0522G
t
NOTE:
With,proper validation
' this form constitutes an
1
YL.'��^•M^.•T..l"•..•-�.. ——.r+,r„'^er."'•"�r��reti.�„�"..•^'tir•�„r""q,-"�.,w.. • 1 a
i
-CITY OF CA QUINTAL 'r '
....�M4..,r•y.1r-
encroachment permit . '' -
APPLICATION FOR _PERMIT
'r. - • Y PUBLIC WORKS CONSTRUCTION (ENCROACHMENT-)'.
OF
# For the. coristr.uction 'of public or private curbs, -driveways, pa ements., sidew'a'lks,- parking lots, sewers, water .mains
and other like public works improvements in connection with MINOR IMPROVEMENTS and`APPROVED SUBDIVISIONS
..
�- Subdivision Improvement Permit �Class,111
Mar. h 8, 1'990
• DATE:• Minor.Improvement Permit Class IV
. f. SB Washington •F$ , 50th`
LOCATION OF CONSTRUCTION
(Street address or Description of Location) .
'Transit Shelter p R appropriate)
PURPOSE'OF CONSTRUCTION - Sketch (attach construction laps if a
'IDESCRIPTION OE CONSTRUCTION 1 nhnes'n j
DIMENSION OFIINSTALLATION OR'REMOVAL �� a+ ar.k�ed "4Y.
" SIZE OF EXCAVATION, IF NEEDED t
• s M o5i9ATM rOTA3- 04w9(? i4
..
'APPROX'IMATE TIME WHEN.WORK WILL BEGIN s. ax. 5.,00
APPROXIMATE TIME OF COMPLETION T °
1 ': .ESTIMATED CONSTRUCTION COST $ ?n nn `' .r ° 'r 1'�►' �+ .�
(Including removal of. all obstruction, materials, 'a nd debris, backfilling, com
pactiori,andrplacing,permiinen.t resurfacing' and/or replacing improvements).. '
Ts
In cons deration of, the granting of this permit, the 'applicant- hereby agrees to:
.Indemnify,. defend and savW,the City,•its.authorizeclagents, officers,Jrepresentatives`and employees, harmless from and against any and all
"• �•, penalties, -•liabilities or,,.'loss�resultingafrom claims or court action and arising out of any accident, loss or damage to persons or,property,
happening or' occurring as a proximate result of any work undertaken under the permit granted `pursuant to tFiis applicatiori
- r
~I Notify the Administrative Authority at least twenty-four (24) hours in advance of the,time•when workjwil) be,
started.
Comply,with all applicable City Ordinances, the terms and conditions of the,,permit and all applicable -ru es and'regulat ons'of the City -of
La Quints and to'pay for any additional•replacement necessary as the result of this=work.
Signature, f Applicant or Agent �• w #
Gtinrw QA onAi a Ing W, Tne1•i a.n Atm _ Palm :Grir•I vtr_x� , (`A t ' ' 17r...7t1.7A*. .
Name of Applicant (plea'se'print) _ ; , Business Address ' �Teloplione No.t ,
Frank Jones same; as 'above , t
'Name of Contractor and'Job Foreman " Business Address r 1'Telephone'No.
John '8}cora' #B-34119
i i• t
Contractor's License No: _ "City Business License No.
Griffith :Sinco.ck 1 N ,0364872T -
Applicant's Insurance.Company Policy•Nurriber
FEES: Subdivision Improvement Permit —Class I I I �•
,Public improvements: 3°/a of estimated construction costs :r • ,. t '
Private•improvements: 3% of estimated construction costs *#
Minor Improvement Permit — Class M'See attached schedule , ; �'.N2
Inspection Fee $ PERMIT VALIDATION ,
Permit Fee
• ir,PERMIT NO.
Penalty
DATE APPROVED"��lq0
Cash Deposit -Surety Bond ,
if required EXPIRATION DATE,
TOTAL: $
DATE ISSUED t.
