13-1043 (PLBG)P.O.:PDX 1504
"78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number 13-00001043
Property Address: 52553 AVENIDA MENDOZA
APN: 773 -302 -015 -
Application description: PLUMBING
Property Zoning: COVE RESIDENTIAL
Application valuation: 1500
AppliFant:
T4t!t 4 4 a"
Architect or Engineer: .
�\W
LICENSED CONTRACTOR'S DECLARATION
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Ihereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with
Section 70001 of Division 3 of the Business and Professionals Code, and my License is in full force and effect.
License Class: 13 License No.: 926128 `
Date: Contractor: ; �— (`p t.�{' L. v� �t� C1
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the
fallowing reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the
permit to file a signed statement that he or she is licensed pursuant to the provisionsofthe Contractor's State
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
(_) I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and
the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of property who. builds or improves thereon, .
and who does the work himself or herself through his or her own employees, provided that the
improvements are not intended or offered for sale. If, however, the building or improvement is sold within
one year of completion, the owner -builder will have the burden of proving that he or she did not build or
improve for the purpose of sale.).
(_) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of
property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
(�) I am exempt under Sec. , B.&P.C. for this reason
Date:
Owner:
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name:
Lender's Address:
LQPERMIT
Owner:
SHELDON BAKER
52553 AVENIDA MENDOAZ
LA QUINTA, CA 92253
VOICE (760) 777-70.12
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
)
iD D 8 13
SEF 2 4 2013
OF LA
Contractor:
DANTOR MARTINEZ CONSTRUCTION
81057 AVENIDA ROMERO
INDIO, CA 92201
(760)702-6209
Lic. No.: 926128
-----------------------------------------------
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued.
I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor
Code, for the performance of the work for which this permit is issued. My workers' compensation
insurance carrier and policy number are:
Carrier WESTCO INS CO Policy Number QWCA1970514
I certify that, in the performance of the work for which this permit is issued, I shall not employ any
person in any manner so as to become subject to the workers' compensation laws of California,
and agree that, if I should become subject to the workers' compensation provisions of Section
.� 3700 of the Labor Code, I shall forthwith com ly with Ithose provisions.
D� Applicant [ 'f\0&\A -P *Jr "\ —t-,t—
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the
conditions and restrictions set forth on this application.
1 . Each person upon whose behalf this application is made, each person at whose request and for
whose benefit work is performed under or pursuant to any permit issued as a result of this application,
the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City
of La Quinta, its officers, agents and employees for any act or omission related to the work being
performed under or following issuance of this permit.
2. Any permit issued as a result of this application becomes null and void if work is not commenced
within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject
permit to cancellation.
I certify that I have read this application and state that the above information is correct. I agree to comply with all
city and county ordinances and state laws relating to but g construction, and hereby authorize repr entatives
of this county to enter upon the above-mentioned pro e y r inspection purposes
Date: Signature (Applicant or Agent
. Ai
Application Number. . . 13-00001043
Permit . . . PLUMBING 2013
Additional desc .
Permit Fee . . . . 11.92 P1an.Check Fee
.00
Issue Date . . . . Valuation . . .
. 0
Expiration Date . . 2/15/14
Qty Unit Charge Per
Extension
1.00 11.9200 EA PLBG BUILDING SEWER
11.92
--------------------------•--------------------------------------------------
Special Notes:and Comments
PLUMBING - HOOK UP TO EXISTING CITY
SEWER (REDIRECT EXISTING SEWER LINE ONTO
OWNER'S PROPERTY) AS PER APPROVED PLAN.
2010 CALIFORNIA BUILDING CODES.
----------------------------------------------------------------------------
Other Fees . . . . . . . . . PERMIT ISSUANCE M/P/E
90.57
PLAN CHECK, PLUMBING
11.92
Fee summary Charged Paid Credited
----------------------------------------
Due
-----------------
Permit Fee Total 11.92 .00 .00
11.92
Plan Check Total .00 .00 .00
.00
Other Fee Total 102.49 .00 .00
102.49
Grand Total 114.41 .00 .00
114.41
I
\ LQPERMIT
Bin #
Y
Otf .,
y of % Quinta
Buildingwr Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
h
• Iv�
Project Address:
Owner's Name: S e 1 N
A. P. Number:
Address:
Legal Description:
Contractor: `-ol- G' N
City, ST, Zip: L a n
Telephone:
Address: 10 yu
o YVV2�Q
Project Description:
ST, Zip:
City,-
1
6
Telephone: 7 60)-72--b-2-0 9
::g:»
Y
V
State Lic. #': 12—to
City Lic. #;
S
Arch., Engr., Designer:
OV'7 w LA—C Ir
"t
Address:
City, ST, Zip:
Telephone:
;F:E��':rj;%ii::: •:'F: '.;:::'l,.i::: �;E::iiii: Lf.
