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11100146CITY OF CUPERTINO BUILDING PERMIT j C BUILDING ADDRESS: 19000 HOMESTEAD RD I FCffOANLTRAP OR: KAISER FOUNDATION "`� �I PERMIT NO 11100146 OWNER'S NAME: MOFF 11 TANTAU HOLDING INC 1780 SECOND ST I DATE ISSUED: 12/22/2011 OWNEWS PHONE: 6503882761 1 BERKELEY, CA 94710-1792 1 PHONE NO: (510)559-5111 1 W LICENSED CONTRACTOR'S DECLARATION License Class �• Lic.# 970 F) 71 Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self -insure for Worker's 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 Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -points ce regulations per the Cupertino Municipal Code, Section 9.18. Signature Date 10-9A— 12 ❑ OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's 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 Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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 Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r MECH r RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: KAISER - COMM T.I (I 190SQFT) MECHANICAL UPGRADE INCLUDES 2 ADDITIONAL ROOFTOP UNITS, WITH STRUCTURAL CALCS 9/24/2012 - REV#2 - REVISED STRUCTURAL AND ELECTRICAL DESIGN - 10/29/2012- REV#2 ISS'D Sq. Ft Floor Area: I Valuation: $60000 APN Number: 31609036.19000 1 Occupancy Type: PERMIT E RES IF WORK IS NOT STARTED WITHIN AYS OF PERMIT ISSUANCE OR 180 DAYS M LAST CALLED INSPECTION. Issued by: Zq %� Date: RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner��jj�thorized agent: Date:^ CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION Signature Date I understand my plans shall be used as public records. Licensed Professiona CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19000 HOMESTEAD RD CONTRACTOR: KAISER FOUNDATIO PERMIT NO: 11100146 HEALTH PLAN OWNER'S NAME: MOFF 11 TANTAU HOLDING INC I780 SECOND ST DATE ISSUED: 12/22/2011 OWNER'S PHONE: 6503882761 BERKELEY, CA 947I0-1792 PHONE NO: (510)559-5111 J0 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class Lic. t! % 8 MECH r RESIDENTIAL r COMMERCIAL Contractor .S e,6 Date I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self -insure for Worker's 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 Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that 1 have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date1-2 ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's 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 Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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 Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. JOB DESCRIPTION: KAISER - COMM T.I (I 190SQFT) MECHANICAL UPGRADE INCLUDES 2 ADDITIONAL ROOFTOP UNITS, WITH STRUCTURAL CALCS 7 i�Z— , ICa_AJ d, Sq. Ft Floor Area: I Valuation: $50000 APN Number: 31609036.19000 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS F OM LAST LLED INSPECTION. Issued by: Ite: RE -ROOFS: All roofs shall be inspected prior to any roofing material berg installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should 1 store or handle hazardous material. Additionally, should 1 use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.I2 and the Health & Safety Code, Sections 25505, 25533, and 25534. agent: Qy Date: / f%/Z CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of %ork's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION 1 understand my plans shall be used as public records. Signature Date I Licensed Professional CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19000 HOMESTEAD RD CONTRACTOR: KAISER PERMIT NO: 1 1 100146 FOUNDATION HEALTH PLAN OWNER'S NAME: MOFF II TANTAU HOLDING INC 1780 SECOND ST DATE ISSUED: 12/22/201 1 OWNER'S PHONE: 6503882761 BERKELEY, CA 94710-1792 PHONE NO: (510)559-511 1 ❑ LICENSED