HomeMy WebLinkAbout062-200-09662-20-96
- 61717-7
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Rock Rd., 0 ' d »-
Jean Mills Tract,lot 3,Berry Creek
ELEC4ZW777 17.
COMPACTION TEST REQ.+ A16
1:� Permit #1761-77MHI
Issu.ed— 0:� - �T - 47
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PERMIT NO. 1640-77E�E
PERMIT EXPIRES
Tom—
i OWNER Sylvester Bazilius
i
CONTR. owner
LOCATION (A.P. 62-20-96 )
E/S Bromilow Lane, app.1200'N.of Bald Rock Rd.;
app. 1000'E.If Jatco Rd., Jean Mills Tract,
lot #3, Berry Creek
de&SS F2onm.- YF-kL-ow Ho,rsi i 42A4
1. Fc aT
Temp. Power Pole
Called PG&E
Temp. Elea. Serv. �' 3-a)
Called PG&E 3-- G�
t
t
Temp. Gas Serv. 6' - 7%)
JOB 7 —7-2
FINALED
(Date
( ignature)
14Z Of �X /1117
A
COUNTY OF BUTTE - DEPARTMENT OF PUBLIC WORKS
BUILDING INSPECTION RECORD
BUILDING A BUILDING (Cont'd) A PLUMBING
befVaCk
F ewall
SaLl Piping
For
Pa ets
1 t Floor
Mai Bldg.
Rest om Finish
2n Floor
Fo tins
Windo
3rd Noor
Stem all
Siding
To out
Slab
Roof Shealibing
Water Pi i
lkg
Piers
Roofing
Sewer
Garage
Fdn. Vents
Fixtures
Footings
Stemwal I
Garage Vents
Insulation
Water Htr.
Heaters
Slab
Carport
Footings V
Prov. forph slcal
handicap ed
Conformance of ex.
structure V
Appliances
Gas Piping & Test
Temp. Gas
Slab
Final
Sanitation
Patio
REP ACE
Final
Footings
I Footing
I ElIECTRIAL
Mesh
Fixtures
Se
Pole
Interior Lath
ntilation
Permanent
oor Closer
anal
inal
MOBILEHOME UTILITIES ------------------ Elec. Service
—
Elec. Pedestal �'--
Water Piping -- r a^
Sewer
�'�, �,,
Gas Piping
E MEINSTALLATION --------------Support
-- —72 4—�
Elec. Continuity 7 _
Water Piping
Drainage
Gas Piping
DATE l 6 7%
REMARKS OR CORRECTIONS
'Po 14 7D
cv94k: L-
&,Pel '�� ` N6 54fP AO 6Z,k P
(NOTE: An entry must be made on this form each time you visit the job site.)
• COUNTY OF 'BUTTE — DEPARTMENT OF PUBLIC WORKS
7 County Center Drive — OroviIle, California 95965
Telephone: 534-4541 (
APPLICATION AND PERMIT
-- �r•���•••�••��� . � vW—Ity — uu — c Ln l uNvn LIIc
above-mentioned property for inspection purposes.
X l%V— -I_ nate i ' �77
Sil;_ ature of Pe``r��mitee or Agent
01
Receipt No. ,& i1 74-1
White-D.P.W. — Yellow -Assessor — Pink -Inspector — Goldenrod -Applicant
This permit is hereby issued under the applicable provisions of
the Butte County Code and/or resolutions to do work indicated
above for which fees have been paid.
Yi
DIRECTOUelF PUBLIC WORKS
rui
ateing permit expiresDate 6-3-7
BUILDING
Owner €x
SQ. F'r. OCC. BUILDING VALUATION
Mailing Addr ss �O
7/ S
Tele hone No.
Fireplace
Contractor
Total Valuation
Mailing Address
Permit Fee
Plan Checking Fee &/or Penalty
Telephone No.
Permit Fee
Building Address �/
Pl O ��
PLUMBING No. @ FEE
PERMIT FILING FEE $3.00
i f7/C Cc "/C� DO / G ,. %�
Each Trap 1.50
O' C ���
Repair drainage or vent piping 1.50
Water piping 1.50
Each gas water heater or vent 1.50
A. P. No.Z
oning & Planning
Gas piping system 1 - 5 outlets 1.50
Each additional outlet .30
F s I
Vil. I
Sartita"fr
I Fire Dept.