Receipt No. '
Received by Date Administrative Authority
Recorded by TELEPHONE: (619) 564-2246
f+ s,.�c�#�,=*�a'�,a""n"'{�E3+stf+w=ni.w.w }.. w� a. q. w� -a.+ c—b.a .r c..� .c. .s ey. cy w. +� �. w ya �r w +a. enc +a. �. �� w w .�,.�. �.... w .• t+. Y..,w rw :i �► ... �. � r�-�++s. �
y
NOTE:
With proper validation
this form constitutes an ' CITY OF LA QUINTA
encroachment permit
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
March 8, 1990 Subdivision Improvement Permit— Class III
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION SB Nashington FS 50th
11
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Transit Shelter Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION�;��T
DIMENSION OF INSTALLATION OR REMOVAL'S
SIZE OF EXCAVATION, IF NEEDED
Q0518?t %3�O�J--��U4
APPROXIMATE TIME WHEN WORK WILL BEGIN 10 CA .I 1 T� i 45x00
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ 1 n nnn
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction and placing permanent resurfacing and/or replacing improvements)
In consideration of the granting of this permit, the applicant hereby agrees to:
Indemnify, -defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all
penalties, liabilities or loss resulting from claims or court action and arising out of any accident, loss or damage to persons or property
happening or occurring as a proximate result of any work undertaken under the permit granted, pursuant to this application.
Notify the Administrative Authority at least twenty-four (24) hours in advance of the time when work will be started.
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulations of the City of
La Quinta and to pay for any additional replacement necessary as the result of this work.
ignature of Apjilicant or Agent
gitnricp morlia 101 1\7- Tnflian Astra_ Palm 9nr4nfxa,C:A 129-7n7R
Name of Applicant (please print) Business Address r Telephone No.
Frank Jones same as above
Name of Contractor and Job Foreman Business Address Telephone No.
John Ekora OB -34119
Contractor's License No. City Business License No.
Griffith Sincock N 0364872
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit —Class III
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $a a
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by Date
y" 3592
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
"'T �' C-,
DATE ISSUED
By
!,
Administrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246
The following General and Special Provisions are attached to and.made a part. of Permit No. Jy�
GENERAL- PROVISIONS
y' The following shall always apply: - t. j `•
_ ENCROACHMENT ON PRIVATE PROPERTY: This permit authorizes work to be accomplished within City of La Quinta right of way
ONLY. Whenever construction extends within private property, it shall be the responsibility of the permittee (or his contractors) to
secure permission from abutting property owners: Such authorization must be secured by the permittee prior to starting work.
TRACKLAYING CONSTRUCTION EQUIPMENT: Cleated tracklaying c6instructio-naqu'ipment shall not be permittedto operate on any..
paved surface unless fitted with smooth -faced street pads. All mechanical outriggers shall be fitted with rubber street shoes to protect '
the paving during excavations. Rubber-tired.equipment only shall be used in backfill operations in paved areas. If the existing
pavement is scarred, spalled, or broken during the term of this contract, or if the pavement is marred, City of La Quinta shall request
that these portions of road be resurfaced over their entire width. Resurfacing shall consist of one coat of two inches (2") of A.C.
surfacing plus appropriate seal coat as specified above.
PROTECTION OF:TRAFFIC: All excavations and work areas shall be properly lighted and barricaded as deemed necessary by the City
Engineer or La Quinta City Public Works Inspectors.Suitable detours and detour signs shall be placed and maintained for the duration
of the project. The City shall be notified 24 Hrs.- in advance of any traffic detours or delineations.,
CARE OF DRAINAGE STRUCTURES:Any drainage 'structure including corrugated metal pipe, concrete pipe, steel culvert and,
concrete structures encountered during excavation which necessitate removal shall be replaced in kind. In the event.it becomes
unecessary to remove or cut existing drainage structures, City of La' Quinta shall be notified prior to commencement -of -this work.
Drainage structures and open drains shall be kept free of debris at all times for proper drainage.
RIGHT OF WAY CLEANUP: Any surplus material resulting from excavation!and backfill operations shall be removed from the rightof
' way. All paved surfaces shall be broomed clean of earth and other objectionable materials immediately after backfill and compaction.
