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PRE 2010 DOCSCity of Fridley, Minn. -.1-1508- 6431 University Ave. N. E., Minneapolis, Minn. 55432 BUILDING PERMIT rate: mune 15, 1972 OWaer: Vern Donnay Realty, Inc. Builder Same ,Adams 7300 - 36th Avenue North Address Same No 1391 Street LOCATION OF BUILDING Meadowmoor Drive N.E. Part of Lot i+ot 19 Block 2 Addition or Sub_Division Meadowmoor Terrace Corner Lot Inside Lot X Setback 35.5' Sideyard 10.5' S"A(Mevatlon 889.57 Min. of 3 feet above mater table . e&e Top of Footing (Water Talbe- 895.1 Approx.) DESCRIPTION OF BUILDING To be Used as: nnwg2l1 ina Front 32' Depth - 24.4' Height. 20' Sq, FL 777.6' X11, r, 15,552' -Ga-ragg_ Front 14' Depth 22' Height 10' Sq. Ft. 308 Cu, F.L 3080 'Type of Construction Wood Frame Est, Cost 19,5580_ To be Completed _Sept. 1972 WATER LOCATION: 10' E. of Sewer Service SEWER LOCATION: 48' W. of E.. Property line. Stipulation: This permit issued subject to stipulations in "Mutual Agreement" signed by Vern Donnay Realty, Inc. and dated June 14, 1972. In consideration of the issuance to me of a permit to construct the building described above, I agree to do the proposed work in accordance with the description above set forth and in compliance with all provisions of Ordinances of the city of Fridley. -IN n o ^ j In consideration of the payment of a fee of 34. Q_Q__, permit is hereby granted to Vern Donnay Realty Inc. to construct the building or addition as described above. This permit is granted upon the express condition that the person to whom it is granted and his agents, employees and workmen, in all work done in, around and upon said building, or any part thereof, shall conform in all respects -to the ordinances of Fridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildings ante city limits and this permit may be revoked at any time upon violation of any of the provisions of said r CLARENCE BELSSLE NOTICE: This permit does not cover the construction, installation for wiring, plumbing, gas heating, sewer or water. Be sure to see the Building Inspector for separate permits for these hems. Land Pannffl y 6875-Ayhmaty -00 We, Land Starve ff y �L Aymrwotvhs 3Z. .S0115 ksMq ENGINEERING, INC. A'ln-cso`° Civil & Uwaipal S!lajet 4-b( t4 ��►ymer y E ncyineers � Sur vecrrs certificate ®f surveir for �'� '_,► , . r AL NOR TH 75 s' LJT 19 10 I I I Nr21 N I _ I I i 75 — MEaaowMooa DRIVE cDENOTES IRON --- DfNOT6S UT/L/TY E DRAINAGE ,f"ASEMENT DoT 19 31,OCK 2 AEADOWWOOR TZ-RqACZ- COONrY OF' 4AVKA l brnab eartr�y 1te i this is o Aw ord cm -act rrprvseatahr n u`'o .wrvey #'#x &w deries rs '* Air aswu�bd ted, aid of Thr lc 4ha efe# & ildin�s , ihrrew. , mid dl risible aw oorh nmifs . Xm w- an smd /and As semveyed ne Iles_ ._._ abvf fEB_ A. 0. MO. SU9UR8AN ENGINEERING , INC. End aws ft Surr ora SCALE / 40 a - - 10 • - -------------------- y T� A) Ila, 0-0 /go 9 �75 Appleaftn for Power Pknis and Neatkqv Coof n9v Venfi7ation, ReMpration and Air Conditioning System and Devices PARTIAL RATE SCHEDULE rvRAV TY WARM AYR: RATE TOTAL Furnace Shell & Duct Work ........................... $10.00 $ Replacement of Furnace ............................. 