PMT14-03132 J
City of Menifee Permit No.: PMT14-03132
29714 HAUN RD. Type: Residential Addition
MENIFEE, CA 92586
MENIFEE Date Issued: 11/26/2014
l
i
PERMIT
i
Site Address: 25872 BETH DR, MENIFEE, CA 92584 Parcel Number: 358-233-004
Construction Cost: $12,000.00
Existing Use: 1 &2 Family Residence Proposed Use:
Description of INSTALL 6'x 153' CITY STANDARD BLOCK WALL WITH 5 PILASTERS, SIDE GATE WITH 3
Work: PILASTERS AND 2 LIGHTS, 3'x 3T CITY STANDARD BLOCK WALL
Owner Contractor
FRED LEWIS
25872 BETH DRIVE
MENIFEE, CA 92584
Applicant License Number:
Fee Description QQtr Amount
Building Permit Issuance 1 27.00
GREEN FEE FEE 1 1.00
SM SIDEN IAWISM1 2:00,
$234.00
The issuance of this permit shall not prevent the building official from thereafter requiring the correction of errors in the plans and
specifications or from preventing builiding operations being carried on thereunder when in violation of the Building Code or of any other
ordinance of City of Menifee.Except as otherwise stated,a permit for construction under which no work is commenced within six
months after issuance,or where the work commenced is suspended or abandoned for six months,shall expire,and fees paid shall be
forfeited.
AA_Edg_Permit_Template.rpt Page 1 of 1
City Of Menifee
LICENSED DECLARATION
I hereby affirm under penalty or perjury that I am licensed under provisions of ❑ I, as owner of the property an exclusively contracting with licensed
Chapter 9 (commencing with section 7000)of Division 3 of the Business and contractors to construct the project(Section 7044, Business and Professions
Professions Code and my license is in full force and effect. Code:The Contractor's License Law does not apply to an owner of a property
License Class License No. who builds or improves thereon, and who contracts for the projects with a
Expires Signature licensed contractors)pursuant to the Contractors State License Law).
WORKERS'COMPENSATION DECLARATION
❑ I am exempt from licensure under the Contractors'State License Law for the
❑ 1 hereby affirm under penalty of perjury one of the following declarations: following reason:
I have and will maintain a certificate of consent of self-insure for workers' By my signature below I acknowledge that, except for my personal residence in
compensation,issued by the Director of Industrial Relations as provided for by which I must have resided for at least one year prior to completion of
Section 3700 of the Labor Code, for the performance of work for which this improvements covered by this permit, I cannot legally sell a structure that I have
permit is issued.
Policy# built as an owner-building if it has not been constructed in its entirety by licensed
contractors. I understand that a copy of the applicable law, Section 7044 of the
❑ 1 have and will maintain workers' compensation insurance, as required by Business and Professions Code,is available upon request when this application is
section 3700 of the Labor Code, for the performance of the work for which this submit,Sp at the lowing Web site:htto//www leoinfo ca gov/calaw html.
permit is issued.My workers'compensation insurance carrier and policy number are: -'YA-J �1V7 (L�f
Carrier Property Owner or Authorized Agent Datb
Expires Policy#
y my Signature below, I certify to each of the following: I am the property
Name of Agent Phone# owner or authorized to act on the property owner's behalf. I have read this
(This section need not be completed if the permit is for application and the information I have provided is correct. I agree to comply
one-hundred dollars($100)or less) with all applicable city and county ordinances and state laws relating to building
construction.I authorize representatives of this city or county to enter the above-
❑ I certify that in the performance of the work for which this permit is issued,I identified pro erty for the inspection purposes.
shall not ample v any persons in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become IMA (( LI7 1
subject to the workers'compensation provisions of Section 3700 of the Labor Property O`wn r orAut orized Agent Da e
Code, I shall forthwith comply with those provisions.
