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9611-010 (BLCK)Ln LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter -o `(commencing withr,Secticn 7000) of Division 3 of the Business and Pro essjonals Code, and my License is in full Torce and effect. License # Lic. Class Exp. Date Date Signature of Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: 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 br offered for sale (Sec. 7044, Business & Professionals Code). ( ) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals (a)` I a ex mp�der Section B&):C. for this reasgn Date a `" Signature of Owner_a4�.vt 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 & policy. no. are: Carrier Policy No. (This section need not be completed if the permit valuation is for $100.00 or' less). sh () I certify that in the performance of the work for which this permit is issued, I all 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 sh I`foitF� Ith comply wit' ose p o is on ! , ; "bate: 1! 0 Applicant °" ' � ic#A, Af Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $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. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his 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 applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 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 State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. Signature (Owner/Agent) � �^" � � DaYetIrI16 s BUILDING PERMIT PERMTk �°NTR°`" �4A a�f9�d� 4279 DATE 0/ Vw_, VALUATION ��q 6�`tb� LOT: TRACT JOB SITE ADDRESS, -7185 Lt1.UGO CIRCLE APN OWNER CONTRACTOR / DESIGNER / ENGINEER 114485 LA11100,0R. LAOJINCA. CA A2253 C,'CILU USE OF PERMIT A 3P ADD 2 (AW SY.f [ 1..24 fALI :.`l(:1t?11U,, °2Q. LX. 11110A)IOU LN M:t PUMIN TF'EC;ti!T I—MARY 9,TJ!, 101-000-418.000 00 ' SUEEI-'3'ULAL E..'Or!a1'1 UCTEO%TAND 17X,:,sLI`dC-H1 CK L.VSS 11Yr\X-PMt) FrJs *5 $0.00 RE EIPT DATE �/� .f' j BY" % i DATE FINALED INSPECTOR t INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS ,Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K to Wrap F.A.U. %ming Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Pasty Wall Firewall Exterior Lath Drywall - Int. Lath Final Final POOLS - SPAS BLOCKWALL APPROVALS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final IV VZ Gas Piping PLUMBINGA OVALS Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test Appliances Final COMMENTS: Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) �.. f CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES PLUMBING FEES 'ST FL. 30 FT ,r E 2ND FL. SO. FT..-yj POR. SO. FT GAR SO. FT. -T CAR P j0. FT .2 WALL SO FT %t 30 �T a ESTIMATED CONSTRUCTION VALUATION S UNITS MOBILEHOME SVC. POWER OUTLET YARDR SYSTEM *BAR ROOF DRAINS DRAINAGE PIPING DRINKING FOUNTAIN URINAL WATER PIPING ' NOTE: Not to be -,sea as-roceny tar ia!uallon BONDING FLOOR DRAIN MECHANICAL FEES FORMS WATER SOFTENER t VENT SYSTEM FAN EVARCOOL HOOD SIGN WASHER(AUTONDISHI APPLIANCE DRYER GAS (ROUGH► GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED OTHER APPJEOUIP. LAUNDRY TRAY AIR HANDLING UNIT CFM TEMP. POLE KITCHEN SINK ABSORPTION SYSTEM B.T U. TEMP USE PERMIT SVC WATER CLOSET COMPRESSOR HP POLE.TEMIPERM LAVATORY HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER BOILER B.T.U. SO. FT. ,&.. c BATH TUB SO. FT. g c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SU. FT. RESIO rd Tta c SEWAGE DISPOSAL SO.FT.GAR V 14c HOUSE SEWER : REMARK& GAS PIPING PERMIT FEE PERMIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE PL.CK.FEE CONST. FEE ELECT. FEE SMI FEE PLUMB. FEE STRUCTURE PLUMBING ELECTRICAL HEATING A AIR