Existing gutter line and drainage ditches shall be replaced to their original standard or better. All excess material shall be removed
prior to paving. Water tanker shall be used, as required, to sprinkle the job site.to keep down dust conditions and shall be used
immediately after backfill. " -
<!. .DE -WATER OPERATIONS: If de -watering operations are required and pumps are forcing water on City of La Quinta roads, itshall be
the responsibility of the permittee (contractor) to control this water and to provide off-street barricades when necessary. "
e CLOSING STREETS: No street shall be closed.'A minimum�of one lane of traffic shall be maintained at all times to provide limited
access for the adjoining property,owners and emergency Vehicles. In the event it is felt bythe permittee that he must close a street for
yany length of time, permittee shall contact this office to obtain the necessary permission.
• y - ' SPECIAL PROVISIONSS`
The follwing shall apply'ONLY'when indicated:
R1 OTIFICATION: Permittee shall notify the City at 564-2246 at least 48 hours in advance of starting construction.
_ R2 CASH DEPOSITS OR BONDS: A cash bond or an approved surety bond in an amount of not less than s
shall be furnished in the name of City of La Quinta to coyer all work involved in the restoration of the various La Quinta
goads and survey monuments. This bond shall be continuous until cancelled by the City Engineer. This bond must be
sted prior to commencement of any work on this project .
r; R3 TILITYCLEARANCE: (Substructures) Prior to making any excavation within the City of La Quinta right of way authorized
Jt .� by permit, the permittee shall contact all concerned utility companies relative to the location of existing substructures.
Damage to existing substructures resulting from operations conducted under this permit shall be thesole responsibility
of the permittee.
+ R4 UTILITY CLEARANCE: (Surface structures) No work shall be done under this permit until all utilities are clear of the '
proposed work site. The permittee shall notify all concerned utility companies of the proposed work.
R5 PAVEMENT WIDENING: Area between the proposed concrete gutter line and the existing road pavement shall be
surfaced with~ inches of A.C. paving placed on 'inches of class aggregate subbase course
having an"R" value of not less than �and incon forma ncewith City ofLaQuinta Road Improvement Standards
and Specifications, Ordinance #461.'
R6 PARKWAY GRADING: Area between the property line and top of the proposed concrete curb shall be graded to a slope of
1/4 inch to one foo[ (1'). ?'
gf R7- GRADES & STAKES: City of La Quinta shall establish grades and stakes for the proposed concrete curb and gutter
• construction. , _
R8 GRADE CHECKING: City of La Quinta shall check grades upon receipt of pian and profile and/or grades as established by
a lirensed engineer., ` `A
a R9 CURB REMOVAL FOR DRIVEWAYS: A portion of the existing concrete curb and/or curb and gutter ( feet) shall be
r removed. Curb and/or curb and gutter shall be saw cut prior to removal. Depressed curb, matching concrete gutter and
concrete driveway approach shall be constructed in conformance with City of La. Quinta Standard #207.
R10 DRIVEWAYS, A.C:: Driveways shall be constructed as not to alter existing drainage pattern. Surfacing between the
property line and the existing road paving shall be 2-1 /2 inches of A.C. paving placed on ( ") of class
aggregate base. Driveway construction shall conform to attached drawing.
R11 CULVERTS: A inch diameter()Culver tshall beinstalled with the invert approximately 1-1/2
inches below and in line with the existing flow line. Culvert installation shall conform to the attached drawing.
' 12 SIGHT CLEARANCE: Sight clearance of 600 feet in either direction shall be assured and maintained.
R13 SOIL STERILIZER: The area to be surfaced shall be treated with soil sterilizer. Rate of application shall complywith the
anufacturer's specifications. '
• y 14 OORDINATE WORK: The proposed work shall be subordinated to any operation ,which the State of California or '
` City of La Quinta may conduct in this `area during the period of this permit. Work shall be coordinated with the State or
! . City of La Quinta forces to preclude delay or interference with State or City of La Quinta projects.
