �'�'i�; � ��
�
ARCHITECT/ ENGINEER INFORMATION:
Name:
Phone (day):
Address: City: ZI P:
Email and/or Fax:
PROJECT INFORMATION: Description of project:
1. Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal &
Water Supply
New Construction ❑ Single Family with ❑ Residence
❑ Addition attached garage ❑ Garage/Accessory Bldg. ❑ Public Sewer
❑ Accessory Building ❑ Single Family with ❑ Deck
❑ Relocation detached garage ❑ Office/Commercial ❑ Private Sewer
❑ Other: (specify) ❑ Multiple Family/Condo ❑Warehouse
❑ Public [t]-8torage ❑ Public Water
"*Any earth movement may also require ❑ Commercial ❑ Other(specify)
MCWD review&permits. ❑ Industrial ❑ Private Well
Minnehaha Creek Watershed District(MCWD) ❑ pther: (specify)
18202 Minnetonka Blvd ,( �,;,V.yt L' . ,�Y ,Q�4
Deephaven,MN 55391 ;
Phone: 952-471-0590
Fax: 952-471-0682
www.minnehahacreek.or
Estimated Construction Valuation (excluding land) $ `"�� � �� /
STRUCTURE INFORMATION:
1.Structure Dimensions 1. Structure Dimensions (continued) 2.Type of Construction
ti
a. Length (ft.)= ��� G' Number of bedrooms=
/Vood/Frame
b.Width (ft.)= ���! Number of garage stalls: ❑ Masonry
Areas in spuare feet Attached= ❑ Metal
�,��, ❑ Pole Bldg.
c. Basement= � Detached = � �.,�r�. • ❑ ICF
d. 15t Story = �/ ❑ On-site Prefab
e. 2"d Story= ❑ Off-site Prefab
f. 'h Story = ❑ Other(please specify):S�a6 ° l` °l G��`�
g.Total Area=
REQUIRED SUBMITTALS:
All of the information must be submitted in order for your application to be processed:
Not
Enclosed A plicable
P�=' ❑ Permit A lication
EY" ❑ Pro osed Buildin Plans
❑ ❑ MN State Ener Code Calculations and Mechanical Code Re uirements Form
❑ Surve meetin all re uirements
❑ ❑ Stormwater Pollution Prevention Plan
❑ ❑ Hardcover Calculation s
❑ ❑ Se tic S stem Site Evaluation Re ort
❑ ❑ Access Permit
❑ ❑ Wetland Buffer Im rovement Plan
❑ ❑ En ineered Plans for Retainin Walls 4 feet or above
❑ ❑ Plan Review Fee
❑ ❑ Application Escrow&Agreement
❑ ❑ Other:
APPLICANT/OWNER ACKNOWLEDGEMENT:
. Agrees to provide all information required or requested by the Building Department;
• Agrees to pay the City of Orono for engineering consultant review costs in excess of$500;
• Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they
are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative
but to reject it until it is complete;
. Acknowledges the Escrow Agreement is completed and signed;
• Understands some or all of the information that you are asked to provide on this application is classified by State law as either
private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject
of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our
purpose and intended use of this irrformation is to annually update our records and records of other governmental agencies
required by law. If you refuse to supply the information, the application may not be issued.
. Agrees that in the event that weather or other conditions prevent the completion of an as-built survey at the time the
Certificate of Occupancy is requested, a temporary Certificate of Occupancy may be issued upon receipt of a $10,000
escrow to ensure completion of the as-built survey and all site improvements.
� �-
� ,
A IicanYs Signature: _ - _ � ' ^-� Date:
PP
Owner's Signature: Date:
PLAN REVIEW CHECKLIST FOR NEIIV STRUCTURES / ADDITIONS
'` .�,� �,, ��.�� �'°°�
Address/Permit Number: � �1�� (�:� �° �� �
Description of work: ����
�' Septic review by: � Y Date Approved:
�oning review by: •C�• Date Approved: �'��f�' d�
Building review by: a�- Date Approved: � "��" t �
Grading rediew by: /`�/�$ Date Approved:
�_` Zoning District: ��'�� Zoning File#: � Reso#: �-- Reso Date: --'
�, �
Zoning: Lot Area: �S `F �l� SF/AC Width: �� � � Lot Coverage: 7 b,'Z.Z� SF _%
k�� Survey Submitted: �Yes 0 No Date of Survey: �'��p'° b� Revised date(?):
Pro ased Setbacks:
Front(Lake) Rear(�eet) � N � E W ) ( �N S E W ) Other Buildings Wetland
ide Side
S� �' ��� ' � � � G �"' �e� � ���-
Defined Height: ��� Peak Fieight: P' FFE: FFE minus 6 feet= xisting Contour)
��
Perime inear feet) = 50% _ #of Stories O YES
FOR A BUILDING WITH A EMENT OR CRAWL SPACE:
�
distance between the Iowest FOR A B DING ON A SLAB FOUNDATION:
START WITH propo oor(of the basement or crawl
space)and i hest point of the roof. START WITH The distance between the top of slab and
If you have a... the highest point of the roof.