Fire Zone
Use Permit
Building sewer 5.00
EQA
Parking
Plans
Parcel
Declaration
Parcel Ma P
60' R/W
Improvements
P
Lawn sprinkler system 2.00
P:1
Bldg. Plans Rk1___
Parcel oval
Plan provaI
Permit Fee $
NEW ❑ ADDITION ❑ UTILITIES ❑ OTHERELECTRICAL
No. @ FEE
PERMIT FILING FEE $3.00
`
/ D/d 5%Q-7 7
Main service 100v OR LESS 5.00
100 AMP OR LESS
Main service EA. ADD'L 100 AMP 2.50
Main service OVER soov 25.00
100 AMP OR LESS
Single Family ❑ Duplex ❑ Mobil Home Others ❑
Main service EA. ADD•L 100 AMP 1.00
NEW OR ADONST ( ACCLBLDGS.LING OCCUP. &) 20sgft
NEW CONSTR. MULTI -OUTLET
NON.RESID. ( BRANCH CIRCUITS) 2.50ea
NEW CONSTR. POWER APPARATUS &
NON.RESID. (SINGLE OUTLET CIR.
CONTRACTORS LICENSE LAW
I am licensed under the provisions of Chapter 9, Div. 3, of the
State of California Business & Professions Code under the name
st le of:
Y
Ex. Occup(OUTLETS OR FIXTURES) BAL@1¢09
Ex. Occu FIXED APPLNS. OR
P• OUTLETS (RESID.) EA) 2.00
Temporary service 10.00
Mobile Home Facilities 15.00
License No. Classification
Misc. Wiring 6.25
I am exempt from the Contractors License Laws of the State of California.
Permit Fee $
WORKMEN'S COMPENSATION INSURANCE
1 am aware of the provisions of Section3700 of the California Labor
Code which requires every employer to be insured against liability
for Workmen's Compensation.
❑ I have placed on file with the County of Butte a certificate of
Workmen's Compensation Insurance.
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 Workmen's Compensation Laws of
California.
MECHANICAL No. @ FEE
PERMIT FILING FEE $3.00
Heating
Cooling
Ventilation
Hood 2.00
Permit Fee $
$
1 certify that I have read this application and state that the above
information is correct. I agree to comply to all County Ordinances
and State Laws relating to building construction, and hereby
d7%
TOTAL PERMIT FEE
OI
-- �r•���•••�••��� . � vW—Ity — uu — c Ln l uNvn LIIc
above-mentioned property for inspection purposes.
X l%V— -I_ nate i ' �77
Sil;_ ature of Pe``r��mitee or Agent
01
Receipt No. ,& i1 74-1
White-D.P.W. — Yellow -Assessor — Pink -Inspector — Goldenrod -Applicant
This permit is hereby issued under the applicable provisions of
the Butte County Code and/or resolutions to do work indicated
above for which fees have been paid.
Yi
DIRECTOUelF PUBLIC WORKS
rui
ateing permit expiresDate 6-3-7
1. Owner's name:.
2. Installer's name:
T ..1 t .•
BUTTE COUNTY DEPARTMENT OF PUBLIC WORKS
7 County Center Drive, Oroville, CA.
PHONE: 534-4541
MOBILEHOME INSTALLATION SHEET
0
MAN
0
3.
Is the site currently under permit? Yes ZZ No
(If yes, furnish permit number�L —7,7
) OR
Is the site an existing site? Yes / / No
/ f/
(If yes, furnish two (2) plot plans.)
4.
r
Will the mobilehome be located at least 5 ft. away from
septic tank
and -leach fields and
clear of all setbacks and easements? Yes / / No
( If no, clarify
`�
)
`
_
_.. .: r _"'". _••"... '�.....,-'� �.` -,mow.{ Y _ � -�-.ry-.�,...,,,,,,•45.,,� _ �..F�+^"- !��"' ��..f
� .._-_..... � - _ ., _ _ � .T
5.
What is the mobilehome electrical rating? -----------------------
Amps
6.
What is the mobilehome site service rating? ---------------------
Amps
7.
What is the mobilehome site circuit breaker rating? -------------
2 Amps.
8.
