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HomeMy WebLinkAboutABAN 97-01_PLANNING � IN� � IY � IAWIV��VIVU� An SEPARATOR SHEET Z (9 - Zl2 - 066 APN PROJECT NUMBER I , PROJECT SUMMARY SHEET 3 I , FILE#: ABAN 97-01 PROJECT TYPE: Abandonment APPLICANT: Robert W.Pike ADDRESS: P.O.Box 784 Palermo CA 95968 OWNER: ADDRESS: REPRESENTATIVE: I ADDRESS: PROJECT DESCRIPTION: Abandonment of portion of Hewitt Avenue Right of Way PROPERTY ZONED: LOCATED: Hewitt Ave.between the north right of way line of South Villa Ave.and the j South right of way line of Ludlum Ave. AP#: TOWN/AREA: Palermo GENERAL PLAN DESIGNATION: 1. Application complete: Amount: $ Receipt#: 2. Comments sent to: 3. Comments received from: 4. Rezone Petition Signatures Checked: 5. Mailing List/Lead-in Sheet: 6. Assigned To: 7. Environmental Determination: State Clearinghouse No: Categorical Exemption-CEQA# Negative Declaration Mitigation Negative Declaration Subject to Fish&Game: Environmental Impact Report Gen.Rule Ex.-CEQA#15061.(bx3) Other 8. Staff Report: Project Video: Release to publish: 9. Clearinghouse circulation required: Yes No Date Sent to SCH: 10. Publication Notice Written: Display Ad Prepared: 11. Notices Mailed: Number of Notices: 12. Newspaper Publication Date: / O C P G B R 13. Planning CommissionHearing(s): �,�a_ ������ /14- Action taken: Special Conditions: Commission Resolution No. n 14. Board of Supervisors'Hearing(s): Action taken: C, U ! Board Resolution No.: Ordinance No: Adopted: 15. Type Use Permit/Send for signature: 16. N.O.E./N.O.D./APPENDIX G: AUG 18 W Fish&Game Fees Paid: Yes No 17. Send validated Use Permit: 18. Assessor's Memo: 19. Copy of Use Permit/Variance to Planning Technician: i �.,, 97-247 Public hearing - abandonment of a public right-of-way, Palermo area - proposed is the abandonment of a public right-of-way in 'the Palermo area, the portion of Hewitt Avenue lying between South Villa Avenue and Ludlum Avenue - 'action requested - ADOPT RESOLUTION APPROVING ABANDONMENT AND AUTHORIZE THE CHAIR TO SIGN. (FROM 7-8-97) (2232) MOTION: Z MOVE TO ADOPT RESOLUTION 97-106 APPROVING THE ABANDONMENT AND AUTHORIZE THE CHAIR TO SIGN. S M VOTE: 1 Y 2 Y 3 Y 4 Y 5 Y (Unanimously Carried) BUTTE COUNTY BOARD. OF SUPERVISORS MINUTES - Augus=t 12, 1997 Robert W. Pike -Abandonment of a public right-of-way fora portion of the-Hewitt Avenue easement located between Ludlum Avenue and South Villa Avenue, Palermo, zoned AR-MH-1. (SB) (File ABAN 97-01) Commissioner Mooney asked if all 60 feet would be abandoned? Craig Sanders said that would be correct. He said the Assessor's Office splits the easement down the middle between the two properties. I Commissioner Leland questioned the use of the extension to the north and south in the future. , Mr. Sanders said the extension to the north has already been abandoned and the extension to the south is used for residential purposes. The item was opened to the public. Robert Pike said that this strip was the only piece for 8 blocks that has not been abandoned. The item was closed to the public. - It was moved by Commissioner Leland, seconded by Commissioner Mooney, and unanimously carried to approve the consent agenda as follows: Robert Pike -Abandonment: Find the application for abandonment of a portion of Hewitt Avenue in conformity with the Butte County General Plan and approve the abandonment with the following condition: 1. Reserve'in the resolution approving the abandonment an easement for public utility purposes over the property being abandoned. 0 Butte County Planning Commission Minutes-June 12, 1997 ❑. Date+ 09/03/97 development Services Depart ent Time 11:11 am Applicant Billing Worksheet Page 1 ABAN 97-01 * Robert W. Pike P.O. Box 784 Palermo, CA 95968 In reference to : Abandonment, Portion of Hewitt Avenue R-O-W Rounding : None Full Precision : No Last bill / / Last aging Last charge 06/12/97 Last payment / / Amount $0.00 Date/Slip# Description HOURS/RATE AMOUNT TOTAL 05/19/97 Larry P. / P 1.00 59. 