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HomeMy WebLinkAboutApplication- PermitNo. 6553 GARP• 7ELD COUNTY BUILDING, SANITATION and PLANNING DEPARTMENT 109 8th Street Suite 303 Glenwood Springs, Colorado 81601 (303) 945-8212 1175 County Road 154, Glenwood Springs Job Address Building Permit Nature of Work Use of Building Owner Remodel Existing Building w/New Shop/Office Addition Old Grand LLC Contractor Walters Company 2,280.71 Date November 26, 1997 .Permit: 1,382.25 Plan : 898.96 Paid $687.21 7-3-97 Amount ofPermit S S. Archuleta Clerk 64itCP2‘•97 PERMIT DAPFI TSCHFf)NO. 0I BUILDING PERMIT APPLICATION GARFIELD COUNTY, COLORADO JOB ADDRESS 1 2 1- e 94 LEGAL DESCR, OWNER 0 LOT NO BLCCK CONTRACTOR Ld ARCHITECT OR DESIGNER 5 6 7 8 ADDRESS ADDRESS 1 1. DRESS 14/ 6,11- . PH. IN6W5/ SUBDIVISION 1175 de IJ'Y 105 dA ii'4 PHQ -;if1 7/ PH. WK PH 9K545] LICENSE NO, 9�SJlvs� ENGINEER T+9c. wet,d �vr � 516— OF BUSLDI G PF Ai USE OF BUILDING ADDRESS 5, F OF LOT PH. HEIGHT LICENSE NO. LICENSE NO. NO. OF FLOORS cl,010 16e. ,6m// m IONRATION REPAIR ❑MOVE ❑ IRE CLASS OF WORK: o NEW o ADD 49imbdd- evieist 461ii DESCRIBE WORK: des/A 10 GARAGE, SINGLE DOUBLE DRIVEWAY PERMIT CARPORT SINGLE DOUBLET / OO/ j7OP = 3 /Jf%' .PC-? u BG (( ,- 2, 2 ro. 71 ON SITE SEW DISPOSAL PERMIT SITE PLAN 11 iM;e00' 4 emu 7.5; Dao• •o STE VALUATION of woAK: S D I D VA . r fiJ‘ 725:2.R./ 2 . �// SPECAL CONDITIONS:ac TIOo) X (SZ l9rr4CM/1) rn wsr# ' 1 9,3" vs.,SI' NOTICE PLAN CHECK FEE -4794 PERMIT , — 3C SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL. PLUMBING, HEATING, VENTLATING OR AR CONDITIONING. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 16O DAYS. OR 1F CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS COMMENCED. 1 HERESY CERTIFY THAT 1 HAVE READ AND EXAMINED THIS APPLICATiCN AND KNOW THE SAME TO BE TRUE AND CORRECT, ALL PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE OF W,ORK WILL BE COMPLIED WITH WHETHER SPECIFIED HEREIN OR NOT, T E GRANTING OF A PERMIT GOES NOT PRESUME TO GIVE A�%' 'TTY TO VIOLATE OR CANCEL THE PROVISIONS OF ANY OTHER STATE OR LOP LAW 'EGU' ' T G CON5TRUCTIO DR THE PERFORMANCE OF CONS R 5 Or ora ed agent (pate} —3,•—a7 rig read T • understood ace abo Building Depar ment AaprovaJda 9� Pinning Depe ent Aporovalld e SCHCOLIMPACTFEE NO. OF BUILDINGS ON PARCEL USE OF BUILDINGS NOW ON PARCEL TOTAL FET1,1J2 'D,71 WATER SUPPLY c5cc a4# DATE PERMIT ISSUED �J CONST. TYPE SPECWL APPRCvALS ZONING RECUIREO REcEIVEO NOT R•RQUIRED HEALTH DEPT. FIRE DEPT SOIL REPORT SETBACKS FLOOD HAZARD MANUF HOME OTHER AGREEMENT PERMISSION IS HEREBY GRANTED TO THE APPLICANT AS OWNER, CONTRACTOR ANO/OR THE AGENT OF THE CONTRACTOR OR OWNER TO CONSTRUCT THE STRUCTURE AS DETAILED ON PLANS ANO SPECIFICATIONS SUBMITTED TO AND REVIEWED BY THE BUILDING DEPARTMENT IN CONSIDERATION OF THE ISSUANCE OF THIS PERMIT THE SIGNER HEREBY AGREES TO COMPLY WITH ALL BUILDING CODES AND LAND USE REGULATIONS ADOPTED BY GARFIELD COUNTY PURSUANT TO AUTHORITY GIVEN IN 30.28.201 CRS AS AMENDED. THE SIGNER FURTHER AGREES THAT IF THE ABOVE SAID ORDINANCES ARE NOT FULLY COMPLIED WITH IN THE LOCATION. ERECTION, CONSTRUCTION AND USE OF THE ABOVE DESCRIBED STRUCTURE. THE PERMIT MAY THEN BE REVOKED BY NOTICE FROM THE COUNTY AND THAT THEN AND THERE iT SHALL BECOME NULL AND VOID. THE ISSUANCE OF A PERMIT BASED UPON PLANS, SPECEFICATIONS AND OTHER DATA SHALL NOT PREVENT THE BUILDING OFFICIAL FROM THEREAFTEOPERATIONRBEEINGICARREDRQURING EONORRECTION OF ERRORS IN SAID THEREUNDER WHEN IN VIOLATIONNS. OFSPECIFICATIONS AND THS CODE OR ANY OTHER OTHER ORDINANCE ANCEOM RPREVENTING REGULATONBUILDING THIS JURISDICTION. THE REVIEW OF THE SUBMITTED PLANS AND SPECIFICATIONS AND INSPECTIONS CONDUCTED THEREAFTER DOES NOT CONSTITUTE AN ACCEPTANCE OF ANY RESPONSIBILITIES OR LIABILITIES BY GARFIELD COUNTY FPR ERRORS, OMISSIONS OR DISCREPANCIES. THE :RESPONSIBILITY FOR THESE ITEMS AND IMPLEMENTATION