Is there any other electric.load to be served by the mobilehome
site service? --------------------------------------------------- Yes No /-
( If yes, identify the Toad and s'ize:1��6
_T 54 n� � (Load) /L (Amps)
P )
9. What is the mobilehome site -gas pipe,size?---------------------- (in,)
y v14
10. _-Wha.t_.i _.th
-- - s e.�_type of��gas' .service? ----=-------=---
11. What is the gas pipe length from meter or tank to the mobilehome? (ft.)
12. What is the.mobilehome gas demand? ------------------------------ (BTU)
(This information not required if pipe length less than 6 ft. on natural gas •-
or less than 50 ft. on LPG.)
k) .
f
MOBILEHOME SUPPORT DATA -
Mobilehome Mfr. �,Z�n� l y a Setup Model No. Year / 9 ��,P
Width f p (ft.) Length -5-3 (ft.) Expando Size t.x ft.
(Draw support details below)
On all mobilehomes manufactured after October 7, 1973, furnish manufacturer's installation
manual and structural setup sheets (if not on file with the County of Butte).
S is
� d
Center enter Support
Support noting Sizes
Locations (in.)
i
'n.)x i,,..
`
A �
ft) (in)(in.
) ,)
i
I
f
-01
X
( n.)(in.)
f
;
(ft. in.)
(in.)(in.) a
*If center piers are other than drawn above,
draw in locations,_spacing, and dimensions.
D. Footings (check one)
1. Wood either
pressure treated or
fdn. grade.
f 2. Concrete pad.
3. Other, specify'
/Supports (check one)
/tT 1. Concrete block
2. Concrete piers
3. Steel piers
4. Other, specify
Typical Support
.x J Footing Size
Max. Pier
(ft.) (`j�ri�) Spacing
- IMax.
Overhang
Aij-(13'n-� )
BUTTE COUNTY
BUILDING DEPAPTMv NT
APPROVED
~COUNTY OF r3UTTG — DEPARTMENT OF PUBLIC WORKS
7 County Center Drive — Oroville, California 95965 /
Telephone: 534-4541 14
APPLICATION AND PERMIT
-^ .v'.�vv..n.uu v...a i uIc V-. y V UUllc lu vmul UFJUII UIC
above-mentioned property for inspection purposes.
d
X �� ,�,=tea ,mate
5ignoture of Permitee or A e _
Receipt No. pp/v v 71
White-D.P.W. IiAs&r _ ,A n�tr�
coldenrod-Applicant
(� f
This permit is hereby issued under the applicable provisions of
the Butte County Code and/or resolutions to do work indicated
above for which fees have been paid.
DIRECTO0`F PUBLIC WORKS
By Date /-/— / L(` 77
ilding permit expires Date �t
BUILDING
Owner ���
SQ. FT. OCC. BUILDING VALUATION
Mailing Address geo Te,
1,,Ielephone
No.
Fireplace
Contractor
Total Valuation
Mailing Address
Permit Fee
Plan Checking Fee &/or Penalty
Telephone No.
Permit Fee
Building Address °PLUMBING
��� 01i
No. @ FEE
PERMIT FILING FEE J$3.00
Each Trap 1.50
/lam
' U
Repair drainage or vent piping 1.50
Water piping
11-11115-er_tnn1g Veri(cafion Only
A. P. No. Z-- �® -• �Zo n
Each gas water heater or vent 1.50
Gas piping system 1 - 5 outlets 4-rw 16,
Each additional outlet .30
F s
Fire Dept.
Fire Zone Use Permit
Building sewer {.9p
EQA
I Parking
Pla
Parcel
Declara 'on
a0el a P
60' R/W
Improvements
P
Lawn sprinkler system 2.00
Bldg. Plans Rec'd
Poic oval
Plan pprovol
Permit Fee $ 3
G
NEW ❑ ADDITION ❑ UTILITIES OTHER ❑
ELECTRICAL No. @
PERMIT FILING FEE $3.00Main
MEE
service 10000 AMP ORSLESS 5.00Main
service EA. ADD'L 100 AMP 2.50
Single Family ❑ Duplex ❑ Mobil Home Others ❑
Main service OVER 600V 25.00
100 AMP OR LESS
Main service EA. ADD'L 100 AMP 1.00
NEW CONST. DWELING
OR ADDNS. ( ACCLBLDGSO.CCUP. &) 20sgft
NEW CONSTR. MULTI.OUTLET
NON-RESID, BRANCH CIRCUITS) 2.50ea
NEW CONSTR. POWER APPARATUS &
NON-RESID. (SINGLE OU ET CIR,
CONTRACTORS LICENSE LAW
I am licensed under the provisions of Chapter 9, Div. 3, of the
State of California Business & Professions Code under the name
style of:
g d
I
a?46iS(
OF
Ex. Occup(OUTLETS OR FIXTURES)50 @259!