City Business License#
Date; Applicant;
WARNING: FAILURE TO SECURE WORKERS' HAZARDOUS MATERIAL DECLARATION
COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS WILL THE APPLICANT OR FUTURE BUILDING
($100,000), IN ADDITION TO THE COST OF COMPENSATION, OYES OCCUPANT HANDLEA HAZARDOUS MATERIAL ORA
- DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE MIXTURE CONTAINING A HAZARDOUS MATERIAL
LABOR CODE, INTEREST,AND ATTORNEYS FEES ❑NO EQUAL TO OR GREATER THAN THE AMOUNTS
CONSTRUCTION LENDING AGENCY SPECIFIED ON THE HAZARDOUS MATERIALS
I hereby affirm that under the penalty of perjury there is a construction lending INFORMATION GUIDE?
agency for the performance of the work which this permit is issued (Section WILL THE INTENDED USE OF THE BUILDING BY THE
3097 Civil Code) APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE
- Lender's Name ❑YES A PERMIT FOR THE CONSTRUCTION OR MODIFICATION
FROM THE SOUTH COAST AIR QUALITY MANAGEMENT
Lender's Address ❑NO DISTRICT(SCAQMD) SEE PERMITTING CHECKLIST FOR
OWNER BUILDER DECLARATIONS GUIDE LINES
I hereby affirm under penalty of perjury that I am exempt from the Contractor's PRINT NAME:
License Law for the reason(s)indicated below by the checkmark(s)I have placed OYES WILL THE PROPOSED BUILDING OR MODIFIED FACILITY
next to the applicable item(s) (Section 7031.5. Business and Professions Code: BE WITHIN 1000 FEET OF THE OUTER BOUNDARY OF A
Any city or county that requires a permit to construct, alter, improve, demolish, ❑NO SCHOOL?
or repair any structure, prior to its issuance, also requires the applicant for the
permit to file a signed statement that he or she is licensed pursuant to the
provisions of the Contractor's State License Law (Chapter 9 (commencing with I HAVE READ THE HAZARDOUS MATERIAL
Section 7000)of Division 3 of the Business and Professions Code)or that he or OYES INFORMATION GUIDE AND THE SCAQMD PERMITTING
she is exempt from licensure and the basis for the alleged exemption. Any CHECKLIST. I UNDERSTAND MY REQUIREMENTS
violation of Section 7031.5 by any Applicant for a permit subjects the applicant to ❑NO UNDER THE STATE OF CALIFORNIA HEALTH AND SAFETY
a civil penalty of not more than($500).) CODE, SECTION 25505 25533 AND 25534 CONCERNING
I, as owner of the property, or my employees with wages as their sole HAZARDOUS MATERIAL f'ZEPORI ING.
co pensation, will do ( )all of or( ) porting of the work, and the structure is PROPERTY OWNER OR AUTHORIZED AGENT
not intended or offered for sale.(Section 7044,Business and Professions Code;
The Contractor's State License Law does not apply to an owner of a property X
who, through employees' or personal effort, builds or improves the property,
provided that the improvements are not intended or offered for sale. If,however,
the building or improvement is sold within one year of completion, the Owner-
Builder will have the burden of proving that it was not built or improved for the
purpose of sale).
III
BUILDINGiPERMIT/PLAN APPLICATION
..'Menifee
DATE It Z41 PERMIT/PLAN CHECK NUMBER
TYPE: C, COMMERCIAL . RESIDENTIAL O MULTI-FAMILY C; MOBILE HOME POOL/SPA SIGN
SUBTYPE: C ADDITION ALTERATION O DEMOLITION O ELECTRICAL "') MECHANICAL
O NEW OPLUMBING RE-ROOF
APPLICATION NAME (e— e,vvt s I
DESCRIPTION OF WORK �Sia.bllh (e. fYGlndl bIOLJk (/llfit� � I A.SfCPS
GOndul � iE� 2eLfi��c�, � 2 fe-06de 11h Jn C4tld qate 9 r C,
PROJECTADDRESS 2,5i?n Be44, DP, I e2
ASSESSOR'S PARCEL NUMBER LOT 2,1 TRACT 49 City of Meni e
Dept.