DURING CONSTRUCTION JESTS SPECIFICALLY WITH THE ARCHITECT, DESIGNER, BUILDER AND OWNER. COMMENTS ARE INTENDED TO BE CONSERVATIVE AND IN SUPPORT OF THE OWNERS INTEREST. Garform.003 I HEREBY ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE AGREEMENT ABOVE (INITAL } Qtr 712' 2-3-9`7 Old Grand LLC - Determination of Valuation New addition: Basement: Mechanical (industrial per Budding Valuation Data IBVDI.sheet using .81 factor for Colorado) 732 sq. ft. @ $26.89 lst Story: Private garage per BVD w/.81 factor., 1,140 sq. ft. @ $17.42 Storage (Warehouse per BVD. using ;.81 factor) 440 sq. ft. @ $19.68 2nd Story: Office per BVD w/.81 factor 1,554 sq. ft. © $48.60 Valuation of Addition Alteration: Valuation as stated by applicant Total of adjusted valuation OldGrand.Vel $19,683.48 = $19, 858.80 ' $ 8,659.20 _ $75,524.40 _ $123,725.88 =: $75,000.00 $198;725.88 GARFIELD COU TY BUILDING AND PLANNI \ 970-945-8212 MINIMUM APPLICATION REQUIREMENTS for SINGLE FAMILY DWELLING CONSTRUCTION including NEW CONSTRUCTION MANUFACTURED HOMES ADDITIONS ALTERATIONS and MOVED BUILDIIN GS G In order to understand the scope of the work intended under a permit application and expedite the issuance of a permit it is important that complete information be provided. Adequate and complete information will prevent delays in the plan review process. Reviewing a plan and the discovery that required information has not been provided by the applicant may result in the delay of the permit issuance and in proceeding with building construction. The owner or contractor may be required to provide this information before the plan review may proceed. This causes delays because other plans that are in line for review may be given attention before the new information may be reviewed after it has been provided to the Building Department. Please review this document to determine if you have enough information to design your project and provide adequate information to facilitate a plan review. If you do not, it may be helpful to obtain a book titled "Dwelling Construction under the Uniform Building Code". This book is available to you through this department at our cost. Also, please consider using a design professional for assistance in your design and a construction professional for construction of your project. To provide for a more understandable plan in order to determine compliance with the building, plumbing and mechanical codes, applicants are requested to review the following check list prior to and during design. Applicants are require to indicate appropriately and to submit the completed check list .at time of application for a permit. For the placement of a manufactured home, questions numbers 1-4 and 19-28 are the only questions that need to be addressed: 1 1 Is a site plan included that indicates the distances of the proposed building or addition to property lines, oti r buildings, set back easements and utility easements? Yes 2. Does the site plan include the location of the LSD. S. (Individual Sewage Disposal System) and the distances to property lines, wells (on subject property and adjacent properties), streams or water courses? — � Yes b]� 3. Does the site plan indicate the location and direction of the County or private road accessing the property? Yes 4. Do the plans include a foundation plan indicating the size, location and spacing of all reinforcing steel in accordance with the uniform building code or per stamped engineered design? Yes 7t 5. Do the plans indicate the location and size of ventilation openings for under floor crawl spaces and the clearanpes required between wood and earth? Yes J�( 6. Do the plans indicate the size and location of ventilation openings for the attic, roof joist spaces and soffits?, Yes '( 7 Do the plans include design loads as required under the Uniform Building Code for roof snow loads, (a rnin}mum of 40 pounds per square