00 #11670 Processing 59.00 05/19/97 Lynn R. / C 1.00 45.00 #11682 Clerical 45.00 05/19/97 Teri B. / C 0.50 17.00 #11683 Clerical 34.00 06/02/97 Lynn R. / C 1. 75 78. 75 #11780 Clerical 45 .00 TOTAL BILLABLE TIME CHARGES 4.25 $199. 75 TOTAL BILLABLE COSTS $0.00 TOTAL NEW CHARGES $199. 75 PAYMENTS/REFUNDS/CREDITS 08/27/96 Deposit - PW Receipt #178180 (50.00) TOTAL PAYMENTS/REFUNDS/CREDITS ($50.00) NEW BALANCE New Current period 149. 75 TOTAL NEW BALANCE $149. 75 TTFoDepartment of Pu lic Works / ° ° C o u n t y o f B u t t e o o ;� J. Michael Crump, Director 7 County Center Drive Oroville,CA 95965 Ronald D.McElroy,Assistant Director (916)538-7681 UN s Y (FAX)538-2140 ttc w August 22, 1997 Robert W. Pike P.O. Box 784 Palermo, CA 95968 Re: Abandonment, Portion of Hewitt Avenue,Palermo (262.008) Dear Mr. Pike: On August 12, 1997, the Board of Supervisors adopted Resolution No. 97-106, abandoning the portion of Hewitt Avenue lying between South Villa Avenue and Ludlum Avenue. A copy of the recorded "resolution is enclosed for your file. Also enclosed is a copy of the filed Notice of Exemption, along with a plat delineating the subject area. At one time you also provided us with a second check for the $25.00 filing fee. The check is being returned. If you have any questions, please call at your convenience. Sincerely, Mike Crump Director of Public Works Ronald D. McElro. Assistant Director RDM/lt cc: Surveys Planning Division, w/o enclosures Planning Division Attn: Lynn Richardson AUG [ 5 .1991 Oroville,California C:� FM,.X .1�.+��i � '�J�I!�Tidy • I' 'a�.� ECLARATION OF FEES DUE (Calrnia Fish and Game Code Section 7 .4) i oI L ER r D NAME AND ADDRESS OF APPLICANT AUG 19 1997 Robert W. Pike CANDACE J.GRUBBS.Butte Co.Clerk P.O. Box 784 13y C. :-MALL Deputy Palermo, CA 95968 FILING NO. CLASSIFICATION OF ENVIRONMENTAL DOCUMENT: 1. NOTICE OF EXEMPTION/STATEMENT OF EXEMPTION (X) A. Statutorily or Categorically Exempt $25.00 Clerk's Documentary Handling Fee ( ) "B. De Minimus Impact - Certificate of Fee Exemption $25.00 Clerk's Documentary Handling Fee 2. NOTICE OF DETERMINATION - FEE REQUIRED ( ) A. Negative Declaration $1,250 State Filing Fee $25.00 Clerk's Documentary Handling Fee ( ) B. Environmental Impact Report $850 State Filing Fee $25.00 Clerk's Documentary Handling Fee 3. ( ) OTHER(Specify) $25.00 Clerk's Documentary Handling Fee PAYMENT /NON-PAYMENT OF FEES: 1. (X) PAYMENT: The above fees have been paid. See attached receipt(s). #15225 2. ( ) NON-PAYMENT: The above fees are required. Not paid. Chief Planning Official By: Craig Sanders Title: Senior Planner Lead Agency: Butte County Department of Development Services Date: Aught 18, 1997 TWO COPIES OF THIS FORM MUST BE COMPLETED AND SUBMITTED WITH ALL ENVIRONMENTAL DOCUMENTS FILED WITH THE BUTTE COUNTY CLERK'S OFFICE. THREE COPIES OF ALL NECESSARY DOCUMENTATION ARE REQUIRED FOR FILING. ALL APPLICABLE FEES ARE DUE AND PAYABLE PRIOR TO THE FILING OF ANY ENVIRONMENTAL DOCUMENT WITH THE BUTTE COUNTY CLERK'S OFFICE. MAKE CHECKS PAYABLE TO THE COUNTY OF BUTTE. j:uinda\noe.nod\f&gfee APPENDIX A NOTICE OF EXEMPTION TO: _ Office of Planning and Research FROM: Butte County Planning Division 1400 Tenth Street, Room 121 7 County Center Drive Sacramento, CA 95814 Oroville, CA 95965 X County Clerk County of Butte . 25 County Center Drive Oroville, CA 95965 Project Title: Abandonment of Public Right-of-Way, File #ABAN 97-01 Assessor's Parcel No.: Applicant: Robert W. Pike Project Location-Specific: a portion of the Hewitt Avenue easement located between Ludlum Ave. And South Villa Ave Project Location-City: Palermo Project Location-County: Butte Description of Nature, Purpose and Beneficiaries of Project: Abandonment of a portion of Hewitt Avenue Right of Way Name of Person or Agency Approving Project: Butte County Board of Supervisors Exempt Status: !Check (One) Ministerial (Sec. 15073) Declared Emergency (Sec. 15071(a)) Emergency Project (Sec. 15071 (b) and (c)) X Categorical Exemption. State type and section number: 15305 (d) Reasons why project is exempt: Abandonment of Public Utility or Road Easements and Rights-of-Way. Contact Person: Steve Betts Telephone: (916) 538-7601 If filed by applicant: 1. Attach certified document of exemption finding. 