OWNER NAME NOV 2
ADDRESS 'y
PHONE at-,I &111 9'V3 _
_. a?qo! 46 412 EMAIL eiW 4K-I # now, c0.*, Recehi d
APPLICANT NAME ReA Lewj'i
ADDRESS
PHONE EMAIL
CONTRACTOR'S NAME PW ieOWNER BUILDER? XYES NO
BUSINESS NAME
ADDRESS
PHONE EMAIL
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION
VALUATION$ 1Q CJ[y' - SO FT L SQ FT
? 2 APPLICANT'S SIGNATURE DATE I I ZlU 6
AI
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE SMIP GREEN 1=�
INVOICE PAIDAMOUNT
AMOUNT <' CASHiECK# %CREDIT CARD VISA/MC
PLAN CHECK FEES PAIDAMOUNT C+ CASH 0CHECK# +'CREDITCARD VISA/MC
OWNER BUILDER VERIFIED OYES C, NO LICENSE NUMBER NOTARIZED LETTER "0 YES <" NO
City of Menifee Building& Safety Department 29714 Houn Rd. Menifee, CA 92586 951-672-6777
www.cityofinenifee.Lis Inspection Request Line 951-246-6213
PERMIT NO.
�` SITE PLAN
fu/
NAME A �if l��l� PHONE(6iC'j) Lf2% 16IZ
SITE ADDRESS
ASSESSORS PARCEL NUMBER
City of Menifee
Provide North Arrow REAR PROPERTY LINE Building & Safety Dept.
NOV 2 6 2GS
Rece� e ,.
' II 11 V � v/�
ND12> i1 �
t) Co rld LA l and <ivjeev?5 to Cr l�
will be 1Y)r-161W Il.4ulo P- PiluSters
Pllc,sier5 for tnlirivig Iasi+a ^
S 06 617ener5 orfd p - 6 - Electvlc por S
Ilghtlny marlCed 'L' gate openers I
D on drawing and ligki,ng D
E p E
P
R NOMC Walls P ago*7asiers R
0 and gG1e5 t' 153' QnVacy block 0
P 3 wall G all P
R 2) Power -from Garage E E E
T pGhel is 9Aje P p P P R
Y openers and j
I7:j
EieAflc Y
➢atiel
L p -
I L
N 37' PLAtJTER. WALL
E 3'�a" CITY 0 MENIFEE
curb _ 5' BUILDING AND SAFETI
B of 11 Pr,'�e
PLAN APPROVAL
�Ight o� wrA�� I o ' '
REVIE ED BY L
FRONT PROPERTY LINE 'Approval of these plans shall not be co,
approval of,any violation of any provisio
regulations and ordb*Kes. This set of a
jobsite until completion.
d_i qq wnd
Pn 1 of 9
City of Menifee
Building & Safety Dept.
FOOTING OPTION. "A" FOOTING OPTION "B"
Received
#4 HORIZONTAL REBAR
(USE BOND BEAM BLOCK)
I
6"OR B" BLOCK
"H" „H„
HEIGHT FROM TOP #4 HORIZONTAL AT 32" MAX.O.C. HEIGHT FROM TOP
OF FOOTING (USE BOND BEAM BLOCK) OF FOOTING
SEE TABLE"A" SEE TABLE"B"
FOR REBAR SIZE FOR REBAR SIZE
AND SPACING AND SPACING
LOCATE PEEAR IN CENIEROP CEW kOCATEREWRINCENfEROFCELU
FINISH GRADE V
(1)-#4 REBAR
IIII CONTINUOUS I E _ J
12" 1a i a - `'i� (2)-#4 REBAR 1r
;'. . z '..-..:Y _ I�. CONTINUOUS _._. '� 70„ 12"
,�, _E
REVERSE
DIRECTION OF W. „W„
HOOK ON EVERY (F�ING WI � WIDTH)
—►II
OTHER REBAR SEE TABLE"A" SEETAB E"B" ,
ALL FOOTINGS ADJACENT TO
-t[ I SLOPES TO BE AT LEAST 5'TO
. GI FF AS_SHOWN-BEt6
"H" "W" VERTICAL ' u VERTICAL 0
REINFORCEMENT Hn "W, —REINFORCEMENT
3' 17" #4 @ 48"O.C. 3' 19" #4 @ 48"O.C.
4' 20" #4 @ 48"O.C. 4' 22" #4 @ 48"O.C.
5' 23" #4 @ 481'O.C. 5' 29" #4 @ 48"O.C.
6' 29" #4 @ 24"O.C. BOTF7- k
6' 34" #4 @ 24"O.C.
FOOTI
NQTE�S: CHECK wrr..H THE-5viLDINg[DEPARTMENT TO
1)THIS DESIGN DOES NOT ALLOW GRADE DIFFERENTIALS OF VERIFY IFA RUII_D1NQ PERMIT IS REovIR.E�.D..