6.00 $ Repairs & Alterations—up to $500.00 ................. 6.00 $ -- Repairs & Alterations each add. $500.00 ............... 3.00 $ NECK. WARM AYR Furnace Shell & Duct Work to 120,000 BTU ............ $10.00 It ILA _ each add. 60,000 BTU ....................... 3.00 $ Replacement of Furnace ............................. 6.00 Repairs & Alterations—up to $500.00 6.00 Repairs & Alterations each add. $500.00 .............. 3.00 $ STEAM or HOT WATER SYSTEM Furnace Shell & Lines—to 400 sq. ft. EDR Steam $10.00 $ Furnace Shell & Line—to 640 sq. ft. EDR Hot Water .. I0.00 $ Each add. 200 sq. ft. EDR Steam ... ......... .:...... 8.00,$— Each .00 $Each add. 320 sq. ft. IDR Hot Water . . . ........ ... 3.00 $ OIL BURNER—to 3 gal. per hour ..... 6.OG $ over 3 gal per hour ---See Fee Schedule GAS BURNER (up to 199,000 BTU) .............. '......... 5.00 $ over 199,000 BTU See. Fee Schedule GAS FITTING FEES: NO RATE TOTAL 1st 3 Fixtures ..... ................ x$ 7.00 $ Dept. of Bldgs. Phone 560-3480 City of Fridley: �Q- was kv The undersigned hereby makes application for a permit for the work hereir specified, agreeing to do all work in strict accordance with the City Ordinance. and ruling of the Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and rfe . corre Yidley, Mnn n 1sbw Owner Kind of Building Used as To be completed about _V017" Estimated Cost, $—� 01400—New Building Permit No. Permit No. DESCRIPTION OF WORK HEATING or POWER team, Hot Water,arm No- 1 Trade Name , , Size No Capacity Sq. Ft. EMA BTU H.P. Total Connected Load'I Kind of Fuel Additional Fixtures ............... x .75 $ BURNER —Trade Name Size No Gas Range to 199,000 ........... x$ 6A0 $ Capaci Sq. Ft. E.D.R BTU HJR AIR CONDiiOIiIN0 FAN HEATING SYSTEM See Fee Schedule VENTILATING SYSTEM $ 1J.5 A -nJA ALTERATIONS & REPAID TOTAL FEE $Sif \y ROUGH FYNAh iet4 (REMARKS—OVER) Business Pho BSEDGWICK RTG. & AtR-GOND. OFA 1001 Xenia Av. S. - 545-1611 lftr apoHs, Minn. 55416 '�...,....r..r....W �.►.�... _..Yeo--.�...e.t�..,.e.,.:..e.,,.,,,,, v„r� 53-84-S-915: 1 City of Fridley Applicatioe for Pbmbbg saki Gas K"kV Faimb DwL of Bldg Phone 980-3480 DESCRIPTION OF WORE 1391 Meadow Moore Drive N. E. Number. Kind and Locatlon of Fixtures PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL Number Fixtures ................ x $2.00 $ Future Fixture Opening ............ x $1.50 $ New Fixture Old Opening .......... x $1.50 $ Catch Basin .................... x $3.25 $ Water Heater (Up to 99.000 BTU) . • . • x $3.00 $ New Ground Run Old Bldg......... x $325 $ Electric Water Heater .............. a $2.00 $ GAS FITTING FEES: NO. RATE TOTAL 1st 3 Fixtures x $2.00 $ Additional Fixtures.................. x $ .75 $ Gas Range to 199,000 BTU ............... 1 x $5.00 t 5.00 REPAIRS A ALTERATIONS—Refer to Code Description ............................................. f TOTAL FEE $ 5.00 (SURCHARGE City of Fridley: The .undersigned hereby makes application for a permit for the arork herei specified, agreeing to do All work in strict accordance with the Qty Ordinance and ruling of the Department of Buildings, and hereby declares that ail the fact and representations stated in this application are true and correct. 