If you have a...
• GABLE OR HIPPED RO o . GABLE OR HIPPED ROOF(no
windows): Subtract half the windows): Subtract half the distance
distance between the highe oint between the highest point of the roof
of the roof to the low po ot the ' to the low point of the corresponding
SUBTRACTION corresponding gab r hipped roof SUBTRACTION gable or hipped roof
(BASED ON ROOF . GABLE OR ED ROOF(with (BASED ON . GABLE OR HIPPED ROOF(with
TYPE) window . ubtract half the F TYPE) windows): Subtract half the distance
dis e between the top of the between the top of the highest
hest window and the highest window and the highest point of the
point of the roof roof
• ALL OTHER ROOF TYPES(flat, • LL OTHER ROOF TYPES(flat,
mansard,etc):No subtraction. m�saLd,etc:No subtraction.
ADDITION Add the distanc tween the top of slab
SUBTRAC N Subtract the distance between the (BASED ON and the highest exis rade adjacent to
(BASE N EXISTING basemenUcrawl space floor and the EXISTING the foundation.
GR�ES) highest existing grade adjacent to the GRADES
foundation OR 10 feet(whichever is less). EQUALS Defined building height
EQUALS Defined building height
Shoreland District MICW►D Permit Receiveci �►vera e Lakeshore Setback Met? �lu�i`
� Yes �No a N/A 0 Yes No
Q Yes �No � Yes � No N/A
Permit Number: Setback:
Storrr�water Quality Existing Proposed �ariance Required CUP Required
Overla District Tier Hardcover F�ardcover
�Q� �----
Q Yes ❑ No � Yes � No
Type(s): Type(s):
— �-��-.—�_
Updated: January 2013
v:\forms�plan review checklist 2013.docx
�
x..>...�. .,. ._ � .°y __.. - . ,. � . . ��� . ,,, .� �.��,� . -:- _�.� - . �,�-
� � .__ __._. . _
a
x�op�£lOZ isi���ayo nnaina�ue�d�siwo}�:n
£lOZ tienue� :pa�epd�
a3�lHIlINI aNH 1IW213d NO a310N 38 Ol- S�121`dW321 lHl�l�j0
ON � S�.l 0 �^^aN ON 0 S3.1 � :6ui�six3 :ssa��d
:pano�ddd a;ea :�(q pannainab :nnaina��ay;p
:(asnou-ui) S�2ibW32i
(�i�ads)�au�0 � �x
�a}�n8 pu�I�aM 0 �
�eui��
�(an�ng;lin8-sd p
� uoi�e�nsu� p
�,
(/�i�ads)�ay;p p 6uiwe�� p
�6�W 0 Pa8 �I�ob uoP��l �
uoi�e6i��� unne� p iGuosew p �(an�ng uoi�epuno� p
uog�auuo��a�naS p a�e�da�i� p II�M Pamod p
uoi;�auuo��a}e/�/� p �i�dag p 6ui;oo� ;
�e�u��a�� p a�i� p �e�iuey�aW p �enowa� �ano�p�eH p
IIaM � 6uill!� / 6uipe�� p 6uiqu.mid � a�!S �
s�iw�ad a;e�g pannbab s;iw�ad a�e�edag 6u��inba� ��oM pa�inbab suoi;�adsu� ouo�p ,
�,��� � :an�en uoi;�n�;suo� pa;ewi�s3 ;
$ = X aBe�e�
$ = X �oo�� puZ
; ;
$ = X �oo��ls�
�
,
$ _ X �uatuase8
a e}oo� a�en g�a $ a �oo j a�en g .