2. Has a notice of exemption been filed by the public agency approving the project? Yes No Date Received For Filing: Signature raig Sanders Senior PI nner j:\linda\noe.nod\noe.abn :7. DATE RECEIPT TOTAL PUBLIC LAFCO USE VARIANCES PUBLIC ZONING ENV OTHER APPLICANT RECEIVED FRC No. Racalvao WORKS PERMITS DOCUMENTS HEALTH RECEIPT 15225 OFFICIAL RECEIPT COUNTY OF BUTTE STATE OF CALIFORNIA OFFICE OF PLANNING • ISSUED BY AGENT ISSUER TfgMers Express Money Order C) >_ CREDIT UNION ' 369 1514 242 W falTRAVELERS EXPRESS COMPANY INC.-DRAWER • 's O P.O.BOX 9476.Ml7jaMN 65480 rG DATE 3 76-53 PAY TO THE 919 < OR ER 3—tIrl-e. ca4wrl -Reco)edel? z -NOT VAUD FOR OVER ONE THOUSAND US.DOLLARS- C) THE-S ' CTS Z AMOUNT UM2 5 DOLLARS P yaw, tr SIGNATURE !aM ADDRESS I IS 9. tff "141:TOTHE SEEIVICE 4 z 5, 1:091900533o: 369 L5142428ul 90 • • OuTrl�o o o � INTER-DEPARTMENTAL MEMORANDUM o 0 PUBLIC WORKS DEPARTMENT o 0C-_�► o oIUD N't TO: TERI BRIDENHAGEN, PLANNING DIVISION FROM: RON McELROY, PUBLIC WORKS SUBJECT: ABANDONMENT, PORTION OF HE AVENUE, PALERMO (PIKE) (262.008)(PLANNING FILE ABAN 97-01) DATE: AUGUST 12, 1997 On this date the Board of Supervisors, under Agenda Item 5.03, approved the abandonment of a portion of Hewitt Avenue, in Palermo. At your early convenience please prepare and file the Notice of Exemption for the abandonment. A check from Robert Pike, in the amount of $25.00, is attached for the filing fee. Please provide us a copy of the filed Notice of Exemption. Upon receipt, a copy of the recorded Resolution of Abandonment will be transmitted for your file. Plaa"hing Division AUG 1 11997 Oroville,California ct • AGENDA REPORT TO: Honorable Chair and Planning Commission FROM: Department of Development Services, Planning Division DATE: May 14, 1997 REQUEST: Abandonment of a portion of Hewitt Avenue Right of Way: This is a request to abandon a public right-of-way for a portion of the Hewitt Avenue easement located between Ludlum Ave. and South Villa Ave., Palermo, in an area zoned ARMH-1. This project is located in Supervisorial District 1. RELATED ITEMS: None FOR: Planning Commission Meeting of June 12, 1997. SUMMARY: This is a report for the abandonment of a portion of the Hewitt Avenue public right- of-way. State law requires that the Planning Commission find that the abandonment will not be in conflict with the General Plan. Staff recommends approval of this request. ANALYSIS: This project is a request to abandon a portion of the Hewitt Avenue public right-of- way, located between Ludlum Ave. and South Villa Ave. in Palermo. A street has never been constructed on this portion of the Hewitt Avenue right-of-way and it currently open space. An elevated power line is located in the right-of-way. Dwelling units are located on the northwest, northeast, and southeast sides of the right-of-way. The Hewitt Ave. easement to the south appears to have already been abandoned because the adjacent property owners have fenced it off and are using it as their own property. However, the Department of Public Works does not show this portion of Hewitt Ave. as being officially abandoned. The Hewitt Ave. right-of-way to the north has been abandoned and is being used as a portion of a public park. Because the Hewitt Ave. right-of-way to the north has been abandoned, and the right-of-way to the south is not used for road purposes, it is reasonable for the Hewitt Ave. right-of-way between Ludlum Ave. and South Villa Ave. to also be abandoned. The loss of the right-of-way will not impact vehicle traffic because vehicles do not currently use the right-of-way. It appears that little, if any, people use the right-of-way as a path