foot in Crarfield County), floor loads and wind loads? Yes 8. Does the plan include a building section drawing indicating foundation, wall, floor and roof constructi. n? Yes 9. Does the building section drawing include size and spacing of floor joists, wall studs, ceiling joists, roof rafte s joists or trusses? Yes 10. Does the building section drawing or other detail include the method of positive connection of all columns a c beams? Yes 2 11. Does the plan indicate the height of the building or proposed addition from the highest point of the building or addition measured at raid span between the ridge and the eave down to existing grade contours? Yes 12. Does the plan include any stove or zero clearance fireplace planned for installation including make and model and Colorado Phas ertifications or phase H EPA certification? Yes No /0 —// / ,i 13. Does the plan include a masonry fireplace including a fireplace section indicating design to comply with the Uniform Building Code Chapter 37? Yes No 14. Does the plan include a window schedule or other verification that egress/rescue windows from sleeping ro s and/or basements comply with the requirements of the Uniform Building Code? Yes No 15. Does the plan include a window schedule or other verification that windows provide natural light and ventilation for all habitable rooms? Yes �1_ No 16. Do the plans indicate the location of glazing subject to human impact such as glass doors, g1a7ing immediately adjacent to such doors; glazing adjacent to any surface normally used as a walking surface; sliding glass doors; fixed glass panels; shower doors and tub enclosures and specify safety glazing for these areas? Yes No 17. Is the location of all natural and liquid petroleum gas furnaces, boilers and water heaters indicated /`F1 on the plan? No - Yes 18. Do you understand that if you belong to a homeowners association, it is your responsibility to obtain written permission fro the association, if required by that association, prior to submitting an application for a building permit? Yes — No 19. Will this be the only residential structure on the parcel? Yes No If no -Explain: - J 20. Have twg2) complete sets of construction drawings been submitted with the application? Yes 3 21. Is this an application for the I cement of a manufactured home? Yes No If yes, have you specified the sr a of the unit (min. 20ft. x 20ft); live roof load (min. 40#); wind design (min. wind speed of 80 mph & 151b. wind load); foundation design; method of anchoring? Yes 22. Have you designed or had this plan designed while considering building and other construction code requi ents? Yes No 23. Does the plan accurately indicate what you intend to construct and what will receive a final inspectio the Garfield County Building Department? Yes No 24. Do you understand that approval for design and/or construction changes are required prior to the applica 'o of these changes? Yes No 25. Do you understand that the Building Department will collect a "Plan Review" fee from you at the time of application and that you will be required to pay the "Permit Fee" as well as any "School Impactl' Septic System" fees required, at the time you pick up your building permit? Yes No 26. Are you aware that twenty four (24) hour notice is required for all inspections? Inspections will be made from Battlement Mesa to West Glenwood in the mornings and from Glenwood Springs to Carbondale in the afternoon. Morning inspections must be called in by 12:00 p.m. the day before; afternoon inspections must be called in by 5:00 p.m. the day before. Failure to give twenty four (24) hour notice for inspections will delay your inspection one (1) day? Yes ( No 27. Are you aware that you are required to call for all inspections required under the Uniform Building Code including approval on a final inspection prior to receiving a Certificate of Occupancy and occupan y • f the building? Yes ► No 28. Are you aware that the person signing the Permit Application, whether the "Owner", "Agent of the Owner", "General Contractor", "Contractor" or otherwise, is the party responsible for the project oplying with the Uniform Building Code? Yes V No 4 1 hereby acknowledge that Y have read, understand and answered these questions to the best of my ability. 