10-13-72 Fridley, inn „ 19, Owner Vern Donnay Homes Inc. Kind of Building Frame Used as Res. To be completed about 10-20-72 Estimated Cost, $ 10.00 Q Old—New. Building Permit No. Pe Signed. By MINNEGASCO Business Phone No ROUGH �ye55 ��a .�ut�atgo 5'S0 DMI�m MEMENEENEENEENEEM EMENNEENNEENEEN . ................. PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL Number Fixtures ................ x $2.00 $ Future Fixture Opening ............ x $1.50 $ New Fixture Old Opening .......... x $1.50 $ Catch Basin .................... x $3.25 $ Water Heater (Up to 99.000 BTU) . • . • x $3.00 $ New Ground Run Old Bldg......... x $325 $ Electric Water Heater .............. a $2.00 $ GAS FITTING FEES: NO. RATE TOTAL 1st 3 Fixtures x $2.00 $ Additional Fixtures.................. x $ .75 $ Gas Range to 199,000 BTU ............... 1 x $5.00 t 5.00 REPAIRS A ALTERATIONS—Refer to Code Description ............................................. f TOTAL FEE $ 5.00 (SURCHARGE City of Fridley: The .undersigned hereby makes application for a permit for the arork herei specified, agreeing to do All work in strict accordance with the Qty Ordinance and ruling of the Department of Buildings, and hereby declares that ail the fact and representations stated in this application are true and correct. 10-13-72 Fridley, inn „ 19, Owner Vern Donnay Homes Inc. Kind of Building Frame Used as Res. To be completed about 10-20-72 Estimated Cost, $ 10.00 Q Old—New. Building Permit No. Pe Signed. By MINNEGASCO Business Phone No ROUGH �ye55 ��a .�ut�atgo 5'S0 City of Fridley ApokcMwi for Pkmbbkg and Gen R"biq Dart. of Bldge. Phone 960-3450 DESCRIPTION OF WORK Number. Kind and Location of lr`lxt w" Location_ gg Y e WATER MA. 11,11ild �3 D p GAS ttEC. Base 1st 2nd PARTIAL RATE SCHEDULE PLVMBING FIXTVRE RATES: NO. RATE TOTAL Number Fixtures ................ x 82.00 $ Future Fixture Opening .... a ...... x 81.50 = New Fixture Olaf Opening .......... x 81.50 t Catch Basin .................... x 83.25 i Water Beater ''Up to 99,000 BTU) ®• • • x 83.00 $ New Ground Run Old Bldg. ........ x $3.25 S Electric Water Heater .............. a 82.00 8 GAS FITTING FEES. NO. RATE TOTAL let 3 Fixtures . • . • e ......... x 8200 $ Additional Fixtures ................ x 8 .76 $ Gas Range to 199.000 BTU .. ,......... x 86.00 State Surcharge $ .50 REPAIRS t ALTERATIONS— gager to Cedo Description ... o. s. 0 0 o s..s.e o.e.w..o ...a.•.. •...•....is TOTAL FEE ��.�'� - City of P�ridley: The undersigned hereby makes application for a permit for the work herei, specified, agreeing to do all work in strict accordance with the City Ordinance and ruling of the Department of Buildings. and hereby declares that all the fact' and representations stated in this application are true and correct Fridley. Minn :Z /' /-- /7 IS,_ Owner Kind of Building Used as ie To be completed about /c2%/ZZ -t- Estimated Cost. $ 14 Old Building Permit No. Permit No. �.Slq D Signed By I Business Phone No ROUGH FINAL d4 53-84-s-915.51 City, of Fridley Appiit ,,,T,n for rk=VAg cad G= M -Mil t Dept. of Bldgs. Phone 580-3430 DESCRIPTION OF WORK 1391 N. E. Neadowmoore Drive Number, Kind and Location of Fixtures Lova a OGAS fn 