GOND. SOLAR SETBACK GROUND PLUMBING UNDERGROUND A.C. UNIT COLL AREA SLAB GRADE ROUGH PLUMB, BONDING HEATING (ROUGH) STORAGE TANK FORMS SEWER OR SEPTIC TANK ROUGH WIRING DUCT WORK ROCK STORAGE FOUND. REINF. GAS (ROUGH► METER LOOP HEATING (FINAL} OTHER APPJEOUIP. REINF. STEEL GAS (FINAL) TEMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM GRADING cu. yd, Z plus xS a: LUMBER GR. FINAL INSP. FRAMING FINAL INSP. ROOFING REMARK& VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATIOWSOUNO FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL tns►aw �Ramull^IunamilmlIwaa GARDEN WALL FINAL OWNER/BUILDER. INFORMATION Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a permit. Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself, you may protect yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the City or County. They are also required by law to put their license number on all permits for which they apply. If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be aware of the following information for your benefit and protection: If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer. If you are an employer, you must register with the State and Federal Government'as an employer and you are subject to several obligations including State and Federal income tax withholding, federal social security taxes, worker's compensation insurance, disability insurance costs and unemployment compensation contributions. There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to worker's compensation insurance. For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State Law, contact the Department of Benefit Payments.and the Division of Industrial Accidents. If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their work personally or through their own employees, without a licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building permit, erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your community or at 1020 N. Street, Sacramento, California 95814. Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, CITY OF LA QUINTA DEPT. OF BUILDING AND SAFETY 78-105 Calle Estado La Quinta,. CA 92253 (619)564-2246 FAX: 619) 564-5617 OWNER'S SIGNATURE/ ATE d If PROPERTY ADDRES % 1l - 0/0 PERMIT NUMBER(s) 14- S. !� 1 i INSTALL 2 COURSES OF p( (N) ORCO 6916 WEDGE - LOCK BLOCK AND GROUT • ALL CELLS WITH REINF 3 STEEL- TEEL"co cow" C n NOTE: TYPICAL WALL SECTION ' HAS BEEN DESWINED BY ORCO BLOCK AS NOTED IN THE ATTACHED DEShGN ' DRILL A.9/I6" DIAMETER CLEAN SHEET FOR '10 MPH WIND DRILLED HOLE 16" (2 COURSES) IN EXPOSURE G THE WALL AT EACH (E)'4 VERTICAL REBAR 6EGTON HAS BEEN DESIGNED LOCATION (32" ON CATER). FORA 6'-0" MAX WALL. INSTALL (NJ 04 VERTICAL BAR WITH THE EXISTING WALL IB ONLY SiMPSON EPDXY-TIE ADHESIVE 4'-6" AND IS CAPABLE OF IN ACCORDANCE WITH IC80 04948 SUPPORTING LATERALLY 2 AND COLA RR281SS. ADDITIONAL COURSES OF DRILLED HOLE 614ALL BE ADJACENT BLOCK AS NOTED. TO (E) STEEL M CENTER OR WALL. I I � • :. I I� I DENNIS S. WISH Z • w 0.'C -0412W m / S -1 I I Er(XPI I I � NIL _._...._..__.. _TEBffffoye&SAFETY DEPARTMENT N CONDITIONALLY SUBJECT TO IWALLATION AS PER ARM CODES 1 % BY LAW OFFICES OF s COSGROVE, MICHELIZZI,• SCHWABACHER, WARD BIANCHI AND ' LEONARD A. COSGROVE A PROFESSIONAL CORPORATION TELEPHONE FRANK G. MICHELIZZI 1 _ - AREA CODE 805 • THOMAS J. WARD r' ` 767 WEST LANCASTER BOULEVARD 948-5021 DAVID W. BIANCHI ,r DAVID T. COLLINS , LANCASTER,. CALIFORNIA 93534-3135 FAX JAMES C. LILLICRAP ` ! rte, 805-948-5395 KEVIN L. VON TUNGELN— � PHILIP M. SCHWABACHER •CERTIFIEO SPECIALIST - FAMILY LAW 1 1913-1993 THE STATE BAR OF CALIFORNIA BOARD OF LEGAL SPECIALIZATION • ♦ A ' J"ALSO ADMITTED IN DISTRICT OF COLUMBIA t ti. 77 -SEE -8847-0 STATE FARM FIRE AND CASUALTY COMPANY 900 OLD RIVER RD BAKERSFIELD CA 93311-6000 A STOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON, ILLINOIS LOAN i 6772597 ° NAMED INSURED MORTGAGEE ' C 1698-F406 G MJ2HELIZZI FRANK G & NIKKI D COUNTRYWIDE HOME LOANS °• SIGNS ATIMA 7 W LANCASTER VD AND/OR ITS AS °• LANCASTER CA 93534-3118 MSN - PO BOXV2? 