R15 SURVEY MONUMENTS:Prior to excavation or beginning of construction, all survey monuments which exist on the
centerline of all streets or property lines when involved shall be completely tied out so they may be readily and correctly
be replaced by a licensed civil engineer or surveyor,at the expense of the permittee. A complete set of notes showing the'
ties to these monuments shall be furnished to the City Engineer prior to the removal of any rnonuments. This office shall `
be notified upon completion of replacement of all survey monuments for proper project clearance.
• RD -31 K
R16 :Y MONUMENTS: Prior to excavation or beginning of cor ion, all survey monuments shall betied out by City
_ luinta and suitable payment or guarantee of payment _.._.. _ie made as reimbursement for all work involved.
R17 PAVEMENT CUTTING: Pavement will be mechanically cut to a straight edge prior to excavation. Method of pavement
cutting shall be approved through the office of the City Engineer. (Under no circumstances shall excavating equipment
be used to excavate prior to cutting of pavement). Excavation material shall be placed in such a position as to best
facilitate the general flow of traffic. Prior to final paving operations, any damage to pavement straight edge shall be
corrected.
R18 PAVEMENT CUTTING: Pavement shall be saw cut prior to removal. Prior to final paving operations, any damage to
pavement straight edge shall be corrected.
R19 LIMIT OF EXCAVATIONS: Excavations shall be limited to 1.000 lineal feet of open trench before backfill operations must
begin. All excavations shall be properly barricaded with lights overnight, on weekends and holidays for the protection of
the traveling public. The Public Works inspector shall determine the suitabilityof excavation barricading in each case. No
excavation shall remain open for a period exceeding five (5) days. No excavation shall be made unless the construction
material is actually on the work site.
R20 BACKFILL MATERIAL: Backfill shall be free of brush, roots or otherorganic substance detrimentalto its use for purposes
of producing an adequately consolidated backfill. Any material which the City of La Quinta deems unsuitable (spongyor
- saturated material) which is encountered during excavation shall not be used for backfill, but shall be supplemented or
replaced by an approved sand or gravel.
R21 BACKFILL SAND: Backfill shall be approved transit -mix sand or equivalent and shall be placed in lifts of notgreaterthan
three feet (3') and vibrated using vibrotamper or equivalent equipment. Alternate methods maybe substituted, but in any
case a relative compaction of 95 percent shall be attained within the structural section of the roadway.
R22 BACKFILL PLACEMENT: Backfill shall be applied in layers of not more than 50 percent of the total depth of the trench
before flooding or a maximum of f ive-foot (5') lifts where trenches are of excessive depths. Care is to be exercised that the
backfill material is not subjected to extreme swell by flooding operations. Backfill material shall be placed so that the
resulting compaction shall be not less than 90 percent or equivalent to the surrounding ground, whichever is the greater
compaction. Where ponding or flooding is used for a maximum settlement, adequate dikes will be constructed to retain
the water. Where jetting is used, the jets shall be of sufficient length to reach the bottom of each layer and the water,
supply shall be continuous.
R23 COMPACTION TESTS: If so required bythe inspector, compaction tests shall be made at intervalsof not more than 1,000
feet and a minimum of one (1) test on each road. One (1) copy of each test shall be forwarded to the City Engineer for
approval and filed prior to making permanent -repairs. Compaction tests shall be made as outlined in Section 6.3.01 of the
Standard Specifications, Division of Highways, State of California, dated January 1973.
R24 COMPACTION TESTS: If so required by the inspector, compaction tests shall be made for each crossing or service line.
One (1) copy of each test shall be forwarded to the City Engineer for approval and filed prior to making permanent repairs..
Compaction tests shall be made as outlined in Section 6.3.01 of the Standard Specifications, Division of Highways, State
of California, dated January 1973.
R25 TEMPORARY PAVEMENT REPAIRS: After completion of backfill and compaction operations, a temporary patch
consisting of 2 inches of SC -800 shall be placed on a prepared subgrade. The SC -800 temporary paving shall be placed
after a maximum of 3,0001iiieal feet of trench has been excavated and backfill operations completed, but in no case shall
the placement of the temporary pavement exceed a five (5) day limit.