a
� (i4i�ads)�ay30
� s��u(1 �bS 30.�aqwnN—�dS
� aa� uoi}e6i�sanu�
a6�ey�anS a3��S
nnaina� ue�d
��uua�
ON S3A pa �e4� aq o;saa�
:(asnoy-uiI S��VW321
����1 �
�' �� TIME
CITY OF ORONO CALLED IN ' �
INSPECTION N TIC CHEDULED � -
PERMIT NO. - � �OMPLETED
ADDRESS � C
OWNER TELEPH E NO� - J�
CONTRACTOR��IIn� �GP�1l� C����!L�1y��
� DESCRIPTION �� ,
�
l� O FOOTING ❑ PLUMBING FIN L ❑ EXCAV/GRADING/FILLING
� ❑ POURED WALL ❑ MECHANICALR ❑ IAKESHORENVEfLANDS
�
Q ❑ FRAMING ❑ MECHANICAL FINAL ❑ TREE REMOVAL
Z ❑ INSULATION � WOOD BURNER/FIREPLACE ❑ SITE INSPECTION
Q ❑ RADON SLAB ❑ WATER HOOK-UP ❑ PROGRESS
� ❑ FINAL ❑ SEWER HOOK-UP ❑ COMPLAINT
� ❑ DEMO-SITE ❑ SEPTIC MAINT. ❑ FOLLOW-UP
_ ❑ DEMO-FINAL ❑ SEPTIC INSTALL ❑ HARD COVER REMOVAL
v ❑ PLUMBING RI ❑ SEPTIC FINAL ❑ f-0UNbATION/REMOVAL
Z OWNERICONTRACTOR TO MEET YOU:_YES_NO
� COMMENTS:
�
� �
j
O �
�
O � %
� >' � _
� ;'
Q _ '�/�
� � � � � �
W �
�
W
�
J
GW ❑WORKSATISFACTORY:PROCEED ❑ PROJECT COMPLEfE
� ❑CORRECT WORK 8�PROCEED ❑ ISSUE CERTIFICATE OF OCCUPANCY
W
O ❑CORRECT WORK,CALL FOR REINSPECTION TEMPORARY
V BEFORECWERING PERMANENT
❑CORRECTUNSAFECONDITIONWITHIN HOURS. ❑ pHOTOTAKEN
INSPECTOR WILL RETURN
❑CITATION ISSUED
❑STOP ORDER POSTED.CALL INSPECTOR �,
❑INSPECTION REQUIRED.CALL TO ARRANGE ACCESS. � �
i
Cail for the next inspection 24 hou n advance. � 49-46��
�-
OwnerfContractor on site: + �
Inspector. ��r `
,%
White Copyllnspector's File Canary CopylSite Notice
��\ Q��E �TIM
1 CITY OF ORONO CALLED IN ,�, — � ��
INSPECTION NOTIC SCHEDULED �rq� — �.U
PERMIT NO. �� -DD�� COMPLETED
ADDRESS � ��'� '� '��"
OWNER F�� TELEPHONE NO���"����7�,�
CONTRACTOR
� DESCRIPTION ����y`�/S�v'
�
ly ❑ FOOTING ❑ P�UMBING FINAL ❑ EXCAV/GRADING/FILLING
� ❑ POURED WALL 0 MECHANICALRI ❑ LAKESHORENVETLANDS
�
Q ❑ FRAMING O MECHANICAL FINAL ❑ TREE REMOVAL
Z ❑ INSULATION ❑ WOOD BURNERlFIREPLACE ❑ SITE INSPECTION
Q ❑ RADON SLAB ❑ WATER HOOK-UP ❑ PROGRESS
� �FINAL ❑ SEWER HOOK-UP ❑ COMPLAINT
� 0 DEMO-SITE ❑ SEPTIC MAINT. ❑ FOLLOW-UP
_ ❑ DEMO-FINAL ❑ SEPTIC INSTALL ❑ HARD COVER REMOVAL
� ❑ PLUMBING RI ❑ SEPTI FINAL ❑ FOUNDATION/REMOVAL
2 OWNERICONTRACTOR TO MEET YOU�YES_NO �
� COMMENTS: N� �����GtL � 'f�t<c -�e�+iG
a �i'4_.�t�c�r � �,(' '
s
� �►'k55 SDcc�rpv�dc�J'�
� - f�Pro��e� 4N�'�sr ��5 W!'IF�i..-., /o� �� D�
° _�D,lt�f�5a l,�� �KaQs �
W
Q D wke✓ ��6( OD �'
z .