109
Ex. QCCU // FIXED APPLNS. OR
P• ( OUTLETS (RESID.) EA) 2,00
Temporary service 10.00
Mobile Home Facilities 15.00
License No. Classification
Misc. Wiring 6.25
I am exempt from the Contractors License Laws of the State of California.
Permit Fee $
$
WORKMEN'S COMPENSATION INSURANCE
1 am aware of the provisions of Section3700 of the California Labor
Code which requires every employer to be insured against liability
for Workmen's Compensation.
❑ I have placed on file with the County of Butte a certificate of
Workmen's Compensation Insurance.
1 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 Workmen's Compensation Laws of
California.
MECHANICAL No.1 @ FEEPERMIT
FILING FEE $3.00
Heating
Cooling
Ventilation
Hood 2.00
Permit Fee $
$
1 certify that I have read this application and state, that the aboveL
information is correct. I agree to comply to all County Ordinances
and State Laws relating to building construction, and hereby
, Q(
TOTAL PEMIT FEE d
$
-^ .v'.�vv..n.uu v...a i uIc V-. y V UUllc lu vmul UFJUII UIC
above-mentioned property for inspection purposes.
d
X �� ,�,=tea ,mate
5ignoture of Permitee or A e _
Receipt No. pp/v v 71
White-D.P.W. IiAs&r _ ,A n�tr�
coldenrod-Applicant
(� f
This permit is hereby issued under the applicable provisions of
the Butte County Code and/or resolutions to do work indicated
above for which fees have been paid.
DIRECTO0`F PUBLIC WORKS
By Date /-/— / L(` 77
ilding permit expires Date �t
i• '� `CL I H StanCaro CovErage Pokey
Copyright — 1974
J
SCHEDULE B
This policy does not insure against loss or damage, nor against costs, attorneys" fees or expenses, any or all of what arise by
reason of the following:
Part One:
1. Taxes or assessments which are not shown as existing liens by the records of any taxing authority that levies taxes or
assessments on real property or by the public records.
Proceedings by a public agency which may result in taxes or assessments, or notices of such proceedings, whether or
not shown by the records of such agency or by the public records.
2. Any facts, rights, interests or claims which are not shown by the public records but which could be ascertained by an
inspection of.the land or by making inquiry of persons in possession thereof.
3. Easements, liens or encumbrances, or claims thereof, which are not shown by the public records.
4. Discrepancies, conflicts in boundary lines, shortage in area, encroachments, or any other facts which a correct survey
would disclose, and which are not shown by the public records.
5. (a) Unpatented mining claims; (b) reservations or exceptions in patents or in Acts authorizing. the issuance thereof;
(c) water rights, claims or title to water.
6. Any right, title, interest, estate or easement in land beyond the lines of the area specifically described or referred to
in Schedule C, or in abutting streets, roads, avenues, alleys, lanes, ways or waterways,but nothing in this paragraph
shall modify or limit the extent to which the ordinary right of an abutting owner for access to a physically open
street or highway is insured by this policy.
7. Any law, ordinance or governmental regulation (including but not limited to building and zoning ordinances) restrict-
ing or regulating or prohibiting the occupancy, use or enjoyment of.the land, or regulating the character, dimensions
or location of any improvement now or hereafter erected on the land, or prohibiting a separation in ownership or a
reduction in the dimensions or area of the land, or the effect of any violation of any such law, ordinance or govern-
mental regulation.
8. Rights of eminent domain or governmental rights of police power unless notice of the exercise of such rights appears
in the public records.