1\.1 MkPhone: q45---ze5 / • (days); Project Name: OLD oc" ' W C O. date -6r7 Project Address: Notes: (evenings) CE/ L9 -e_)) If you have answered "No" on any of the questions, you may be required to provide this information at the request of the Building Official prior to beginning the plan review process. Delays in issuing the permit are to be expected. Work may not proceed without the issuance of a permit. If it is determined by the Building Official that additional information is necessary to review the application and plana to determine minimum compliance with the adopted codes; the application may be placed behind more recent applications for building permits in the review process and not reviewed until required information has been provided and the application rotates again to first position for review, delay in issuance of the permit or delay in proceeding with construction. PerApp02.95 Effective August 15, 1995 5 Nc 65-5-3 1/4 Assessor's Parcel No. Date //-v7! -97 BUILDING PERMIT'�CARD9 Job Address �1 75- i& -a .L /rye '��Cf &dn girt. Ownera a�� >qZk4- e Address %J w^^ -t-- Phone 9ys-'QS/ lactaW OA • (E D ) Front R� r Contractor tbacks: Soils Footing t'2 - ! 6 _t 7 Foundation 1 — r - 4 A -awn Address Phone # 1���ia�6 Zoning;r�) E TIONS Q - Ci" 5L77-5737 Grout Underground Plumbing 1-1-1- 9e) kAkr-Final Rough Plumbing 3- R9 din -P25 /"a/c Certifi Framing 40- (ID 'if-7-02-7604— Insulation 3-2-°z A...). t Septi Roofing Drywall 4#7....,, .,� Dj,Gt A -94 0A ID/JV/4 Gas Piping / i—haeOthe Weatherproofing Ctic% -7qf 53' / Mechanical Electrical Rough (State) Electric•I Final State) .tea s e, Ram a* ecklist Completed9 ate Occupancy # Date System # 1 Date ((�/ Final rie>3 Agrg- N 9.4 64 A.5, i'PA/ 0-Ev t terse, es r{•z303red ( ntinue on vin File notes Permit was issued 11-97 to include new construction of a basement/mech room, garage/storage/office first floor and 2 offices on the 2nd floor. A remodel of the existing building included a main floor cabinet shop, storage, and office with the 2nd floor being 2 apartments. Work progressed sporadically till a final was called for in July 2004. During the final review it was determined there had been some changes in the original approved plans. An amendment to the plans was submitted to change the new construction basement to an apartment; the l" floor added an office, with the 2°d floor being changed tokatzapetment. The remodeled portion of the building did not change to a great degree. The amended plans were reviewed for building requirements and a zoning review and were approved on 7-7-04. Subsequent to the review process were 2 more inspections to verify redlined items from the amended plans. On extra layer of 5/8 type X sheetrock was added to the ceiling of the shop, egress windows were verified and smoke detector locations were reviewed. A final inspection was passed on 8-06-04. See complete file for additional data. Andy Schwaller 8-06-04 Lit ir (056-3 ....06891T/07 10:54 trsto 842 8370 ROY ROMFIR Governor JOHN J DONLON Executive Director RICHARD O. PIPER State Inspector al Oac February 7, 1997 CHEVRON U.S.A. Iib002 DEPARTMENT OF LABOR AND EMPLOYMENT Oil Inspection Section Tower 3. Suite 600 1515 Arapahoe Street Denver CO 80202-21 1 7 13031 620-4300; Fax 13031 620-4028 STEVE WOODHEAD CHEVRON PRODUCTS BLDG L RM 2130 6001 BOLINGER CANYON RD SAN RAMON CA 94583 RE: Closure for Former Bulk Plant, 1175 Road 154, Glenwood Springs, Garfield County. Colorado Dear Mr. Woodhead: The Oil Inspection Section (018) has