g C�jr fCc� —+ ,Og r w�i c r� ��
W
�
J
a
� ❑WORK SATISFACTORY:PROCEED �ROJECT COMPLETE
�QRRECT WORK&PROCEED ❑ ISSUE CERTIFICATE OF OCCUPANCY
O✓�CORRECT WORK,CALL FOR REINSPECTION TEMPORARY
V BEFORECOVERING PERMANENT
❑CORRECT UNSAFE CONDITION WITHIN HOURS. ❑ PHOTO TAKEN
INSPECTOR WILL REfURN
❑CITATION ISSUED
❑STOP ORDER POSTED.CALL INSPECTOR
❑INSPECTION REQUIRED.CALL TO ARRANGE ACCESS.
ail for the next inspection 24 hours" dv �j� 249-46�0
Ownerl ntractor on site: G`��'I, �ts�s�a-.� R 2
. _
Inspector. � /M-
White Copyllnspector's File Ca�ary CopylSite Notice
� [ -�. 5L � - . � • . - �� /. : ._ _��.�/t . _ 7. `/V 1�7 ,� 1 � �" _ ' � .... .. . .
� � , { F. e, r � � . ' .:� -��./• .. .•_ � i" 'i' ' � . � � . .�
` � ' , , � " ' � '' ,Q; ��O a `� . - t '�� � �9�� �pU� _�GC� . .
� . _ �= : . . - . � .;�.s , �.� r . . . : : � , ��� �����=_
_ - _ - . . �08 . . . . .��
_ - ' . � ( . � ;,, 1��1� , � �'U ��.- ` ; � _ - , - _ .
`„ - �� ;; . � ;��, �,�fi � . � , ��� - „ - ,_ .
� t�� -,, - ., ,,c_. .
.. .it .��' - .� . - � �.\^�' . . - . .. � . J'� r �, . � c 4.. j - T ';t - . - � .',-
. s : ' / �� ' - ' �\�O•� � � "!'- + �
� ,_ , •�\ - =�„ . . - _ ' -
, ; ` � { r� � _ -. � " 1�� - :. � � - . .� ;�, . �� ;� � ��� .��' � _ -� :SC�,L� : 1,� _ 6�
` 1; i. �� � ' �K ' t� . . f, �S :1 ' `�� I �`.' .�' �.. L'.� ' _
�P _ �_x �_ t � � f��� . . �. . . �.s l�y.� �- \ � � � i. �` .t . /� , _ '.fh
. s � _�.� �SM c' ' ' �/ �`\_ . .. . � - ( .�c�: ., , :� ;\ �- � :� `` -. '. � � ^ ' �� . . -
s � �-, �a , . r��� � �' � _ �� . . �,- _,�,- . <
y -' � ' . _� � "' ` ` � , - ��3� Q� �����
.�, �r � .t� . � , `Q _ T , V+u . 1.-. .�t :.� � � � . - �.�� � -
a „ -.i - .� � � ;' ` yy y � " ,
.-'�' �r l �l� '` �. ��, � ' .r�—� �"7"-►. IZ��..y��x- � ', .._ ' ',rT ,. , _� � � �y pp GR�DING PLAN�.
f w �yr, ,y, ►` — '1'�'I �•� '.\ .; ' } r • . �c� � 1F : .y r � �` S��t i-�l1i-�
' ` . �- L. � - `' . ' '' - fG'' f,�i�?--� '�'` f�A� ,�!-DO i �oN
, . ��`-. . . - - \, , _�. �- ;� � . ��4fC� f
`� , .�j . . ` . �ti, . - . :...' ` � r��=���,;;�� � ��iT�-? �VeS,C�1�S
T ��IN� ��� ' 1 � C , I� �a
` �'!,�^� .i� . . .' oQ .. _ \� . . �� .� � .. i - f - � ..f + :p ��f'iP,y ��(� .
�� � �� ..
Si � _. ' � ' . 'Cj� �� \ ' . .�l ,� � ' f �� -a �I 4;t,.fP��4 �ll,� _4"
. :��(1� � +; t . ''')�� _ � . � � �:lr
� �H�V�t[ �l�� ���IVf� . t .. .� ��. �.���.- / -- . r�- y?�.� � �� , . .',� {�, - �t ti; S- � ` �g
� !'�{� � 't , Ci' . c\�.��` i r P r > ,�, V u.� , W._
� . [�` �}il . . . . . . >t;� \/P 1 {l�" �� _ ' .. � - /'�� - _. t
y � 1 ! ,�3,�`rr � , � �u
. ,1
.. . , ..