between Ludlum Ave. and South Villa Ave. There is a recorded easement for the Hewitt Ave. right-of-way reserving access for public services, such as sewer and water lines, and power and telephone lines. A condition of this abandonment will require the public utilities easement to be reserved. The applicant submitted a petition, in accordance with Section 8321 of the Streets and Highway Code of the State of California. The petition, signed by 13 people, at least two of whom are residents of the road district in which the project is located, requests the abandonment. According to California Government Code Section 65402, the abandonment of property must be in conformance with the General Plan. This request is in conformance with the Butte County General Plan and will not conflict any adopted or proposed element of the General Plan. ■ Butte County Department of Development Services ■ 1 ENVIRONMENTAL DOCUMENTATION: This project has been determined by the Secretary of Resources to be Categorically Exempt under the California Environmental Quality Act Section 15305. RECOMMENDATION: Staff recommends that the Planning Commission find the application for abandonment of a portion of Hewitt Avenue in conformity with the Butte County General Plan and approve the abandonment with the following condition: 1. Reserve in the resolution approving the abandonment an easement for public utility purposes over the property being abandoned. Attachments: A: Vicinity Map B: Site Plan C: Property Description K:\PROJECTS\ABN\FiEWITT.ABN\HEWITT.PC m Butte County Department of Development Services ■ 2 Kf • • ' Vicinity Map s Geo Pau ay � m vil ad �o P m` Q4 LE O Proje Location ad th Vol a ABAN 97-01 APN IRMH1 s ARMH-1 m N VA-11a Ave ve 9 MH-1 R H-1 0 eranza P- rmo d V 9 0 Z Kenilworth Ave 9' m , 3 m m 27 P-Q A MH- m m s � Project Loc on 2. `s x m m ARMH-1 ARMH-1 ARMH- ARMH-5 BUTTE COUNTY DEVELOPMENT REVIEW COMMITTEE Applicant: Robert Pike Owner: Hearing Date: Existing Zone: ARMH-1 A Request: Abandonment of a portion of Hewitt Avenue Right of Way. No Scale Assessor Parcel No: File: 97-01 �:� . _ utte lcounAf PLANNING DIVISION DEPARTMENT OF DEVELOPMENT SERVICES 7 COUNTY CENTER DRIVE - OROVILLE, CALIFORNIA 95965-3397 TELEPHONE: (916)538-7601 FAX: (916) 538-7785 June 12, 1997 Robert W. Pike P.O. Box 784 Palermo, CA 95968 Re: Abandonment, File ABAN97-01 Dear Mr. Pike: The Butte County Planning Commission at their regular held June 12, 1997 found your request to abandon a public right-of-way for a portion of the Hewitt Avenue easement, in conformity with the Butte County General Plan and recommended approval subject to the following condition: 1. Reserve in the resolution approving the abandonment an easement for public utility purposes over the property being abandoned., was recommended for approval. Should you have any questions regarding this matter, please contact Stephen Betts at this office between 8:00 a.m. and 4:00 p.m., Monday through Thursday. Sincerely; Lynn Richardson Planning/Administrative Support Service Assistant /Ir cc: Public Works AGENDA REPORT TO: Honorable Chair and Planning Commission FROM: Department of Development Services, Planning Division DATE: May 14, 1997 REQUEST: Abandonment of a portion of Hewitt Avenue Right of Way: This is a request to abandon a public right-of-way for a portion of the Hewitt Avenue easement located between Ludlum Ave. and South Villa Ave., Palermo, in an area zoned ARMH-1. This project is located in Supervisorial District 1. RELATED ITEMS: None FOR: Planning Commission Meeting of June 12, 1997. SUMMARY: This is a report for the abandonment of a portion of the Hewitt Avenue public right- of-way. State law requires that the Planning Commission find that the abandonment will not be in conflict with the General Plan. Staff recommends approval of this request. ANALYSIS: This project is a request to abandon a portion of the Hewitt Avenue public right-of- way, located between Ludlum Ave. and