12 N WATER MTR. fLEC. Base 1st In tjll Gas G ' 11 2nd 3rd 4th , • Future Connection Openings t New Fixture, Old Openings Connected with Bower Cesspool a PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL Number Fixtures ................. x $2.00 $ Future Fixture Opening ............. x $1.50 $ _ New Fixture Old Opening .....:.... x $1.50 $ Catch Basin ...................... x $3.25 $ Water Heater (Up to 99,000 BTU) .... x $3.00 $ New Ground Run Old Bldg......... x $3.25 $ Electric Water Heater .............. s $2.00 $ ZAS FITTING FEES: NO. RATE TOTAL 1st 3 Fixtures x $2.00 $ Additional Fixtures ................. x $ .75 $ Gas Range to 199,000 BTU... ,........... x $5.00 tj City of Fridley: The undersigned hereby makes application for a permit for the work herei specified, agreeing to do all work In strict accordance with the City Ordinance and ruling of the Department of Buildings, and hereby declares that all the fact and representations stated in this application are true and correct Fridley, Pill— 8-9-74 19� Owner Daryl V. Rollag Kind of Building Frame Used as Res. To be completed about 8-15-7k Estimated Cost, $ 10.00 A Old—Building Permit No. Permit No. �v Signed 2=" tes By MINNFGASCQ - - Business Phone No ROUGH FINAL. 7 ' % ' % S� REPAIRS 8c ALTERATIONS—Refer to Coda .50 State Surcharge Description .....Install......G...... .............. i 5.00 TOTAL FEE $ 5.50 Class 9IA5' Surcharge, .50¢ . CITY OF FRIDLEY APPLICATION FOR PLUMBING AND GAS FITTING PERMIT Job Address Jepartme+nt of Buildings City of Fridley Tel. #571-3450 The undersigned hereby makes application for a permit for the work herein specified agreeing to do all work in strict accordance with the City Codes and rulings of the Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and correc, Fridley, M1. /% — / C7' , 19 7r, OWNER KIND OF BUILDINGy USED AS TO BE COMPLETED ABOUT PARTIAL RATE SCHEDULE ESTI.MATED COST PLUMBING FIXTURE RATES: NO. N TOTAL tov ,V _ber Fixtures x $3.00 K e r^sture Fixture Opening Water $2.00 $ Company New Fixture, Old Opening x $2.00 - $ � y a $5.00 u o, Water Heater - to 99,000 BTU x $5.00 Hcater Tel. No. u ,-0 $10.00 M E •' r, W $ N I; r. $5.00 $ ROUGH INSP. v Date Electric 'rater Heater x $5.00 $ GAS FITTING FEES: FINAL INSP.S 2 -3 -off C O '4 q � n fy O 4 .i dJ N to G ij In M N •'I ji Gas Range to 199,000 BTU 'lec y y u REPAIRS 6 ALTERATIONS nw v; Z' u en a u State Surcharge 0 as TOTAL FEE $ __- lst 2nd I 3rd I ' "Iia ."..h t (R) = Future Connection Opening Connected with Sewer (") =Near F inure, Old Opening Wates Job Address Jepartme+nt of Buildings City of Fridley Tel. #571-3450 The undersigned hereby makes application for a permit for the work herein specified agreeing to do all work in strict accordance with the City Codes and rulings of the Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and correc, Fridley, M1. /% — / C7' , 19 7r, OWNER KIND OF BUILDINGy USED AS TO BE COMPLETED ABOUT PARTIAL RATE SCHEDULE ESTI.MATED COST PLUMBING FIXTURE RATES: NO. RATE TOTAL OLD - NEW BUILDING PERMIT NO. PERMIT NO. ,V _ber Fixtures x $3.00 $ r^sture Fixture Opening x $2.00 $ Company New Fixture, Old Opening x $2.00 - $ Signed By Catch