;fi ; :•,i::
`#:>::r;%:,.s;:>::;:>;<:>:;:<:::;>::::»::>:<:>::z
zz>;:<;:<;:>;
Construction Type: Occupancy:
State Lic. #
Project type (circle one): New Add'n Alter Repair
Demo
Name of Contact Person:
Sq. Ft.:
# Stories:
# Units:
Telephone #,of Contact Person:
Estimated Value of Project: U 1 .
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Title 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2°" Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'"' Review, ready for correctionsfissue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Pel •t Fees
PLEASE COMPLETE THIS INFORMATION
RECORDING REQUESTED BY:
VERONICA J. MONTECINO, City Clerk
AND WHEN RECORDED MAIL TO:
CITY OF LA QUINTA
Attn: Veronica J. Montecino
P O'Box 1504
La Quinta, CA 92247
DOC # 2010-0154505
04/05/2010 08:00A Fee:NC
Page 1 of 3
Recorded in Official Records
County of Riverside
Larry W. Ward
Assessor, County Clerk 8 Recorder
• 111QIN 1111111 III 111111 IIIII I(II Illlill fll IIIII Nii ILII .
S
R
U
PAGE
SIZE
DA
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LONG RFD I COPY
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465
426
PCOR
NCOR
SMFNCH EJ%XAM
CTY UNI
T:
NOTICE OF SUBSTANDARD RU!LDING OR PROPERTY
Title of Document
Ofi2
THIS AREA FOR
RECORDER'S
USE ONLY
THIS PAGE ADDED TO PROVIDE ADEQUATE SPACE FOR RECORDING INFORMATION
Exempt Recording Fees per Government Code Sections 6103 and 27383
RECORD/NG REQUESTED BY
AND WHEN RECORDED MAIL TO:
Veronica J. Montecino, City Clerk
CITY OF LA QUINTA
P.O. Box 1504
La Quinta, Ca. 92247-1504
Exempt Recording Fees per Government Code Sections 6103 and 27383
NOTICE OF SUBSTANDARD BUILDING AND/OR PROPERTY
Notice is hereby given to all persons, pursuant to the provisions of the La Quinta Municipal Code,'as adopted
by Titlel 1 of the La Quinta Municipal Code that the property described below has been inspected and found
to be substandard as defined in Chapter 11.72 of the above code and the owner of record have been or will be
notified.
Violations consist of: LQMC 11.72.030 (M) Violation of adopted Uniform Code — sewer lateral installed on
incorrect lot.
This document will be expunged only when the City Building. Official finds that the public nuisance has been
abated and either that such abatement has been accomplished at no cost to the City or that any such costs
have been repaid to the City or that such costs have been placed upon the tax rolls as a special assessment
pursuant to the Government Code. Detailed information regarding this Declaration, Code Violations; or any
costs or fees that must be paid the City, may be obtained by contacting the Building & Safety Department,
Building Division.
LEGAL DESCRIPTION
Owners of. Record: Sheldon R. Baker Area: 020-104
Situs: 53553 Avenida Mendoza
APN #: 773-302-015
Lot 2, BloA 143Unit No. 15, S to Carmelita at Vale La Q.uinta as shown by map on file in Book 18, Page
92 of Ma in the office oft a Co my Recorder of Riverside County, California..
By: DATE: March 30. 2010
City La 'nta
Greg Butl , Building & Safety Manager
State of California
City of La Quinta
County of Riverside
On March 30, 2010, before me, Pamela Nieto, Notary Public personally appeared Greg Butler, who proved to me on
the basis of satisfactory evidence, to be the person whose name is subscribed to within said instrument and
acknowledged to be that he/she executed the same in his/her authorized capacity, and that by his/her signature on the
instrument the person or the entity upon behalf of which the person acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and
correct.
WITNESS my hand and official seal
Signature:
Notary Public .
