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Home My Public Portal About10317 OLIVE ST_Building__ 76A698ACE0809B-641LICATION FOR BU1 . ING PER ILJI COUNTY OF LOS ANGELES BUILDING / DEPARTMENT OF COUNTY ENGINEER ADDRESS 5101 BUILDING AND SAFETY DIVISION LOCALITY ` JOHN A. LAMBIE-. COUNTY ENGINEER NEAREST COLEMAN W. JENKINS.SUP'T OF BUILDING CROSS ST. DIS RLICT NO G TYPE. PR FOR APPLICANT TO FILL IN L CONST. f BUILDING STATISTICALSIFICATION SE E AP ADDRESS ! ® I IJP` CLASS NO. DWELL UNITS BK PG LOT NO. ar- �er BLOCK USE ZONE MAP /J C NO. V TRACT mL�a,fl SPECIAL NO. OF BLDOS.. CONDITIONS SIZE OF LOT NOW ON LOT USE OF �j E IST G V V�I/L �� BLDG. SETBACK FROM TEL FRONT PROP. LINE OF - (STREET) OWNER y C+d3ILI- TYPE OF EXISTING SETBACK HIGHWAY YARD = TOTAL ADDRESS /f�j. �.�•C/^ HIGHWAY D 'F. MC.L. CITY �—cw-, tz, c" ARCHITECT OR TEL. BLDG. SETBACK FROM ENGINEER NO. SIDE PROP. LINE OF (STREET) TYPE OF EXISTING SETBACK HIGHWAY + YARD = TOTAL } ADDRESSI1�� HIGHWAY WIDTH FROM C.L. a C N RAC�TOR rrt Zri7 N L. ba$' + ADDRES 83 '6 10C.14+ �5 7� CORNER CUTOFF YES NO 0 CITr��►� - CL SS T3 1 SEE REVERSE SIDE FOR SPECIAL APPROVALS ,v DESCRIPTION OF WORK y Z NEW ADD ALTER REPAIR DEMOLISH Q.FT. 4/ 0 4b Z,Y23NO. OF NO. OF SIZE 'T STORIES FAMILIES USE OF STRUCTURE 1�NF+J� rLm+ F ' SIG ,NATURE OF APPLICANT VALUATION$ �6 APPROVALS DATE INSPECTOR'S SIGNATURE P.C. PMT. FOUNDATION, LOCATION FEE$ FEE$ . FORMS,.MATERIALS FRAME, FIRE STOPS, / ', '•: '1p 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION BRACING BOLT h i G• AND STATE THAT THE ABOVE ISCORRECT AND AGREE TO COMPLY FURNACE: LOCATION WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING - GAS VENT. DUCTS 9UILDING CONSTRUCTION. 1 CERTIFY THAT. IN DOING THE WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA- LATH. INT. TION OF THE LABOR CODE OF YHE STATE OF CALIFORNIA RELAT- ING TO WORKMEN'S COMPENSATION INSURANCE. f� LATH. EXT. -24- 10iP' a.:•-�� •�¢' SIGNATUREOF HOUSE NUMBER COR-- PERMITTEE RECT AND POSTED. l' I �/r�s 1�" i ADDRESS 0 ' J----fwnotn Fl NAL JOHN F. LEWIS. PRINCIPAL STRUCTURAL ENG R PLAN CHECK VALIDATION cK: M.O. CASH _ PERMIT VALIDATION CK. M.O. CASH .6 8 2 8� JAN23 1 D 8.01 �' 19 �GAB86A CIS#903 41-8 APPLICATION F'OF2- BUIL®INC PERMIT. 1 COUNTY OF LOS ANGELES BUILDING , 'DEPARTMENT OF COUNTY ENG01EER ADDRESS BUILDING AND SAFETY DIVISION LOCALITY a JOHN A.LAMBIE,COUNTY ENGINEER NEAREST CASSATT D.GRIFFIN SUPT OF BUILDING CROSS ST. DISTRI�. GROU I TYpE OCESSED Y FOR APPLICANT TO FILL IN CONST. BUILDING " STATISTICAL SSIFICATION SEWERPAP ADDRESS K �' �' CLASS.NO. DWELL.UNI S LOT NO. BLOCK MAP • ,� STATE YES NO NUMBER HWY. TRACT ^j' K U E ZONE SPECIAL ` NO.OF BLDGS. CONDITIONS SIZE OF LOT `tlp 7.