Basin x $5.00 $ _ Water Heater - to 99,000 BTU x $5.00 $ Tel. No. 100,600 BTU to 199,000 BTU x $10.00 $ Water Softener x $7.00 $ New Ground R.'r. Old Building r. $5.00 $ ROUGH INSP. Date Electric 'rater Heater x $5.00 $ GAS FITTING FEES: FINAL INSP.S 2 -3 -off Date 1st 3 fixtures x $3.00 $ Additional Futures x $1.00 $ APPROVAL FOR PEFu+SIT Gas Range to 199,000 BTU x $10.00 $ REPAIRS 6 ALTERATIONS First $100.00 each add. $100.00 or fraction $5.00 $2.00 $ $ MINIMUM FEE FOR ANY PLUMBING PERMIT IS $7.50 State Surcharge $ .50 TOTAL FEE $ __- REINSPECTION FEE ($10.00) — ,._— .—. - --- -- --_ - — - — _ __ 5-7 Building Inspections 7.63-572-3604 DATE 1 � 11106 SITE ADDRESS 13 THIS APPLICANT IS: PROPERTY OWNER/ TENANT CONTRACTOR SUBMIT A COPY OF YOUR STATE LICENSE WITH APPLICATION PERMIT TYPE r rrl"Illm,, CrrY OF FRIEDLEY YOUR E-MAIL ADDRESS 2 lA 0 U t1J o 0'- P-ok N ❑ OWNER '1SC,`ONTRACTOR I\1I'll ,--1l,0 &I._i-,©.-1 ADDRESS: I f)'71 IF 1 C uun vtu irI UL) ti PHONE:_6 S i- to 5 i- 0 (- SSI Pemiit No.:w Received By: Date Rec' d: ATEW ZIPa `i3e_ COMPANY NAME: CONTACT PERSON: 8910 Wenll••• rkh Ave STATE LICENSE # Minnea Ino is. MW ADDRESS: (95218819000 CITY STATE ZIP PHONE 'SINGLE FAMILY 0 TWO FAMILY TYPE OF WORK: 1 O NEW REPLACEMENT DETAILF.]D DESCRIPTION OF WORK I a. Cly a -P r a� l n e/1JlPsV 1�,L4[" t3Zy FAX ❑ TOWNHOUSE ❑ ALTERAn0N/REMODEL ti 1,1 11P w u -H :� io Q d-7 PER MS 16B.665 the permit fee is a minimum of $15.00 or 5% of the total cost up to $500.00, whichever is greater, for the improvement, installation or replacement of a residential fixture, excluding the fixtures. (This should reflect only the cost of labor ) Labor cost under $300 = $15.00. Labor cost between $300 to $500 = cost of labor X.05 FOR PROJECTS WHERE LABOR EXCEEDS $500, FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)2- Equipment Installed MFG: UAVAwAc MODEL: 1.581 wl SIZFBTU MFG: MODEL: C- 40 -i -AA 3!o '7o SIZE/BTU -70, WD i"S1A MFG: MODEL: SIZEBTU X A/C $25.00 _FIREPLACE (GAS) $15.00. GAS RANGE/OVEN $10.00 AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 _ � GAS UNITHTRRILL $010.00 FURNACE $35.00 —BOILER SLINER $10.00 -GAS DRYER $10.00 _POOL HEATER $35.00 DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00 Permit Fee $ D . © Number of fixtures @ $10.00 x $10.00 = Surcharge .50 Number of fixtures @ $15.00 x $15.00 = $ TOTAL DUE $ 0 . Number of fixtures @ $25.00 l x $25.00 = $ Zs • c� v Number of fixtures @ $35.00 x $35.00 = $ 3 S State Surcharge = $ 50 Total = $ b U . S b THIS IS AN APPLICATION FOR A PERMIT NOT VALID UNTIL PROCESSED I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Fridley and with the Minnesota -Construction Codes; that I understand this is not a permit but only an application for a permit and work is not to start without a permit; that the work will be in accordance with the approved plan in the case of all work whic tures-review and approval of plans. SIGNATURE OF APPLICANT l,�T NAME g �' S� e1 Cy``tcCDATE , 1� b(> City of Fridley Building Inspections Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3604 FAX: 763-502-4977 ba$b—oci N4,'150r) Imp -9�( J Mb -1 Building Permit Fee BUILDING 61 'J . 