0213 2 VAN NUYS CA 91410-0213 + HOMEOWNERS POLICY - EXTRA FORM 5" AUTOMATIC RENEWAL If the POLICY PERIOD is shown as 12 months, this policy will be renewed automatically sub- ject 'to the premiums, rules and forms in effect for each succeeding policy period. If this policy is terminated, we will give you and the Mortgagee/Lienholder written notice in'compliance with the policy provisions or as required by law. POLICY PERIODI ,12 MONTHS :THE POLICY PERIOD BEGINS AND ENDS AT 12x01 AM EFFECTIVE DATE: 04/08/ 2 STANDARD TIME AT THE RESIDENCE PREMISES EXPIRATION DATE: 04/08/9 AOF PREMISES CRCLE LA GUINTA C.A 92253-5912 .d LEGAL TITLE OF NAMED INSURED HUSBAND AND WIFE AS. JOINT TENANTS THIS POLICY DOES NOT INCLUDE EARTHQUAKE COVERAGE THIS POLICY INCLUDES BUILDING CODE UPGRADE COVERAGE OF ! 15,000 COVERAGES 6 PROPERTY LIMITS OF INFLATION COVERAGE INDEX, 134.5 SECTION I' LIABILITY DEDUCTIBLES - $ECiION 0I A DWELLING 153000 ALL LOSSES 1,0 0 DREXTENSION B PERSONAL PROPERTY 112,000 ACTUAL LOSS C LOSS OF USE SUSTAINED IN CASE OF LOSS UNDER THIS POLICY, THE DEDUCTIBLES WILL BE SECTION It APPLIED PER OCCURRENCE AND WILL L -PERSONAL LIABILITY ! 300,000 BE DEDUCTED FROM THE AMOUNT OF (EACH OCCURRENCE) THE LOSS. OTHER DEDUCTIBLES MAY DAMAGE TO PROPERTY APPLY - REFER TO POLICY. OF OTHERS ! 500 — M MEDICAL PAYMENTS TO OTHERS (EACH PERSON) �! 2,000 FORMS OPTIONS, 6 ENDORSEMENTS EXTRA FORM 5 (EXTRA REPLACEMENT COST DWELLING AND REPLACEMENT COST ON CONTENTS) POLICY ENDORSEMENT AMENDATORY ENDORSEMENT 10X BOL LENDERS LOSS PAYABLE END FP-7925.CA FE -1829 FE -4360 80 POLICY PREMIUM ! DISCOUNTS APPLIED, HOME ALERT NEWER HOME RENEWAL 6+ YEARS OTHER LIMITS AND EXCLUSIONS MAY APPLY — REFER TO O POLICY • COERSIGNED CJPPEEPARED BY 1,# O167004C YOUR POLICY CONSISTS OF THIS PAGE, ANY ENDORSEMENTS 0 9 4 1- 2 6 2 8 I R E I N S AGENCY AND THE POLICY FORM. PLEASE KEEP THESE TOGETHER. INC 388.00 19 q& AGENT 6TAii FARM " JIM McGU IRE, CLU, INSURANCE AGENCY, INC. INSURANCE - me . Bus ED "ANdASTER, CA679293 93534 PHONET(805) 948-262811 FAX.723-3588Ve LANCAS , November 04, 1996 FRANK MICHELIZZI 79185 LATIGO CR LA QUINTA, CA 922535912 DEAR FRANK:. RE: LIABILITY'& WORKER'S COMPENSATION CITY 01" LA QUINTA, CA. PLEASE USE THIS LLTTER TO ADVISE THE CITY OF LA QUINTA CALIFORNIA THAT YOUR SPATE FARM HOMEOWNER POLICY NUMBER 77 -EE -8847 -OF. CONTAINS PROVISIONS TO PROVIDE LIABILITY AND WORKERS COMPENSATION COVERAGES FOR YOUR HOME IMPROVEMENT PROJECT INVOLVING THE CONSTRUCTION OF THE NEW BLOCK WALL PROJECT. PLEASE REFER THE CITY TO ME IF THEY HAVE ANY. QUESTIONS OR CONCERNS. THgNK YOU. SINCERELY, t �/ 74 ICBG Evaluation Service Inc. A subsidiary corporation of the International Conference of Building Officials EVALUATION REPORT Report No. 4945 Copyright © 1994 ICBO Evaluation Service, Inc. June, 1994 Filing Category: FASTENERS—Concrete and Masonry Anchors (066) POLY -ALL EPDXY ANCHORING SYSTEMS ACKERMAN JOHNSON FASTENING SYSTEMS, INC. 136 OFFICIAL ROAD ADDISON, ILLINOIS 60101 DAYTON SUPERIOR CORPORATION 721 RICHARD STREET MIAMISBURG, OHIO 45342 GUNNEBO FASTENING CORPORATION 180 SOUTH HARTMAN STREET YORK, PENNSYLVANIA 17403 SIMPSON STRONG -TIE COMPANY, INC. 4637 CHABOT DRIVE, SUITE 200 PLEASANTON, CALIFORNIA 94588 I. Subject: -Poly-All Epoxy