PAMELA S. NIETO
Commission # 1723211
-� Notary Public -California
Riverside County '
My Comm. @0M Feb 2.2011
,n-- - - _ --- - T__ AP
X 1 VFc1 Ly i111VA 1114 LAUll
Primary Owner:
BAKER SHELDON ROY
Secondary Owner:
N/A
Site Address :
52553 AVENIDA MENDOZA
Bathrooms :
LA QUINTA, CA 92253-3387
Mailing Address:
79120 FOX RUN
Lot size :
LA QUINTA, CA 92253
Assessor Parcel Number: 773-302-015
CountyName : Riverside
Tax Account ID :
Phone : N/A
Census Tract: 0451.10
Housing_ Tract Number: N/A
Lot Number: 2
Page Grid: -
Legal Description: Lot: 2 ; Block: 143 ; Abbreviated Description: LOT:2 BLK:143 LOT
2 BLK 143 MB 018/092 SANTA CARMELITA VALE LA QUINTA UNIT 15;
City/Muni/Twp: LA QUINTA
71___-_ _--- /"Il_ --�___•-'.
K i VAGI iy %,u41 4a;«1 laiilw
Bedrooms :
2
Year Built:
2008
Square Feet :
1114
Bathrooms :
2.0
Garage:
A
Lot size :
6098 SF
Partial Bath :
0
Fireplace:
Y
Number of Units:
1
Total Rooms:
0
Pool/Spa :
N
Use Code :
Single Family Residential
Zoning :
N/A
r - - rT - - T - r- ---- -'.
04lc1uuall i11iUl lual.lull
Transfer Date : 10/25/2007 Document #: 2007-0658642
Transfer Value: N/A Cost/Sq Feet: N/A
First Loan Amt: N/A Lender:
L•1SS�SSIIi�II1/ 1dX 1I11Ul1ilAl.1U11
Assessed Value :
$185,000
Tax Amount:
$2,688.56
Land Value:
$85,000
Tax Status :
Current
Improvement Value:
$100,000
Tax Rate Area :
20-104
Percent Improvement:
54%
Homeowner Exemption:
N
Data Deemed Reliable. But Not Guaranteed.
Copyright 2004-2010 FIS Data Services. All Rights Reserved. All other trademarks and wpyrights are the property ottheir respective holders.
03=12010 13:24:18 PM Customer Service Rep: Mike Bowens
Printed on 03-30-2010
Printed at 1:25 PM
Riverside County Title Tax
773-302-015-6
Page I
ORDER#
Fidelity Title
Customer Service Request Only
Information is sourced from public records and is deemed reliable, but is not guaranteed.
[Tax Year: 2009-2010 Assessor's Parcel 773-302-015-6 --Payments as of 03/26/2010
JjescnDed As: LUF 2 BLK 143 AM 018/092 SANTA CARAIELITA
Address: 52553 AVENIDA MENDOZA LA QUINTA 92253
City: LA QUINTA
Billing Address: 79120 FOX RUN LA QUINTA CA 92253
Assessed Owner(s): BAKER SHELDON ROY
Mailing Name(s); BAKER, SHELDON ROY TR
Tax Rate Area: 020-104
Value
Conveyance Date: OCT 2007
Payment Date Balance
Land: 85,000.00
Conveying Instrument: 658642
Use Code: RI
Improvements: 100,000-00
Date Transfer Acquired:
Single family residential
Personal Property:
Vesting: NO
Region Code:
Fixtures:
Year Built:
Zoning Code:
Inventory:
Year Last Modified:
Taxability Code: 0-00
Exemptions
324.60
2nd 182.17
Homeowner:
Square Footage
Tax Rate: 1.16707 %
Inventory:
Land:
64.44
Personal Property:
Improvements:
Religious:
052834057-9
Bill #: 0511897
All Other:
Tax Defaulted:
Issue Date:
......8.
........
Improvements
Installment Amount
Penalty
Due Date Status
Payment Date Balance
1st 1,344.28
134.40
12/10/2009 PAID
01/31/2010
2nd 1,344.28
162.40
04/10/2010 PAID
01/31/2010
Account
Special Lien Description
Amount
68-1859
COUNTY SERVICE AREA
9.98
68-2373
CITY OF LA QUINTA LDS & LTG
35.60
68-2376
CITY OF LA QUINTA WASTE DISPOSAL
140.28
68-4556
COACHELLA VALLEY MOSQUITO AND RIFA
9.14
68-4612
CHCL VLY AD 93-1 NINT FEE MILL -RS EXP
9.90
68-4834
CVWD SEWER CHG 11" 55
324.60
Supplemental Tax Due To.