MORE THAN 6"ON OPPOSING SIDES OF THE WALL. THIS IS WHEN A PERMrr IS REQUIRED,THE FOLLOWING
NOT A RETAINING WALL. INSPECTIONS ARE REQUIRED:
2)FENCE HEIGHTS ARE REGULATED—CONSULT ZONING 1)F.00TIN.�R.:EXCAVATION TRENCH CLEAN WITH
REGULATIONS BEFORE BEGINNING CONSTRUCTION. STEEL IN PLACE AND SUPPORTED 3"ABOVE Ap�E 'AU MI
ry1�
3)NO WATER COURSE OR NATURAL DRAINAGE SHALL BE AWAY FROM THE SURROUNDING EARTH/DIRT./ u
OBSTRUCTED. 2)RE@AR./PRE-GROUT;BOND BEAM REBAR AND
4)GROUT ONLY THE CELLS CONTAINING REBAR. THIS WALL VERTICAL REBAR IN PLACE-INSPECTION PRIOR TO
1S NOT DESIGNED FOR ALL CELLS TO BE GROUTED. PLACING GROUT.
5)ALL REBAR TO BE ASTM SPEC.A61 5,GRADE 40 MINIMUM. 3)FINAL:AFTER GROUT IS PLACED-PRIOR TO Y
6)ALL REBAR LAP SPLICES TO BE 24"MINIMUM. DECORATIVE CAP PLACEMENT.
7)ALL MASONRY UNITS TO BE ASTM C-90 GRADE N. a
8)REBAR TO BE CENTERED IN MASONRY CELLS.
WESTERN RIVERSIDE COUNTY CODE UNIFORMITY PROGRAM
'SEE PAGE 2 FOR ADDITIONAL INFORMATION' CITY OF MENIFEE trued 1 beapermft
QISCL.AIME.R; I BUILDING Sr SAFETY DIVISION�UI IIt ederal,Sti(r
ALTERNATE DESIGNS MAY BE POSSIBLE
WHEN PROVIDED WITH AN ENGINEERED FREESTANDING BLOCK WALL IarismiNtb
ANALYSIS. USE OF THIS STANDARD DESIGN
IS AT THE USER'S RISK AND CARRIES NO 29714 HAUN ROAD
IMPLIED OR INFERRED GUARANTEE AGAINST 951.672.6777
FAILURE OR DEFECTS, MENIFEE, CA 92586
REBAR PLACEMENT
ILLUSTRATION FOOTING OPTION 8
Do (TYPICAL)
ALL REBAR SPLICES
24 MIN. OVI=SLAP— -- -- - _ —
4.r
rl
s,
sV
• (TYPICAL)
ONLY CELLS AND BOND BEAM
COURSES WITH REBAR TO BE
GROUTED
(DO NOT SOLID GROUT ENTIRE WALL-USE
.� GROUT STOP MESH AS APPROPRIATE)
FOOTING OPTION A (TYPICAL)
ALL. REBAR SHALL HAVE A
MINIMUM OF 3" CONCRETE
COVER AT FOOTINGS
D E�UGN PARAMETI=RS; WESTERN RIVERSIDE COUNTY CODE UNIFORMITY PROGRAM
ACTIVE SOIL PRESSURE(PSF) =30 �
PASSIVE SOIL BEARING(PSF) =150 CITY OF MENIFEE
COEFFICIENT OF FRICTION =0.25
ALLOWABLE SOIL BEARING(PSF) =1500 _ NIF - =� BUILDING Sc SAFETY DIVISION
WIND=BO MPH,EXPOSURE C
SEISMIC: fat FREESTANDING (BLOCK WALL
NA=1.3.NV=1.6,Z=0.4,SOIL PROFILE=So _,_
29714 HAUN ROAD~
951.672.6777 MENIFEE, CA 92586
City Df Menifee
TOP VIEW
Building 8, Safety Dept.FOOTING NOV 2 6 2014 I 1
E;E ! BLOCK
27" GROUT ReceiVed I
�. .:: . .., \ STEEL REBAR
REBAR
PLACEMENT
r---27^
ILLUSTRATION
� I I
m;
II. SEC_ TION VIEW
I I
I;
BLOCK
(12"X 12"OR 16"X 16')
Iti, ya I I
`' uF
SOLID GROUT
i MIN.24"
6' 12*4
(4)-#4 REBAR REBAR I 1
I 1E
MAX '`+� '? (ONE AT EACH CORNER) OVERLAP O
I1117
.J
- ALL FOOTINGS ADJACENT TO
" SLOPES TO BE AT LEAST S'TO
t
DAYLIGHT AS SHOWN BELOW.