Anchoring'Systems. II. Description: A. General: Ackerman -Johnson Fastening Systems, Inc., Poly -All anchoring systems described in this report are stud -type adhesive anchors for use in concrete and unreinforced brick walls. The an- chor systems consist of two-part epoxy adhesives and a threaded steel rod or deformed steel reinforcement bars. For installation in unreinforced brick walls, a screen tube, steel sleeve and steel plate are also used. The adhesives are packaged in dual side-by-side cartridges with a 1:1 volume ratio. The cartridges are used with a manual or pneumatically activated tool. The adhesive is mixed by a static mixing nozzle as it is dispensed from the dual cartridge. B. Poly -All PAC -24: 1. General: Ackerman Johnson Fastening Sys- tems, Inc., Poly -All PAC -24 has a shelf life of one year when stored in a dry environment at temperatures ranging from 45°F. to 90°F. The recom- mended hardening time is noted in Table No. 1. 2. Concrete: a. General: Anchors are for use in normal -weight stone -aggregate concrete having various compressive strengths. Allow- able tension and shear values are tabulated for the various threaded rod sizes indicated in Tables Nos. II and III. Allowable tension values for de- formed steel reinforcing bars are noted in Table No. IV. The allowable val- ues in Tables Nos. 11 through IV must be adjusted in accordance with Fig- ure No.1 when the anchors are installed in locations where the concrete temperature exceeds 720F. b. Installation: The anchor is installed in a predrilled hole in concrete that has been cleaned with compressed air and a nylon brush. The hole diameter, anchor embedment, spacing and edge distances must comply with Tables Nos. 11 through IV. The mixed adhesive is injected into the hole to fill it approximately one-half full. Threaded rods or steel reinforcing bars, free of oil, scale and rust, are pushed to the bottom of the hole and twisted clockwise to ensure coverage of the threads or bar surface with adhesive. The adhesive must be level with the concrete surface after inser- tion of the rod or bar. 3. Unreinforced Brick Walls: a. General: Anchors installed in existing unreinforced brick walls with Poly -All PAC -24 adhesive are designed to re- sist seismic loads only. The existing unreinforced brick walls must have a minimum thickness of 13 inches. The anchor is installed in three config- urations as shown in Figure No. 2. The adhesive, threaded rod and screen tube are used in all anchor installations. Configuration A has a straight threaded rod embedded 8 inches into the wall. Configuration B consists of the threaded rod bent and installed 13 inches into the waif at a 22.5 -de- gree angle. Configuration C uses a through -bolt, steel sleeve and a steel plate. The threaded rod for Configurations A and B is a'3/4 -inch -diameter ASTM A 307 rod. A 5/8 -inch -diameter ASTM A 307 threaded rod is used in Configuration C. The screen tube is a steel screen formed into a tube with a 31/32 -inch diameter and a length of 8 inches, except for Configuration B where the tube length is 13 inches. An 8-inctr-long sleeve formed from C 1010 steel used in the through - bolted condition of Configuration C has an outside and inside diameter of 13/16 inch and 11/16 inch, respectively. The steel sleeve has a plastic plug in one end. A 6 -inch by 6 -inch by 3/8 -inch -thick ASTM A 36 steel plate is located on the back face of the wall at the end of the threaded rod of the through -bolted connection. Allowable shear value for Configurations A and C is 1,000 pounds. The allowable tension value for Configuration B is 1,200 pounds. Allowable values are for short duration