Tax Year: 2008 Type: SECURED
Assessed Owner(s):
BAKER SHELDO
Situs:
52553 AVENIDA MENDOZA LA QUINTA CA 92253
Installment Amount
Penalty
Due Date
Status
Payment Date Balance
1st 182.17
18.22
12/10/2009 PAID
12/10/2009
2nd 182.17
46.22
04/10/2010 PAID
12/10/2009
Total 364.34
64.44
Value
Supplemental Bill #:
052834057-9
Land
-57,800.00
Issue Date:
07/0712009
Improvements
92,350.00
Tax Defaulted:
Effective Date:
07/01/2008
Total
34,550.00
*** END OF REPORT ***
WHEN RECORDED MAIL TO:
Sheldon R. Baker
79120 Fox Run
La Quinta, CA 92253
MAIL TAX STATEMENTS TO:
Sheldon R. Baker
79120 Fox Run
La Quinta, CA 92253
CAPN: 773-302.015 j
DOC # 2007-0658642
10/23/2007 08:00A Fee:7.00
Page t of 1
Recorded in Official Records
County of Riverside
Larry U. Uard
Assessor, County Clerk b Recorder
1111111111111111111111111111111111111111111111111
S R I U PAGE SIZE UA I MISC LONG RFp
I COPY
1
M A L 465 1 4261PCOR COR SMF NCHG
CTY UNI
DOCUMENTARY TRANSFER TAX $ -0-
X Computed on the consideration or value of
property conveyed; or A A
Computed on the consideration or value less
—' II or encumban= remaf g at 0 - f sale 515
Sig ature of Declarant or Agent Wermininj tax
GRANT DEED
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
SHELDON R. BAKER, a married man as his sole and separate property,
hereby T( ) to SHELDON ROY BAKER, as Trustee of The Sheldon Roy Baker Revocable Trust
Dated ��, 2007, executed by Sheldon Roy Baker as Settlor and as original Trustee,
the real property in the City of La Ciulnta, County of Riverside, State of California, described as
(Lot 2, Block 143, Unit No. 15, of Santa Carmelita at Vale La Quinta as shown by map on file in
c. Book 18, Page 92 of Maps, in the office of the County Rqcorder of Riverside County, California. �
Dated 11hC��!?-�•t� O d'� 1 '
SH ON R. BAKER
STATE OF CALIFORNIA )
COUNTY OF RIVERSIDE )
On ['V) N o 6./ . 2007 before me, I A 1'0 I .P r-,
Notary Public, personally appeared Sheldon R. Baker, personally known to me OR proved to me on the
basis of satisfactory evidence to be the person(s) whose name(s) Is/are subscribed to the within
instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized
capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon
behalf of which the person(s) acted, executed the instrument.
WITNESS my hand and official seal.
MARMN wALF1IEi.R1
I
Cmm.i1651246 K'
cra�MIC-CAUM
EvlCam
0
1 0N
03/30/2010 01:26 PM 1 of
I
RECORIG REQUESTED BY:
First American Title Company
AND WHEN RECORDED MAIL TO:
Sheldon R. Baker
79120 Fox Run
La Quints, CA 92253
APN: 773-30z-ol'0
1h: oto- 0/-�
DOC # 2007-0095976
02/09/2007 08:00A Fee:10.00
Page 1 of 2
Recorded in Official Records
County of Riverside
Larry U. hard
Assessor, County Clerk b Recorder
11 11111111111111
S R U PAGE SIZE I DA I MISC I LONG1 RFD
COPY
M A I L 465 426 O NCOR SMF NCMG
EXAM
azo
No.: 2622389 Escrow No.: 270013 -RW
INTERSPOUSAL TRANSFER GRANT DEED
(Excluded from reaeoraisal under California Constitution Article 13 A Section 1 et sea_
(X) computed on full value of properly conveyed, or
I I computed on full value less value of Liens or encumbrances remaining at time of sate.
(X I is exempt from imposition of the Documentary Transfer. Tax, pursuant to Revenue and Taxation Code Section
11927(a), on transferring community, quasi- community, or quasi -marital property, assets between spouses pursuant
to a judgment, and order, or a written agreement between spouses in contemplation of any such judgment or order.