R26 PERMANENT PAVEMENT REPAIR: After backfill and compaction operations have been completed, a temporary patch
consisting of two inches (2") of SC -800 shall be placed immediately. A permanent patch of inches A.C.
surfacing placed on a inch class base shall be placed no later than days after completion of
temporary road repair.
R27 PAVEMENT REPAIR: F.A.S.: Uponcompletibn of backfill and compaction, a temporarypatch consisting of two inches (2")
of cold mix paving (SC -800) shall be placed immediately. A permanent patch of three inches (3") of A.C. surfacing shall
be placed on six inches (6") concrete base as directed, but not later than fifteen (15) days after completion of temporary
paving. Concrete base shall be of five -sack mix and shall conform to the City of La Quinta Road Improvement Standards
and Specifications, Ordinance #461.
R28 FOG SEAL: A fog seal coat consisting of an application of asphaltic emulsion shall be applied over all patch areas as
determined by the City Engineer.
B29 SEAL ARMOR COAT: A seal coat consisting of an application binder and screenings shall be applied on all patch areas
where such seal coats existed prior to issuance of this permit. Seal or armor coats shall be applied as specified in Section
37, Standard Specifications, State of California, Division of Highways, dated January 1973. Work of pavement repair to
be accomplished by a licensed contractor engaged in the business of pavement repair.
R30 STREET RESTRIPING: Where street striping is still visible on streets to be excavated, such striping shall be replaced upon
completion of permanent repairs.
R31 TREE RELOCATION OR REMOVAL: Tree relocation within the City of La Quinta road right of way shall be accomplished
by a licensed, bonded and insured tree service, and handled safely without interference or hazard to the traveling public.
It shall be the responsibility of the permittee to maintain the tree in a vigorous growing condition at its new location.
Trees to be removed shall be removed in sections which can be handled safely without interference or hazard to highway
traffic. The entire width of the tree stump shall be removed and disposed of so that no debris remains in view of the
highway. The stump hole shall be backfilled and thoroughly compacted as specified in the following paragraph. Where it
becomes necessary to restrict traffic, the work shall be restricted to a maximum of 500 feet at any one time. Adequate
signs, flagmen and/or barricades shall be provided to protect the traveling public at all times.
Large holes resulting from tree removal shall be backfilled and compacted to not less than 90 percent or equivalent to the
surrounding ground, whichever is the greater compaction as determined by the impact or field method. Compaction
tests shall comply with Section 6.3.01 of the Standard Specifications, Division of Highways, State of California, dated
January 1973.
R32 TREE TRIMMING:
a. Only the necessary trimming shall be accomplished to provide clearance of the facility for one calendar year.
All broken or weak sections within the trimming shall be removed.
b. Where it becomes necessaryto restrict traffic, the work shall be restricted to a maximum of 500 feet at anyone time.
Adequate signs, flagmen, and/or barricades shall be provided to protect the traveling public at all times.
c. If tree trunks are partially outside of the City of La Quinta road right of way, permittee shall make his own
arrangements with adjoining property owners for consent to the trimming in addition to the authorization provided
by this permit.
d. All tree trimming on EVERGREEN TREES, PALM TREES, and other ORNAMENTAL TREES shall be accomplished to
the satisfaction of the City Public Works Inspector.
e. Abutting property owners shall be contacted, in all instances, prior to trimming or topping trees.
I. Pruning shall, in all instances, be at the shoulder of the crotch to insure even, fast healing in all cuts of two inches
(2") and above in size. Sealant shall be applied to all cut sections as directed by the City Public Works Inspector.
ADDITION- —ENCROACHMENT PERMIT N0:05'22 -----CONDITIONS
R33
be: luce'or.
Survey ,monume*s. shall protected,-..inF
'
re -established -pursuant to City •standards . and .the "State: of.
Califor'nia Lana `Surv,e 'or'.s Act:
R34, -.Work
-shall be coordinated'with the City of La Quinta's ,
forces ;to. preclude`delay .or• interference' with the; City of La, '.
t
Quintal: s projects .