2- 5 See Back Page for Fee Schedule Permit Noda -0,)(0 Inspections 65% of Building Permit Fee RESIDENTIAL APPLICATION Received By: 763-572-3604 Surcharge CITY OF FRIDLEY 1,52 .0005 x Permit Valuation Minimum $.50 Dat %": MAY,0 763-5LL,,02-4977 FAX , 60 $5.00 (State Licensed Residential Contractors) SAC Charge $ $1825 per SAC Unit (Plans to MWCC for determination) Curb Cut Escrow EFFECTIVE 1-1-08 ft + 6 ft = ft x $21= $ Erosion Control DATE '1 —d'9 ^ 06 YyOUR E-MAIL ADDRESS Park Fee "� Fee Determined by Engineering Sewer Main Charge SITE ADDRESSi�T�l I M C4OLt) nQf 10Y ea Total Due THIS APPLICANT IS: ❑ OWNER ftONCRACTOR 10(p 49 Make checks payable to: City of Fridley_ _ Attach Stipulations PROPERTY OWNER/ NAME: Ni NiP L 501-1 ADDRESSAClf MtAa0Wn-yM►r Once CITY �f_ i STATEMNZIP 55LIXa TENANT PHONE:�j S-�SS�;)" NAME: ADDRESS: -7 35, ( i r K(rr al) e! N # /WJ CITY_MAC 6LOVE STATE-PAZIPA _ CONTRACTOR SUBMIT A COPY OF PHONE ltd --I 9b'r9CXX) FAX iO3-1 1�b',;ZQ03 YOUR STATE LICENSE 3131 STATE LICENSE #_oZ �C � -&5 EXP DATE / 07 PROPERTY TYPE `;GINGLE FAMILYINEW CONSTRUCTION SIZE ❑ TWO FAMILY/NEW CONSTRUCTION STORIES PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED NDOWS ❑ BASEMENT FINISH ❑ ROOF 0 DRAIN TILE ❑ DECK ❑ SIDING ❑ OTHER ❑ SWIMMING POOL TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION KIAINTENANCE/REPAIR ❑ REMODELING DESCRIBE WORK BEING DONE: SIZE OF IMPROVEMENT LENGTH WIDTH WEIGHT SQ FT ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT: NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Plan GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used PROPOSED HEIGHT: SIDING FOR NEW CONSTRUCTION INCLUDING DECKS, ❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT: ❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures ❑ Other ❑ Fascia and proposed project. 2. Two sets of construction plans WINDOWS IN EXISTING OPENINGS Os ❑No LOCATION OF WINDOWS 3. Energy Calculations OR FOR NEW OPENINGS -DESCRIBE SIZE OF OPENING CHANGES & TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS 3 ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS: (USING THE 1997 UBC FEE SCHEDULE) TOTAL JOB VALUATION $ 3151.LI5 OCCUPANCY TYPE Permit Fee $ 61 'J . 2- 5 See Back Page for Fee Schedule Plan Review $ 65% of Building Permit Fee Fire Surcharge $ .001 times the total job valuation Surcharge $ 1,52 .0005 x Permit Valuation Minimum $.50 License Surcharge $ , 60 $5.00 (State Licensed Residential Contractors) SAC Charge $ $1825 per SAC Unit (Plans to MWCC for determination) Curb Cut Escrow $ ft + 6 ft = ft x $21= $ Erosion Control $ $450 Conservation Plan Review Park Fee $ Fee Determined by Engineering Sewer Main Charge $ Agreement necessary ( ) Non Necessary ( ) Total Due $ 10(p 49 Make checks payable to: City of Fridley_ _ Attach Stipulations THIS IS AN APPLICATION FOR A PERMIT -NOT VALID UNTIL PROCESSED I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a permit but only an application for a permit and work is not to start without a permit on site; that the work will he in accordance with e a roved plan ' e case of all work which requires review and approval of plans. SIGNATURE OF APPL N _PRINT NAME Ana i e n 6C7UIC DATE AC i APPROVED BY