(X) A creation, transfer, or termination, solely between spouses, of any co-owners interest.
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
Gina M. Baker, spouse of the grantee herein
hereby GRANT(s) to: 0
Sheldon R. Baker
the real property In the City of La Quints, County of Riverside, State of California, described as:
Lot 2. Block 143, Unit No. 15, of Santa Carmelite at Vale La Qulnta as shown by map on file in Book 18, Page 92 of Maps in
the office of the County Recorder of Riverside County, California.
Also known as: 52553 Avenida Mendoza, Le Ouinta, CA 92253
A.P. # 773-302-015.6
DATED January 30, 2007 r
STATE OF CALIFORNIA
COUNTY OF RIVERSIDE Gina M. Baker
On JANUARY 30, 2007
Before me, AMY NICOLE DONOVAN
A Notary Public in and for said State, personally appeared
GINA M. BAKER
personally known to me (or proved to me on the basis of
AW OOCOU 00WVAN
satisfactory evidence) to be the person(s) whose nameMCOWanission 0 16717&!s) Nom heft . CWo
islare subscribed to the within instrument and acknowledged BIM fIOe �
to me that he/she/they executed the some in his/her/their /
authorized capacty(tes), and that by his/her/their slgnature(s)
on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the Instrument.
WITNESS my hand and official seal.
sturewI�WV E\A 1J 1 VVWU KN v (This area for official notarial seal)
TAX STATEMf NTS$'TO PARTY SHOW BELOW; IF NO PARTY SHOWN, MAIL AS DIRECTED ABOVE:
03/30/2010 01:26 PM 1 of
L
RECORDING REQUESTED BY:
First American Title Company
AND WHEN RECORDED MAIL TO:
SHELDON R. BAKER
79120 Fox Run
La Quinta, CA 92253
AAV: 713- OZ- 015-9
r" I., OZO-O/;
2622388
DOC # 2007-0095975
02/09/2007 08:00A Fee:7.00
page 1 of 1 Doc T Tax Paid
Recorded In Official Records
County of.Riverside
Larry U. Nard
Assessor, County Clerk 8 Recorder
I !!1111 I!Illll I!!ll If ! III11 IlIII! Illl11IN IIIlI 1111 IIII
S R U PAGE SIZE DA MISc LONG RFD COPY
M A t 48 4I8 COR KOR SMF NCHG
VA- VZ2 026
NT DEED
THE UNDERSIGNED GRANTOR(S) DECLARE(S)
DOCUMENTARY TRANSFER TAX is $162.25
[XJ computed on full value of property conveyed, or
(J computed on full value less value of liens or encumbrances remaining at time of sale.
[ J Unincorporated area [XJ City of La Quinta AND
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged, LO,2�
Sherry A. Mc Donald, Executor of the Estate of June B. Loop
hereby GRANT(s) to:
SHELDONR.BAKER A MARRIED MAN AS. HIS SOLE AND SEPARATE PROPERTY
the real property in the City of La Quinta, County of Riverside, State of California, described as:
Lot 2 Block 143, Unit No. 15, of Santa Carmelita at Vale La Quints as shown by map on file in Book 18, Page 92
of Maps In the office of the County Recorder of Riverside County, California.
AP#: & 773-302-01"
�Y
DATED
STATE OF
COLIFY OF A►�l'DO
On _ t? . 00
Before me. MI
A Notary Public je and for sjCrci State, pergonally appeared
personally known to me (or proved to me on the basis of
satisfactory evidence) to be the person(s) whose name(s)
islare subscribed to the within instrument and acknowledged
to me that he/sheithey executed the same in his/her/their
authorized capacity(es), and that by his/her/their signature(s)
on the instrument the person(s), or the entity upon behalf of
which the persons) acted. executed the instrument
WITNESS my hand and official seal.
Sherry A. Mc Donald, Executor of the Estate of June B.
loop
BY:
erry A c Donald, xecutor .
�� •�� err fill
Signature (This area for official notarial seal)
MAIL TAX STAT O PARTY SHOWN BELOW: IF NO PARTY SHOWN, MAIL AS DIRECTED ABOVE:
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Copyright 0 2004-2010 F15 Data Services, All Rights Reserved. A11 other trademarks and copyrights are the property of their respe.^tive holders.
3130/Z010 Customer Service Rep: Mike Bowens
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