Viz' ii7
3i1
MIN 24"
REBAR C?.
OVERLAP �`
GRADE tI+I Obi ' -
s' ::i::::;:::::
'¢3s ` BOTTOM
4" _ sze -r. = OF 5'MIN.
FOOTING
LIMITATION—s:
FOOTING RERARS 1 PILASTER SPACING SHALL NOT EXCEED 20 FT.WHEN OTHER INFILL FENCING
20, HAVEA MIN.6"IgNG NO
HOOK AND A MIN. IS ATTACHED.
tg' CONCRETECOVER OFS". Z,ONLY OPEN TYPE FENCING(SUCH AS WROUGHT IRON)MAY BE ATTACHED TO
PILASTERS. SOLID TYPE FENCING MAY NQj BE ATTACHED TO PILASTER.
3.GATES AND DOORS ATTACHED TO PILASTER ARE LIMITED TO 200#MAX,
WEIG14T AND 4 FT.MAX.WIDTH PER PILASTER.
' I 4-THIS PILASTER DESIGN IS INTENDED TO BE USED O LY AS A FENCING�- ,1 27' —ry FEATURE AND IS NOT INTENDED TO SUPPORT ANY OTHER LOADS. 1r
S.FENCE HEIGHTS ARE REGULATED—CONSULT ZONING REGULATIONS BEFORE
O1i_EGK WITH THE BUILDING.DEPARTMENT BEGINNING CONSTRUCTION.
TO VERIFY IFA BUILDING,PEamiT IS REQUnjED. 6.INSTALLATION OF ELECTRIC CIRCUITS,CONDUITS,OR LIGHTING FIXTURES
WHEN A BUILDING PERMIT IS REQUIRED, REQUIRE ELECTRICAL PERMITS AND INSPECTION.
THE FOLLOWING INSPECTIONS ARE ALSO REQUIRED: 7 FOOTINGS TO BE PLACED IN UNDISTURBED SOIL OR PROPERLY COMPACTED
1)FOOTING; EXCAVATION TRENCH CLEAN WITH STEEL AND ENGINEERED FILL-
IN PLACE AND SUPPORTED 3"ABOVE AND AWAY FROM 6.FOR DESIGN PARAMETERS,SEE FREESTANDING BLOCK WALL STANDARD.
THE SURROUNDING THE EARTH/DIRT. AT
2) REBA]34PREGRQUT; VERTICAL REBAR IN PLACE- WESTERN RIVERSIDE COUNTY CODE UNIFORMITY PROGRAM
INSPECTION PRIOR TO PLACING GROUT. ran
3)HNAL;AFTER G ROUT IS PLACED-PRIOR TO ANY CITY OF MENIFEE or ty
DECORATIVE CAP PLACEMENT.
DIVISION
BUILDING & SAFETY ON 'ke on the
MSC AiMER: __
ALTERNATE DESIGNS MAY BE POSSIBLE WHEN PROVIDED WITH MASONRY PILASTER
AN ENGINEERED ANALYSIS.USE OF THIS STANDARD DESIGN IS
AT THE USERS RISK AND CARRIES NO IMPLIED OR INFERRED 29714 HAUN ROAD
GUARANTEE AGAINST FAILURE OR DEFECTS. 951.672.6777
MENIFEE, CA 92586
November 13, 2014 City of Menlfee
Building & Safety Dept.
Fred N. Lewis NOV 2 6 2014
25872 Beth Dr. Received
Menifee, Calif. 92584
Subject: Approval to install block wall on property line
I am signing this letter to approve the installation of a block wall on our shared property line.
This will be a 6 (six)foot high wall replacing 120 feet of existing split rail vinyl fence.
I am also agreeing to pay you $1920 as my portion of the total cost.