CONTRACTOR'S DECLARATION Ir License Class � � G 7 Li,. N � � � 1 BUILDING PERMIT INFO: BLDG EUECT PLUMB � )— . Contractor K4 lS KR Date /Z MECH RESIDENTIAL COMMERCIAL I hereby affirm that [ am licensed under the provisions of Chapter 9 JOB DESCRIPTION: KAISER - COMM T.I (I 190SQFT) MECHANICAL UPGRADE (commencing with Section 7000) of Division 3 of the Business & Professions INCLUDES 2 ADDITIONAL ROOFTOP UNITS, WITH STRUCTURAL CALCS Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the Sq. Ft Floor Area: Valuation: $50000 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this APN Number: 31609036.19000 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the / 2-1--Z, C-f granting of this permit. Additionally, the applicant understands and will comply Issued by:� Date: with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. 1 7 Signature //" Date 2— RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous 1 have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should 1 use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505, 25533, an 4. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: r' Date: permit is issued. 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 Worker's Compensation laws of California. If, after making this certificate of exemption, 1 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 19000 Homestead DATE: 09/24/2012 REVIEWED BY: jsg APN: BP#: *VALUATION: $10,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE. PENTAMATION 1B TI PERMIT TYPE: WORK Revision #2 to existing ermit. Revised structural and electrical desi n. SCOPE OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID B (Tenant Improvements) II-B,III-B,IV,V-B 0 $0.00 $0.00 TOTALS: 0 $0.00 $ $0.00 lsff ii Ir _s s < £ •t 'rG !r • s'Izls- .11s'�lF.'i, 1 .:'i S^lh �,,' i f:=h 1 fE vs r �.�:I�. ,tifc<ch. Plun 06'• a' P17140, Plum Clio Floc. P1un Check yklech. Permit Fee. Plumh. Permit Fec Elec. Peewit Fee: Other Much. Insp. Other Plum[) Insp.Li Other Elec. Insp, E17- Alech. Insp. Fee: Plumb, flop. Fee: Elec. Insp. Fee: NOTE. This estimate does not include fees due to other Departments (i e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). These fees are based on the nreliminary information available and are only an estimate Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11-053 E . 711111) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes Q No $0.00 3 7 hours Plan Check, Hourly $399.00 ISTPLNCK Suppl. PC Fee: Q Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-0 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: Administrative Fee: 0 0 Work Without Permit? 0 Yes 0 No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential 0 Building or Structure 0 i Truvel Documentafion Fees: Stronp, Motion Fee: IBSEISMICO $2.10 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 e S �' � � �a � - ;;Sir'..1� s `fr.5:a `. � $3.10 • <sst§i=`3`.r ' i -.' ��x� ._i4.� ti-.; •r � t $399.00 $ 402.10 Revised: 07/01/2012 FM_7 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 19000 homestead rd. DATE: 10/20/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$50,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: PENTAMATION 1 B TI PERMIT TYPE: WORK commercial mechanical upgrade includes 2 additional rooftop units with structural calcs. �t.i. SCOPE OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA S.I. PC FEES PC FEE ID BP FEES BP FEE ID B (Tenant Improvements) II-B,III-B,IV,V-B 1,190 $1,955.20 IBTIPLNCK $1,096.88 IBTIINSP TOTALS: 1,190 $1,955.20 ' `. $1,096.88 IFz` ' is �i1�'I Y•:::::.: ;:1!es.:..' ' I : :.......................... ' s JR 1fi:? 's'?1?eS f . E '`;: :.:';Qc':'f'es•.'.:.: ........ Mech. Plan Check 0.0 hrs $0.00 Mech. Permit Fee: 1MPERMIT;.... , ,�; > <,.. Other Mech. Insp. 0.0 hrs NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). These fees are based on the orelinsnary information available and are onlv an estimate. Contact the Dent for addn'l Info. FEE ITEMS (1,'ee Resolution 11-053 E . 711111) FEE QTYIFEE MISC ITEMS Plan Check Fee: $1,955.20 = # Mechanical $260.00 IBCAIRHA Air -Handling (<=10K efm) Suppl. PC Fee: 'Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $1,096.88 Suppl. Insp. Fee,0 Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $44.00 0 Work Without Permit? 0 Yes 0 No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential 0 Building or Structure 0 i Travel Documentation Fee: ITRAVDOC $44.00 Strong Motion Fee: IBSEISMICO $10.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $2.00 .�.�.�.•.�:•::::.::.:•.�.:.�.:.::::.•.•.�:::•.�::•�:'�.�:�.��:•.�:•:•.........:..:..:.......�.•��., $ 52.58 $260.00 �•��; '`< �.TA�. ........ : $3,412.58 Revised: 10/01/2011 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION DDRESS: 1900 homestead rd. DATE: 07/31/2012 FAPN:BP#: 11100146 REVIEWED BY: bobs. 'VALUATION: Iso PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY Commercial Building USE: PENTAMATION 1GENCOM PERMIT TYPE: WORK revise scope of work: repair fan coil add new fan coil unit rebalance existing mechanical system. SCOPE sz,S.f[i !,.tSkrr��.'.Y,..,s,•,3.?+lrs?-f�i;:�S[ ��!>i[$�i'ti•)��r�� 3:�1F-N[.. , r.> r f , "i � .. r,. }-�r', •„• > = r5' 't r s • c "t "s•?:�•t"'• -'k rs� � 5 ••SS�rC•i'-f .,�s: r:,s •.I• }i``'. C 5'�• J v 1':- �i 3 �'�3:: i 'e rF ..S 1 .v ���� �:� f e/ram ft-• .� •.f^ � • •:� •� V�''., 11��� .7 : . f>•�i::-'••%?:•�.,. 7...i.. ,.1��:.';�, i. , ti ��, .:s� 3>..�.. ). ]�;: .�,2 r� 3i--;7 p 1 S ''f r . u •c... r , > . .;rr.... r.:., .�Z r /• ..F..�, •:-aa %. ,4c-'�:fv,.1�: .��=•:. �• � F.- Si' � ] i '•r 4 S i'd5 � f �, .� \e. S ->-,S ^.'-'7 t; :-.: [i i:.....f_::,.. ;:.. .,�=:r .:: ,. t n r S. •: it o• Y�..r �;i 1., of F.:: ` ., , >;,r i f ,✓, > , .:..,a , ,.:�.::<'a.: ,::•...., r•;t• 3•..Z ..., -•, s. E...�� r 3�tj/.s rr �.. s r. ? =5:,r� _r 'r a<..i ..I,3r:r ai.... �.e ��::.... r...,...e.� si.., . • J:.?:.;: Zr:!.:, �T::i•-::..:., ..r.... :•�:.'le1�?a... ; ... _. ..,✓. t.... S.. t .� �.,.] > . ._.r.n.s...._...�......� ).-- c.:..Zf,..�.i...r-...•,13.. J... 5?Irer� i1•::... S. S :r�• ::-r,S• 4. l'Lln Lphtrr,h. New ChoeA Elec. Plan Check Lle>ch- Permil Fee, Plumh. Permil Fee: F_lec, Pc!)mir Pi"' �11117� Ocher ,llec h. /nsp. Ocher Plumb Ins[). Usher Flee. Insp. Mech. [,Op. ! a, Numb. Iusp. Fee: Alec. Insp. Fee. NOTE. This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District. eta). These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addn7 info. FEE ITEMS (Fee Resolution 11-05.3 Ef) 711111) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes Q No $0.00 F-27 hours Plan Check, Hourly $266.00 ISTPLNCK Suppl. PC Fee: Q Reg. Q OT F0,01hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feee Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 C"�tltsir-ticfion �ci.v`: 0 Work Without Permit? 0 Yes 0 No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure 0 i Travel Docrorrentulion Foes: Strong Motion Fee: $0.00 Select an Administrative Item Bldg Stds Commission Fee: $0.00 `";.i':�: rsi:•��. •3• •.2t•3`-v :/'•::i enei'!T)i�ir:� ^S,S G•7.'-,':� 2:�i'•N i 3 Y ci:s)I i £.!r � )�3, .r rF {,.�,E_. �. •:i:�:l ?I.r: �, '•',: ;, S;. = rF� �:'.l rf r w •:.fir, --'';i. } ";'i. :1�:):ti;i!-.:'::S<::.,./�i:/�. \('ii.1Y.,s,'r�ii. f:'.r ? �!,>.':r. ..•e =�:•.,�:;;;.`.;::.1:::::�5;:'rc.[:........-::r.:.:�!�.r.r..�..).......::::r.....«....�.[ai�.S...„itar.a. ice, .��%:1 .�f:. uM�; $ 0.00 ''l:)'irsl2'1'�S':sY@:r�y� s•_: if . 7Zvt S`%.r �'4''; r�F �...,��£^s \.t:.�''r..ei w. .t;: � t. 266.00 ' ' fir, �. , t: .s r $ �..ii; �)1:y.��., �. �;:$^. t%%s�::a�rii--•>.ti r./�•.....a a �.vri:�i'•:fr: ..,....[. 266.00 Revised: 07/01 /2012