seismic loads and cannot be increased for .short-term loads. The adhesive for the installed anchors must be pro- tected from direct weather exposure. b. Installation: The anchors are installed in 1 -inch -diameter holes drilled with standard rotary drill bits for use in concrete or masonry, and a rotary drill or rotary hammer drill used in the "rotation only" mode. The hole is drilled perpendicular to the wall face with a depth of 8 inches for Configurations A and C. Theftle for the Configuration B anchor is at the angle and embedment -described in Section IIB 3-a using a guide which is hand held or attached to the drill. The holes are cleaned with oil -free compressed air and a nylon brush. The mixed adhesive is injected into the screen tube until the tube is completely full. The tube is then placed into the drilled hole. The threaded rod of Configurations A and B or the steel sleeve of Configuration C is slowly pushed into the screen tube forcing the adhesive through the screen into the hole. The adhesive must be cured at the temperature and. time periods noted in Table No'. I before load application to Configurations A and 8 or before continuing installation of the Configuration C anchor. After the adhesive is cured in the Configuration C anchors, 5/8 -inch -diam- eter holes are drilled with standard rotary drill bits through the plastic plug in the end of the steel sleeve and completely through the wall. The 5/8 -inch threaded rod is inserted through the hole and attached to the other side of the wall with the metal plate and a nut. c. Miscellaneous: Anchor installations require the following items: (1) Use of the anchors must be approved by the design engineer. (2) The anchors must be installed under special inspection in accor- dance with Section 306 of the code. (3) Configurations A and C for shear loads due to seismic forces: (a) Allowable load is applicable only where in-place shear tests indicate a minimum mortar quality of 50 psi net. (b) One-fourth (25 percent) of the anchors must be tested by a special inspector using a calibrated torque wrench set at a minimum torque of Evaluation reports of 1CBO Evaluation Service, Inc., are issued solely to provide information to Class A members of ICBG, utilizing the code upon which the report is based Evaluation reports are not to be construed as representing aesthetics or any other attributes not specifically addressed nor as an endorsement or recommen- dation for use of the subject report. This report is based upon independent tests or other technical data submitted by the applicant The 1060 Evaluation Service, Inc., technical staff has reviewed the test results and/or other data, but does notpossess test facilities to make an independent vertAcation. There is no warranty by 1CBO Evaluation Service, Inc., express . or implied, as to any "Finding" orother matterin the report oras to any product covered by the report This disclaimer includes, but is not limited to, merchantability. Page 1 of 6 EARTH SYSTEMS CONSULTANTS SOUTNERN CALIFORNIA 1 79-811 B Country Club Drive Bermuda Dunes, CA 92201 (619) 3451;1588 Client Name ����K� Client Client Phone DATE (n�/U 0-19-9 JOB N.O. S`'�D PROJECT ji 4.G 1 LOCATION CONTRACTOR OWNER WEATHER TEMP. o at AM at PM PRESENT , SITE l THE FOLLOWING WAS NOTED: ►� O \ � S �'�nC �o < C� � CMCJ W ec,� e� OCA �, �r �¢.��ejj \' � r 70 )AN,,, �:)©l �elnc?1 [Rvr1_ Cii c 0 YN C 444sn C 40 1, e CA � W© CO ��'�cl afa_ � 14 wa-4, SJOWINC pg 1S oftacL , ` 2 o ' v 4 4 e �� MAS -1) IN t U %A) Vic cl \10 cw_v a c. Vii.. SL% t' O to 1101 ►3 A 00 i t Y ` ' LCA t3 v CLIENT REPRESENTATIVE SIGNATURE FIELD REPORT TECHNICIANS SIGNATURE