� I NOW ON LOT �/ USE OF - EXISTING BLDG. Zh C BUILDING EXIST. YARD HWY STREET N ME OWNER C Q`�•� SETBACK WIDTH FRONT. --r 6a, 1 ADDRESS 113 t , ,e_ S ` .SIDE CITY is e-Vw C C �� TEL 'P.L. No. INSPECTION RECORD ARCHITECT OR TEL. - ENGINEER. NO. TEL CONTRACTOR NO. a• �1 DDRESS �� i -..,�sF • DESCRIPTION OF WORKRE 6 NEW ,.ADD ALTER REPAIR DEMOLISH SO.FT: NO.OF NO.OF SIZE STORIES FAMILIES USE OF STR CTURra E SIGNATURE OF r f APPROVALS APPLICANT •� DA lk' -ACTOJt:,S_S.GN••,URE ADDRESS tj%X. V UNDATION: LOCATION someastum. FORMS,MATERIALS s�' P.C. S FRAME: FIRE STOPS. - _1 FEE BRACI NG..-BOLTS i VALU ION $ O'y` FURNACE:LOCATION, UC1" �*.�+►'/'^� FEE GAS VENT,DTS - IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP- LATH.INT. PLICATION AND STATE THAT THE ABOVE IS CORRECT AND — AGREE TO COMPLY WITH ALL C LINTY OR. NCE AND LATH,EXT:;. .STATE ,TAWS TINGULAB DIN CON RU ION. SIGNATUREO HOUSE NUMBER COR- PERMlTTE RECT AND POSTED' ADD RESS FINAL CLYDE N.DIRLAM.PRINCIPAL STR URAL ENGINEER PLAN CHECK VALIDA N ce. M.O. cash PERMIT VALIDATION c M.O. CASH 0 C- 2.2. 7 JUN`�_. 1 Aa 1-2.00 ,. . 4'. 76A BA CE#6038-64 ;APPLICATION _FOR BUILOIN. -PERMITV COUNTY OF LOS ANGELES BUILDING ° DEPARTMENT OF COUNTY ENGINEER ADDRESS BUILDING AND SAFETY DIVISION LOCALITY , `�, c_ - l � JOHN A. LAMBIE. COUNTY ENGINEER NEAREST 1 COLEMAN W. JENKINS SuP r.oF BUILDING CROSS S.T. -Q_�N� v DI ICT Na,. GRPOUTYPE. PROC SSED BY FOR APPLICANT TO FILL IN ,. CONST BUILDING STATISTICAL CLASSIFICATION SEWER MAP ADDRESS \� ,�, CLASS NO: � DWELL UNITS 8K PG LOT NO. .it "-' BLOCK USE ZONEMAP a NO. TRACT [.' SPECIAL NO. OF SLOGS. CONDITIONS SIZE OF LOT' NOW ON LOT USE OF E IS NG BLDG. BLDG. SETBACK FROM EL. mNT PROP. LINE OF /h91� (STREET) OWNER ` ` O. Lu E OF EXISTING SETBACK HIGHWAY + YARD = TOTAL ADDRESS II \\ h \f\ %/!•-( - HIGHWAY .WIDTH 'F FROM CC..L: CITY 1 ��li� 1'1 \� "�\��p1 T r K FROM + BLDG. SETBACK FROM ARCHITECT OR TEL.; \ SIDE PROP. LINE OF (STREET) ENGINEER NO. TYPE OF EXISTING SETBACK 'HIGHWAY } YARD TOTAL ADDRESS HIGHWAY WIDTH FROM C.L. n CONTRACTOR j \^ e`P�` NOL + — L ADDRESS LNO I CORNER CUTOFF YES NO C CITY ' �� LIC SEE REVERSE SIDE FOR SPECIAL APPROVALS DESCRIPTION OF WORK C, a •'15��n .� �-10 ' .r, �.��! a 4,. �_ NEW ADD ALTER REPAIR DEMOLISH ` SQ.FT. NO. OF NO. OF WU 1 `.�/�ffr!I .� I SIZE STORIES FAMILIES' �' G USE OF .f/Jt l.Bl7`O7F. : STRUCTURE ..Gs!S ..Itx- StA*L'�.4'1�4# �Is<+@Ld•P;}i�. �O�i�GLSW� •.�711.�µ�G arr SIGNATURE OF « t., e f�N'f• - GLS l�� APPLICANT � VALUATION$ APPR VALS ATE INSPECT R'S SIGNATURE CI FOUNDATION, LOCATION (, � l 'FEE$ FEE$/J FO'RMS,.MATERIALS,:, -•-,a►"—*/, 'FRAME, .FIRE STOPS, ` I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION BRACING BOLT AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION 1 WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT. DUCTS �/ • + ar7 9UILDI NG CONSTRUCTION. I CERTIFY THAT. IN DOING THE WORK yy-,y� py,, AUTHORIZED HEREBY 1 WILL NOT EMPLOY ANY PERSON IN VIOLA- LATH. INT. - ti� r TION OF THE LABOR CODE OF THE'STATE OF CALIFOR - ■■■ cy ING TO WORKMEN'S.C MPENSATION INS ;NCE: LT)3 �r yl ' LATH. EXT. 0. C SIGNATURE OF HOUSE NUMBER COR-- d� ' PERMITTEE RE AND POSTED A ADDRESS I +^ • + w� -FINAL u-IL'.