South Villa Ave. in Palermo. A street has never been constructed on this portion of the Hewitt Avenue right-of-way and it is currently open space. An elevated power line is located in the right-of-way. Dwelling units are located on the northwest, northeast, and southeast sides of the right-of-way. The Hewitt Ave. easement to the south appears to have already been abandoned because the adjacent property owners have fenced it off and are using it as their own property. However, the Department of Public Works does not show this portion of Hewitt Ave. as being officially abandoned. The Hewitt Ave. right-of-way to the north has been abandoned and is being used as a portion of a public park. Because the Hewitt Ave. right-of-way to the north has been abandoned, and the right-of-way to the south is not used for road purposes, it is reasonable for the Hewitt Ave. right-of-way between Ludlum Ave. and South Villa Ave. to also be abandoned. The loss of the right-of-way will not impact vehicle traffic because vehicles do not currently use the right-of-way. It appears that little, if any, people use the right-of-way as a path between Ludlum Ave. and South Villa Ave. There is a recorded easement for the Hewitt Ave. right-of-way reserving access for public services, such as sewer and water lines, and power and telephone lines. A condition of this abandonment will require the public utilities easement to be reserved. The applicant submitted a petition, in accordance with Section 8321 of the Streets and Highway Code of the State of California. The petition, signed by 13 people, at least two of whom are residents of the road district in which the project is located, requests the abandonment. According to California Government Code Section 65402, the abandonment of property must be in conformance with the General Plan. This request is in conformance with the Butte County General Plan and will not conflict any adopted or proposed element of the General Plan. ■ Butte County Department of Development Services ■ 1 ENVIRONMENTAL DOCUMENTATION: This project has been determined by the Secretary of Resources to be Categorically Exempt under the California Environmental Quality Act Section 15305. RECOMMENDATION: Staff recommends that the Planning Commission find the application,for abandonment of a portion of Hewitt Avenue in conformity with the Butte County General Plan and approve the abandonment with the following condition: 1. Reserve in the resolution approving the abandonment an easement for public utility purposes over the property being abandoned. Attachments: A: Vicinity Map B: Site Plan C: Property Description K:\PROJECTS\ABN\HEWITT.ABN\HEWITT.PC ■ Butte County Department of Development Services ■ 2 Vicinity Map D _ Pau aY G vil ad �o P m` • 44 LERR O Proje Location ad l lk a ABAN 97-01 APN RMH 1 s ARMHA m N Villa Ave :T-TH71 FIJ: El- -- : i ve MHA R H-1 m eranza A P- d n 0 'a Kenilworth Ave 9' Ame m � 3 m m s. P-Q A MH- Project Loc t on s x Z ARMHA ARMHA ARMH- ARM H-5 BUTTE COUNTY DEVELOPMENT REVIEW COMMITTEE Applicant: Robert Pike Owner: Hearing Date: Existing Zone: ARMH-1 A 1 Request: Abandonment of a portion of Hewitt Avenue Right of Way. No Scale Assessor Parcel No: File: 97-01 1 �I ` .._ 7 Suitecounty ., �;f PLANNING DIVISION DEPARTMENT OF DEVELOPMENT SERVICES 7 COUNTY CENTER DRIVE - OROVILLE, CALIFORNIA 95965-3397 TELEPHONE: (916)538-7601 FAX: (916)538-7785 May 20, 1997 Robert W. Pike P.O. Box 784 Palermo, CA 95968 Re: Abandonment, File ABAN 97-01 Dear Mr. Pike: Enclosed is a copy of the report concerning your request for the abandonment of a portion of Hewitt Avenue right-of-way line of South Villa Avenue and the south right-of-way line of Ludlum Avenue, Palermo. You request will be considered at the regular meeting of the Planning Commission on June 12, 1997. This meeting will be held in the Board of Supervisors' Room, 25 County Center Drive, Oroville, California and is scheduled to begin at 9:00 a.m. . The