reviewed the 1998 monitoring reports for the above referenced location. Based upon the information submitted it appears you have removed the source of contamination and reduced the potential for endangerment to human health, safety, and the environment as a result of the contamination at this properly In Tight of the remedial action taken at this site, the OIS hereby approves your remedial action and does not require any further investigation or remedial action at this time. If conditions change, the OIS reserves the right to determine it any additional actions are necessary. Please be aware the OIS cannot release you from any liability which may be associated with contamination at this site. Your cooperation in dealing with this site is appreciated_ Should you have any questions concerning this letter, please contact me at (303) 620-4017. Si le Cotter vironmental Protection Specialist Storage Tank Remediation Program Oil Inspection Section JC1chev1175.do 02/28/97 12:00 TX/RX NQ.1246 P.002 • Ed Walters Walters and Company 1175 County Rd. 154 Glenwood Springs CO. 81601 July 12, 2004 Dear Ed, Garfield County BUILDING & PLANNING DEPARTMENT In follow up to a site visit on July 9, 2004 it was determined that an additional layer of type X sheetrock will need to be added to the ceiling of the garage area. This is needed to acquire a 1 hr. fire separation rating between the garage and living space above. The 1 hour separation is also required in the ceiling area above the mechanical room on the lower level. This could be achieved with a spray on fire resistance material. Also the smoke detectors on the upper level will need to be made functional for the final inspection. Please call if you have any questions. Thank you for your at(ention to these areas. Andrew Schwaller Building Official ?ctnoocc.lsvw, &V : Snap S4*+-aw,a..t 2 ApTr IpT S t O f-Fic i -t 3, 3, F -z, S -Z Q fig. ?-&e4 413. DW 1 • _Vasa ILt.t ( 7TCR'p ,N ,4Gcti Ree. 4144 1A2 RACIZ ole SF, Gia,c Jo r4)cto-ntilamirr !AI crL1(„m4 . 108 8th Street, Suite 201, Glenwood Springs, Colorado 81601 inn) nec 011) /MOnl 10C 14)7' s..... in7ni 204 tin Date Z9 --O4% To 27) 0ct /'et5 //7 5 wC/e/Sy /enopaU 2gaa ,c.n o SGO/ BUILDING & PLANNING DEPARTMENT Dear Permit Holder, Please refer to our previous letter, dated /. -/ 7'-c 3, advising you that your Building Permit, number to 53 3 , was due to expire, per section 106.4.4 & 5 of Uniform Building Code, and that you had been given an additional thirty days to call for the required inspection or to request other action from the building department. The above permit has expired and been closed. The work authorized by the permit has not been inspected or approved. It is a violation of Colorado Revised Statutes 30-28-205 & 210, Uniform Building Code section 109, to use or occupy the building or area unless final inspections have been completed and a Certificate of Occupancy has been issued. Records of this failure to comply are included with property records at the Garfield County Clerk and Recorders office. You are entitled to protest this action to the Garfield County Board of Commissioners Yours truly, Andy Schwaller Building Official 108 8th Street, Suite 201, Glenwood Springs, Colorado 81601 (970) 945-8212 (970) 285-7972 Fax: (970) 384-3470 Date:/Z—/ 7-0 3 To: (9/7t-7,rernof LLL' //7.