9. Defects, liens, encumbrances, adverse claims, or other matters (a) created, suffered, assumed or agreed to by the in-
sured claimant; (b) not shown by the public records and not otherwise excluded from coverage but known to the
insured claimant either at Date of Policy or at the date such claimant acquired an estate or interest insured by this
policy or acquired the insured mortgage and not disclosed in writing.by the insured claimant to the Company prior
to the date such insured claimant became an insured hereunder; (c) resulting in no loss or damage to the insured
claimant; (d) attaching or created subsequent to Date of Policy; or (e) resulting in loss or damage which would not
have been sustained if the insured claimant had been a purchaser or encumbrancer for value without knowledge.
Part Two:
1. General and Special Butte County taxes for the fiscal year 1976--1977;
1st installment - paid; 2nd installment - unpaid.
2. A Road Maintenance Agreement executed by Rex Se Ashauer recorded
October 7, 1976, in Book 2109, of Official Records, at page 498.
For further particulars, reference is hereby made to said document.
3. An easement for road and public utility purposes as conveyed to
Rex Ashauer, a single man and John H. Bromilow and Georgia M.
Bromilow, husband and wife, by instrument recorded December 7, 19761
in Book 2126, of Official Records, at page 44.
4, Easements and set bac': lines as shoran on said Parcel t.'ap referred
to herein.
5. A non-exclusive easement for road and public utilities purposes as
reserved.in the deed from Rex Ashauer, a single man to Sylvester
Bazilius and Genora A. Bazilius, his wife, as Joint Tenants recorded
February 10, 1977 under Butte County Recorder's Serial No. 25268.
t
I
�.f Form No. 1056.4 _
All Policy Forms `
SCHEDULE C
The land referred to in this policy is situated in the State of California County
of Butte and is described as follows:.
A portion of hot 3,.as shown on that certain t-fap entitled, "JEAN MILLS
TRACT", which Mp. was filed in the office of the Recorder: of the
County of Butte, S.tate.of California, August 4, 1966, in Book 34 of
Pups, at page '4.9', ..more particularly described as follotrs:
arcel 1 as shown on .that certta.in.Parcel Map recorded in the office.of
the Recorder of the County o£ -Butts, State of -California, on December 7,
1976, in Book 60of Parcel.. claps, at pages 19 and 20..
TOGETHER WITH a .non.-exclusive.right of way for road and public utility
purposes 60.feet:in width -along the existing road, beginning on Bald
Rock Road and ending at the Southwest corner of the above described
parcel of land.
ALSO TOGETHER WITH a: nonexclusive easement for road and public.utility
purposes 60 feet in with as shown on said Parcel Map.
0
I
�;cL.ic1S
Cd C'���Arf�vG�
1
1
COUNTY OF BUTTE
DEPARTMENT OF PUBLIC WORKS 7 COUNTY CENTER.DRIVE
OROVILLE, CALIF. - 534-4541
CERTIFICATE OF OCCUPANCY
This mobilehome has been installed in accordance with the Arequirements
of the C ifo nia Administrative Code, Title 25, C apter 5, up der permit
number '- for the following location: 1 132o/h�cy
iAPJ*- SC l. -b ' a/ o f ��� & cIC R6.. %3 !C
Owner --,q11, (/ESrff/, Ba :21 Q'45
Owner's Address 6-20 5Q.. 91V,45774 f,<I>'k&ws (2/4
Mobilehome Mfg. aAMe/VC ® Model --g -- Ye
Insignia No. _ %V4 Serial No. Z /— '?0 1
It is hereby certified for occupancy at the above described location and
may be occupied.
Direc of Publi Wor
�q f
Date By
THIS CERTIFICATE IS VOID WHEN MOBILE OME S RELOCATED
�-� ,�,�,-,,,r.y #;; ••r':Cw �.1,c .'-�^-,Y.s�-r� .,,wr,h ask
COUNTY OF BUTTE
DEPARTMENT OF PUBLIC WORKS 7 COUNTY CENTER DRIVE
OROVILLE, CALIF. - 534-4541 `
CERTIFICATE OF OCCUPANCY
This mobilehome has been installed in accordance with the requirements
of the California Administrative Code, Title 25, Chapter 5, •under, permit
number��41i - '7-) for the following location: L/5 d20.a1C,4�--i-A
Owner .AVL. UES7"�/L � :21 L1L
Owner's Address 6-20 50, x/-645 /74 w14 4&dS 0
Mobilehome Mfg. t- L ArhrNC�V() Model Year
Insignia No. %y4 Serial No.,� �•>`��Q
It is hereby certified for occupancy at tO*above described location and
may be occupied.'