Planning Commission recommends that the applicant or their authorized representative be present at the hearing to respond to any questions the Commission may have. In the event that no one will represent the applicant, please contact the Planning office prior to the scheduled public hearing. Should you have any questions regarding this matter, please contact this office between 8:00 a.m. and 4:00 p.m., Monday through Thursday. Sincerely, 4LynRichardson Planning/Administrative Support Services Assistant /Ir Enc. INTER-DEPARTMENTAL ° ° _ MEMORANDUM ° ° °- PUBLIC WORKS DEPARTMENT cOUN'�y TO: TOM PARILO, DIRECTOR OF DEVELOPMENT SERVICES FROM: RON MCELROY, ASSISTANT DIRECTOR OF PUBLIC WORKS SUBJECT: PROPOSED ABANDONMENT, PORTION OF HEWITT AVENUE, PALERMO (262.008) DATE: APRIL 2, 1997 Attached for your review and further action is a copy of a petition for abandonment of a.portion of the Hewitt Avenue right of way, in Palermo, along with plats delineating the subject area. The present $262.00 abandonment processing fee has been paid. At your early convenience, please have the proposed abandonment considered by the Planning Commission in regard to the findings that the project is categorically exempt from environmental review and the proposed abandonment is in conformance with the Butte County General Plan. Following Planning Commission action our department will further process the abandonment with County Counsel and the Board. Note that there is an easement reservation for utilities. Please advise us of the schedule of processing by your department and provide us a copy of the Planning Commission minutes documenting the Commission's action. All correspondence should be addressed to Robert W. Pike, P.O. Box 784, Palermo, CA 95968. If additional information is required, contact me at your convenience. Attach. cc: Robert W. Pike Surveys Planning Division APR 0 2 1997 QMVI119, Calitomia PETIAN FOR ABANDONMENT OF PUBLIPHIGHWAY No. 262.008 TO THE HONORABLE BOARD OF SUPERVISORS COUNTY OF BUTTE DATE:, 19&;11 Dear Board Members: The undersigned, being ten or more freeholders, at least two of whom are residents of the Road -District in which some part of the highway affected is situated; and who are taxable therein for highway purposes, do hereby petition your Honorable Board of Supervisors in writing, in accordance with provisions of.Section 8321 of the Streets and Highways Code of the State of California, to ABANDON the following-described COUNTY HIGHWAY of the COUNTY OF BUTTE: A portion of Section 8, Township 18 North; Range 4 East, M.D.M., Butte County, State of California, and being more particularly described as follows; 'Being a portion of Hewitt Avenue in the Town of Palermo, as shown on the " Map of Subdivision No. 1 of the Palermo Citrus Tract "Wall map number 3, on file in the Office of the_-Recorder, County of Butte, State of California; Being all of Hewitt Avenue lying between the North right of way line of South Villa Avenue and the South right of way line of Ludlum Avenue in said Town of Palermo. EXCEPTING AND RESERVING any existing public service easement and/or rights at any time, or from time to time, to maintain, operate, replace, remove, renew and enlarge the existing public service facilities and facilities incidental thereto, including access to protect the property from all hazards in, upon, and over the highway herewith to be abandoned. See abandonment record on file at the Department of Public Works, County of Butte, State of California. r D1W ORDDOMMEW M-L ABN 1 ` PETITIO.OR ABANDONMENT OF PUBLIC F&WAY No. 262.008 1 Signature `- � Addresses' Y ! i Print Name,"/. Tftt,:� e--+ H rl- 4-L- City. Stater: ip ate ' -`�7 Signature Address1!C, Print Name n, ,,, City 0'.01 P,V) StateC,h Date Signature( , otoi�l_7�/y;c � I Addr9 s a Print Nan T'-L City r� QP xo -StateAl Zip 9 Date,3- Signature Address jo U y Print Name City StateCgl ip4?CZ,(2 Date "5'S_ ? 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