- (2 /5y 605. Go. 31!off? Garfield County BUILDING & PLANNING DEPARTMENT Code Compliance Office shackett(a ga>field-county.com Dear Permit Holder, Please refer to your building permit number (Q53-3 , issued / /-Z..6 —97 A routine review of our open building permits indicates that we have not received a request for an inspection on this permit since 471-2-3-03 Please be advised that building perznits expire, per Uniform Building Code, section 106.4.4. "Every permit issued by the building official under the provisions of this code shall expire by limitation and become null and void if the building or work authorized by such permit is not commenced within 180 days from the date of such permit, or if the building or work authorized by such permit is suspended or abandoned at any time after the work has commenced for a period of 180 days. Before such work can be recommenced, a new permit shall first be obtained to do so, and the fee therefore shall be one half the amount required for a new permit for such work, provided no changes have been made or will be made in the original plans and specifications for such work, and provided further that such suspension or abandonment has not exceeded one year. In order to renew action on a permit after expiration, the permittee shall pay a new full permit fee." Please contact this office at your very earliest convenience, in writing, to advise us about the status of your permitted work If you have not responded within thirty days from the receipt of this notice the permit will be closed and a permanent notation will be placed in the property records at the County Assessors office that indicates that the work permitted was not inspected, is not approved and that the building or area may not be legally occupied. Thank you for your cooperation. Tim Ifofbday Dave Mead- Building eadBuilding Inspectors f(1A Ar7, Qf..nnf P.afn 1/11 /'7 .............] 0....:._.... l'.. 7.......7.. 016/11 , 4S.muc, y '1 0 Atm hasett C-0013/AZA- SAW) i 2 SIP E - .� ,Dtoi J`TV L4L.LE, bcr -` 3729 3.F 3216 s.7.. Ce9,4016 SF. 1 7945nu-r.cc /S ITCH 732 s. F: 2) Gstrataz A7 -s-4444_ 4 7 AS -St S -F. aJ Y449 7 ztt ' s 2 DFFKrJ ± /S 851 3 °once set: OLD G 471 49 ato aerrr ?r4 -n.", - /Sat.- 4 retiZ eneliernaelri rou: Ai no t a GLC 7.3 -?7 /1/441.J ` c 7 /.:30 94S- 2851 373 -S7Y% rbs—r- - 73z 5-F tT- y /S.8° 3.f 1 Sie4ity - z OFFICE 3 729 S•F: t -04049-i bet- irs4 s.f �D Q tLn4!s TS) c O2 su, S /41-4Pre'd, -4)13 ?PROT-144 eKaief do cec & ,— / op c' cd : «z C f kt ) D c-tJ 7 ,- Ala A- ,S @ 7 C , cFtk`' iLAe--iris c.ff 75 at yAreS *C.t1/4-1k ala9Je3 — 30 do./ £x gran -ha by knay sca\<er 945-&212_ r, INSPECTION WILL NOT BE MADE UNLESS . THIS CARD IS POSTED ON THE JOB 24 HOURS NOTICE REQUIRED FOR INSPECTIONS BUILDING PERMIT GARFIELD/COUNTY, COLORADO Date Issued h J i7..Zoned Area Permit No AGREEMENT In consideration of the issuance of this permit, the applicant hereby agrees to comply with all laws and regulations related to the zoning, location; construction and erection of the proposed structure for which this permit is granted, and further agrees that if the above said regulations are not fully complied with in the zoning, location, erection and construction of the above described structure, the permit may then be revoked by notice from the County Building Insp eorand I EDIATBECOME NULL AND Vt OFAAe,' Use Address /ooa�r egal essccriiption 1 t , ter" pl ra�� OwaerV t •lu LL`e, Contractor et fled; S Setbacks Front Side Side Rear This Card Must Be Posted So It is Plainly Visible From The Street Until Final Inspection. INSPECTION RECORD Footing 12 — l (- cl -7 A ,o Foundation • , _ .\ • - Underground Plumbing ; Insulation 3,..20,4_,)11-0(1'..- _,) ' `� Viae Rough Plumbing ',PT' ."9 r `--- Drywall ,,:,140,4 6.5r A5 . t:,-° 1 Chimney & Vent y_eo_oZyie--- Electric Final (by State Inspector) ir':S ',it-' Gas Piping/44--14--4172;rt E:..,..a- Final 5 --`,,‘ bye ,By,•` Electric Rough (By State Ipspector) ' -<.Septic Final Framing 3 -/O -7't C1G„ c(-/c-0.e (To include Roof in place and Windows and Doors installed). Notes: D(,ceW 4»- 4714,164•i3a3qr-- (y -f/-&4 61"; C i"" g• S Fume, ALL LISTED ITEMS MUST BE INSPECTED AND APPROVED BEFORE COVERING - WHETHER INTERIOR OR EXTERIOR, UNDERGROUND OR ABOVE GROUND. qF THIS PERMIT IS NOT TRANSFERABLE Phone 9491SiI 109 8th Street County Courthouse Glenwood Springs, Colorado. APPNa�/OVEDDYO� NOT DESTROY THIS CARD Date/ ML f ByF f f l t"�' IF PLACED OUTSIDE COVER WITH CLEAR PLASTIC