_, 6 _;� ' ' .: ,. � ', . - � � . . , Cf 1 - i .
� w ._ .� � �. .� - . . . • . _ . �,. - ' 'O. . "
, .. � .. y'. :. ' a
,M` � �� _ :.� � � .. � .
� \ � �'' ` :li. � 1 \"_ /
..
� �Li Fr. /���.� � � �..� /� . �_ t
:. 'A. - - ' � ` p. . .. .Y�.. . � �� �. :`����7.. '`.( F � �'.� `�
� ,, , �
' . , i .• ,"� ��nsA . ` �` .' � � �.�) . Ik ' �� � "� ��'• '- _ . ' ..
�j � ! . � - - , � ���7,..; 1�����`. ,' �� ` ;, _ i
.��s�� � �T � a�� . . , , �- , . �� '���� ,E . - _
- �_ z ,�. � - . . . .: ` r �. � � . . �
�.a t :3 r `.'�lIOV/1 : � , . t. . i`�_� ,�' � .`` . 4 \,1 � ? _ ,. • •- . , ���D y ' . .
_ 1 - ., ;+�� . , .. . . . , . � '�Oz \ � r -_. � ' . . , ��J i1��� >..
_ - - - � _ l c: -��- \ � _ ; � , . . - .
. - . .. A C ! T 0� . - . � . ,,n;� � -�,.�� ,,� -� � - � � t� , . . - . � _ . �
L��1� .�:L-�KE C,��NTRY CL�UB D ! . � . . r . L _ � _ _
. . �-.... : �; . "a �r -.r .' _�le` ,� ' w . ' . : . ., � _ ._ . � .y ' . ` . .. ' � "
.. •J; . 1�a.' 1 �, _ � . ' . , . - . .. " . `, : .�_�. . _ .t 5j , .
. ..R l� t . . . . � . . ' '. " � � , ! , ' " " ' . . . . .
� Prr . - ` t ' ' � . �. ^.y" `'�/� - ; � • .
-� �' � -��, , ', . , . . , . _ \ -. _ • • `� � :th e b o n -
�- � - • �• � ��-�. � d �correc t�-�re r--�s�r�tati�o� of a ` sur.�ve ;of:,�. �, u dar i es . .
s �� = ,�e _ hereby�-cer:t� fy, � t�at tth� s = � s� a � tr.�e. n . . � : � � and� all � � .
��� at�ic�n� `a�- �a l�t b�u�� ld,it�. �s =� f any;�� �t ereon; �
� � -of :th�e�1,��1an�: oYe _ . , .. ; . ��� _ .
:ab _�escr-ibed and� of�_ the� �.oc . � . _ _
'y� �: :{ 4.
. , �. _ e� croachments" - .� f�"an � froro� �r +onF� sa� cl �a�nd rk r�.���� z t .�:� � k t � � �: � S �: , , � � �- .
� v� sibl��� � ; y _ . , j � �� a ,. � . .
'', v� � ' ;�'.- ��, � '{-I�. � .. �1 . � _ ' ' '- .. . - ` '� ^�� -9'• . t' 1 . t ' .
' . ' A.• _ � - . ' _' �1 •'4 - y .L. D _E�:&� -N. .0.. W �A K . ..
���:: n�� E� 4� Af �1 � :�, � � _ .
Da�ed t�:thi s y ,�- - _day of �1 �` . .: � _19�1 � �:; - _ , - .� .� �� ; ,� . n: . , . .
._��._...�....i� � �; ,_. .
� . _ . • ,:� i n; �,. �-•
. _ ��x.� � � � . , : ; � . . - � � .� s�� .SurYe o s - . . .
.:� � �-� =Y� :, � ;. TL _ . . r .,� Y�_� �� :� ��� eer
_ . � . � -� ti: rr .. . .Y . � . . �t� . - _ _ � � �. :�� �-_� :.s � :,- 9. -�_ -�: - �y- . - .
. �'�z. r x�a . _ �. ,�. .�. . . .
� � � � � Book .�i�o� , _ . � 4 -, , b� .;:_x .
- _ : F.i le�� No.� � 210� , . . � �_ - _ : _ , . _ - . . . . � . , � -
. . . . _. : , . .__ . . . . _ : : . . - . :� ._ -