Printed Name ���"
Address: 25 f� �j$ /3,-O'? D,1t'e Me-211ee q�U'F1V
Signed
Date:
J
Note:Must be signed and notarized.
it
CALIFORNIA ALL-PURPOSE
CERTIFICATE OF ACKNOWLEDGMENTCity '
Building&f Menifee
safety Dept.
State of California
County of Riverside NOV 2 6 2014 i
Received
On 111181201Y before me, Isabella Sukga, Notary Public _
(lien insert nanic and title of the ofliccr)
personally appeared N1)Aze) Davzi0s
who proved to me on the basis of satisfactory eviden to be the Person/whose nani 1s arc subscribed to
the within instrument and h I(nowledged to me tha she/they executed the same in its ier/their authorized
capacity,(0<. and that b hi-- her/their signalurevon the instrument the person , or the entity upon behalf of
which the persol91acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the Stine of California that the roregoing paragraph
is true and correct.
ISABELLA SUKUA
COMM. #2007429 Z
WITNESS my hand and official seal. °�, as Notary Public•California o
/I 1 e. Riverside County —
'//�—�5� � " o M Comm.Expires Feb.12,2017 ;
� l/ I
signanuc of Notary Public
(Notary scan
i
I
I
ADDITIONAL OPTIONAL INFORMATION
INSTRUCT-IONS FOR COMPLETING THIS FORM
Pop• ucku"u ledgmenl ( np(eled in ('nikin'rtia "nut contain rerhiage emetic as
DESCRIPTION OF THE ATT'ACI-[ID DOCUMENT nppeurr uhove in Ire "alarr..'emm.. ur"..rpm',nr"eAno"'hd4lnenl,hnmr nmal he
l 1 pruperit uinplethd and anuth•d In thin doonnenf. /ht ool)' exception Is I/ o
Ap}�YOd2 I fJ it a� OG`{ dur"nonl is In he I n o"I"f ...hide n ("L nr"i" In .ut h inrltnmr.r.Ina-uhemanire
F_(' �..._.._.... 1..b W 11 9n r r i t
(I isle air description ol'tntached documenq
- nrknmi heh'nrcru relGwFc as "un he pruned rrrl such a dlcu"Ie'n .o Inug as the
..11 le•I beige due.not rerJune Ilrt•"nlar) In do.v"nellring ILN io rllehal/in a area,.in
(}sljfnrnirl(i.e. veliff•inq Ike authorized cal aci(r of the signer'). Please check she
it —..'_—..— d"..Inert'"'ehdA�fr"'pruprrnoh"'I'davurinlg nod nnmdr Ihir Inrnr ifr'e<"irrd
(`le nr descrgnion at at ached document Continue ee) u /
1.,f / �J 7 . state unit County information trod be tile d
e State Ind County where the oeuatent Number of(ages_..__ Document Date siener(s)persnnolly:gapatmd beline the n6luty public for acknowledgment.
L] - one of notariiution mini be the date Ihnr the signer(s)personally appeared which
must also be the same late the acknnwledgntenl is completed.
(Additional information) - The notnry public intent print his or her name as it appears within his or her
conouission followed by a comma and then your title(notary public).
- Print the namels) of document signet(s) who persumdl) appear at the lime of
notarization.
CAPA Y CLAIME Y THE SIGNER - Indicate the correct singular or plural forte by crossing off incorrect I'ornis(i.e.
ldlvidual helsheAbeY-is hire)or circling the correct forms.Failure to correctly indicate this
infnnnation may lead to reieclimt of document recording.
El Corporate Officer - The notary seal impression must be clear and Photogrophically reproducible 1
Impression mina not cover test or lines. If seal impression smudges.re-seal if a
I fide) sufficient area permits,otherwise complete a different acknowledgment linen.
❑ Partner(s) - Signature or the notary public must imnch the signature on rile with the office at '
❑
rite county clerk.Attorney-in-Fact Additional alternation is not required but could help to ensure this
❑ Trustee(s) acknowledgment is not misused or attached to a dil7ercla document.
❑ Other Indicate title or type of aaached document,number ol'pages and date.
<• indicate the capacity claimed by the signer. If the claimed capacity is u
corporate officer.indicate the title(i.e.CFO.(PO,secretary).
- Securely attach this document to lie signed document
In
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