,> R35
Contractor shall comply -with the, :localnoise ordinance. -and
. , t
,
construction,�operations, and, maintenance. of equipmentb within'
one half. mile of -.human, occupancy shall be- performed only
- during the time periods. 'asfollows:.r . s '
October, 1st -,to April 30. Monday -Friday 7:00a.m.-5:3OR•.m. s..
.
w ! Saturday 8:00a -M -,.75 ,:00p. -.m.
` -May'1st
to, September 30: Monday -Friday i6 OOa.m.-7:
ak
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MICHAEL WIEFELS '
255 CAMINO
1• 9 ' ' 1 6
19
BUENA .VISTA".
'
PALM SPRINGS; CA', 92262,
Pa t):the,l�� ry> of �-.4' 3�u;�r;q •
'order
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of .
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Bank
Dollars
of America asA
Palm SP(in9s Main Office 0950
P.O. Box 1507
Springs, CA 92262
.4Palm
'. '.. Memo
1: 1'2,20006r,,, 164611109508 06,2 S
fin•.'
,.
NOTE:
With proper validation'
this form constitutes an CITY OF LAQUINTA
encroachment permit
APPLICATION FOR PERMIT
t_ PUBLIC WORKS CONSTRUCTION.' (ENCROACHMENT)
,y OF
For the construction of public or - private curbs, driveways, pavements, sidewalks; parking; lots, sewers, water mains
and other like public worke.improvements in connection with -MINOR IMPROVEMENTS and APPROVED -SUBDIVISIONS
? /
/no, t. ` Subdivision Improvement Permit — Class lII
DATE: Minor. Improvement Permit Class IV
s SB Washington FS 50th ,
LOCATION OF CONSTRUCTION
(Street address or Descr;pron of Location)
•. ' Transit Shelter -
PURPOSE OF CONSTRUCTION•' Sketch•(attach construction plans if appropriate)-. .
DESCRIPTION OF CONSTRUCTION ahnva
t
DIMENSION OF INSTALLATION OR REMOVAL 'see rawing ,
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK V/ILI. BEGIN
APPPDXIMATE. TIME- Or COMPLETION._
EST111ATED CONSTRUCTION COST $ 110 i 000.
(!r•aluding removal of all obstructon,`inatedals, and debris, backfilling, com-
paction and placing pern'ranent .resurfacing and/or replacing improvements),
In consideration of -the gran:ing'of this permit, the applicant +hereby agrees to:
Ind^.mnify„defend and savt the City, its authorized agents, officers, representatives and employees, harmless from and against any and all
penalties, liabilities or'loss resulting from. claims or court action -and arising out of any,accident_ loss or damage to persons or property
happening or occurrirgIas a proximate result of any work undertaken under the permit granted pursuant to this application:
Notify the Administrative Autnority at least twenty-four. (24) hours in advance of the time when work will be started: ,
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulations of the City of
La Quinta and to pay for any additional replacement necessary as the result of this work:
Signature of Ap lica gent
Sunrise Media 303 N. Indian Ave.' Palm .Spri.ngs, 619-T25 10f/9, ,
Name of Applicant (please print' Business Address Telephone No.
Frank Jones same.as above
Name of Contractor and .Lob Fort:man . � Business Address Telephone No.
_John Sk&a #B=34119.'.
Cori -tractor's. License No. • City Business License No:
Griffith Sincock Nr036.4872
Applicant's Insurance Comperiy Policy Number `
FEES:' -Subdivision Improvement Permit — Class I I I -
Public improvements: 3% of �-stirnated construction costs
Private improvements: 3% of .estimated construction costs
Minor Improvement Perrr;:t.- C1; ss IV: See attaches! schedule
Inspec-Jon-Fee $ '~ PERMIT VALIDATION
'Pert iit Fee PERMIT NO. }
Penalty x
Cash Deposit,Surety Bond DATE APPROVED
# 4if requireo : EXPIRATION DATE
.` TOTAL:
DATE ISSUED,
Raceipt No.
By
Receioed by Date Administrative. Authority
Recorded by TELEPHONE: (619).5664-2246