Director of Publi64orks r
Date
By
THIS CERTIFICATE IS VOID WHEN MOBIL HOME IS RELOCATED
i
r
bi0}31i,ia}O:t.l: IIVSI'ALLATION INSPECTION CHECK LIST
1. Is the mobilehome locatc,il.wii_h equired separation from lot lines and buildings and generally
conform to plot plan? Yes _ No
2, Does the mobilehome have re uired clearances above L/
q ground. (Sec.5085) Yes No
3. Are foot'in,;s and supports properly sized, spaced, and braced as per pproved plans?
possible variation at spring shackle -s.) (Sec. 50 & 5083) YesNo_
4. Is the mobilehome level.? (Sec. 5088) Yes
4fee-
5Ae
than a single unit, are crossover connections properly installed? (Sec.j508.8)
sNo
(Note
5. Water f
b
A. Is fle _ble connector of adequate size and properly installed (1/2" ID min.)? (Sec. 5566)
Yes No
B. Test - Does. water piping withstand working pressure or 50 lbs, air test? Yes .'I No
C. Backflow - If coach is not State<No
alifornia approved, does station have backflow device
and pressure -relief valve? Yes
7. Wastes and Drains
A. Is connection made with Schedule 40 DWV and have flex connectors at each end? Yes- /No_
'B. Does it have minimum z;" per foot slope and is it properly supported? Yesdl-No
C. Are any leaks detected in -drainage system after running 3 -gallons of water through each
fixture including washing machine standpipe? Yes No
D. If coa is not State of California approved, does station have required trap and vent?
Yes No
8. Gas Piping and Gas Vents
A. Connector - Is mobilehome connected to the gas supply with an approved 3/4" minimum
mobilehome connector not more than 6 ft. long? Note: All piping is to be at least as
large as the mobile' me gas line inlet without;reductidns other than the mobilehome
connector. Yes No
B. Test OK as per following procedure? Yes_ �,No ,
Open all appliance connector valves. j
Shut off appliance burner and pilot valves.
Air test with manometer to 10"-14" water column, or test with slope gauge (minimum
6oz.-maximum 8 oz.) calibrated in tenth pound increments. Test for 10 min, without
drop.
�Cornect: gas meter to mobilehome with connector, turn. on gas, test connections with
soapy water.
C. Are all appliance vents properly installed? Yes sf No
9. Electrical.
A Is service large enaugh to provi ' ,adequate amperage to mobilehome (must equal rating of
mobilehome (aith a ::;i_nij;:um of amp) and other facilities on lot, i.e., water pumps,
garage, cabana, etc.? Yes_ No
l;. Is thea ;roper. clearances around panels? Yes No_
No
C. Is power supply cord or feeder assembly properly fused? Yes_
D. Is continuity test satisfactory as per the following procedure? Yes_ No_
-energize electrical wiring, system of the mobilehome at the pedestal.
'
v� 2. Make sure that t'ne power supply cord or feeder assembly conductors, including neutral
conductor, have been disconnected.
3. Switch all breakers and switches in the mobilehome to the "on" position.
4. Connect one 1, -,ad of a test instrument to the mobilehome grounding conductor and
apply rite Otuei IAL'au %u cavil Iliuul.�CUWue Sri t CunurictGr, iliCluUlitg YLC�1Lrdt.
;9
.. -,/All nor. -current, carrying metal parts of the mobilehome (aluminum siding, gas line,
w.iter line), including fixtures and appliances, shall be tested for continuity from
such equipment and the grounding conductor.
6. Upon corrpleticn of the above procedure, the power supply cord or feeder assembly
conductors shall be connected to the site service equipment. A further continuity
te=;L :shall then be made between the ;rounding electrode and the chassis of the
cibilehome. Upon satisfactory completion of the electrical tests, the lot or site
ci.
service equipment may be approved for energizing.
;.ri, Is job card si-ned by tlealth Departmeat for water and sanitation?
1.1.. If everything okay, sign off card and- ta; services.
MOBTLEilO L•' DATA _
Manufacturer and/or Namest:yleI/�U'��?(�
Length_ Width L
Vehicle Serial No.
State Identification No. 1 -V -A
i
A dd L t Tonal Information or/6onunent s :
Y �.