� r , soi JOHN F. LEWIS. PRINCIPAL ST R RAL ENGINEER PLAN CHECK VALIDATION CK. -M.O. CASH PERMIT VALIDATION CK. M.O. CASH 8 1 D Ll�,o 0 .8 3 1 { P,R 2 1°5 N rt ' 76Ae:5�ea1:51;k•808 9-67 "APPLICATION OR BUI rING PERMIT COUNTY OF LOS ANGELES BUILDING DEPARTMENT OF COUNTY ENGINEER ADDRESS /D3 J • G-i dE BUILDING AND SAFETY DIVISION LOCALITY M Oe, C j11r Se JOHN A. LAMBIE, COUNTY ENGINEER COLEMAN W. JENKINS, SUPT OF BUILDING NEAREST CROSS ST. /12.13 FOR APPLICANT TO FILL IN DISTRIC�NGROUP CONST. P ES Y Print or type only) 157 BUILDING /V� STATISTICAL CLASSIFICATION SEWER MAP ADDRESS rO3%7 . C/VC CLASS NO. DWELL.UNITS BKPG LOT - �^—Is fBLOCK USE ZZ)ONE MAPINO �� c TRA j /� SPECIAL • NO.OF BLDG (J CONDITIOmee SIZE OF LOT NOW ON LOT USE OF EXISTING BLDG. i BLDG.SETBACK FROM TEL FRONT PROP.LINE OF (STREET) OWNER ScAyee de- No. - _ TYPE OF EXISTING SETBACK HIGHWAY + YARD - TOTAL ADDRESS 10311 L-i o- At, HIGHWAY WIDTH FROM C.L. Y a. + CITY OLJa{ C I T' �' - ARCHITECT OR TEE. SIDE ACK M ENGINEER NO. SIDE PROP.LINE OF (STREET) TYPE OF EXISTING SETBACK HIGHWAY + YARD = TOTAL ADDRESS HIGHWAY WIDTH FROM G.L. TEL + = Com. CONTRACTOR //yam NO. Ar' � .91 O ADDRESS .3D3-/Y.C&feTly, NO (�f 1.3 CORNER CUTOFF YES ❑ NO m CITY y I✓, CLL C'- 2-7 --SEE REVERSE SIDE FOR SPECIAL APPR VALS DESCRIPTION OF WORK L" ISS z N ADD ALTER REPAIR DEMOLISH T. NO. OF NO. OF " O • SIZE z4 ,25cSTORIES FAMILIES USE OFST�RCUC R fi • J 1 K�j aw-/ .7 4a C �f SI ATU OF O A PLICA /- .Z*%A'O (00 VALUATION 5 CIO e� APPROVALS DATE INSPECTOR P.C. PMT. O d FOUNDATION: LOCATION FEE$ FEE$ - - .FORMS, MATERIALS FRAME: FIRE STOPS, I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION BRACING BOLTS AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION, WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT, DUCTS BUILDING CONSTRUCTION. I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA- TION OF THE LABOR CODE OF THE STATE OF CALIFORNIA RELAT- LATH, INT. ING TO WORKMEN'S COMPENPATION INSURANCE. LATH, EXT. SIGNATURE OF r HOUSE NUMBER COR- PERMITTEE RECT AND POSTED ADDRESS p f iJ1Z`T-iS FINAL JOHN F. LEWIS. PRINCIPAL STRUCTURAL EN GASH PLAN CHECK VALIDATION CK. M.G. CASH PERMIT VALIDATION CK. M.O. `I: o'46 7 6P,3 Xff 1 � 1 2 Q 0N n 78A638A CE#803 3-88PPLICATION OR BU I I NG PERMITA L COUNTY OF LOS ANGELES BUILDING DEPARTMENT OF COUNTY ENGINEER ADDRESS BUILDING AND SAFETY DIVISION LOCALITY JOHN A. LAMBIE•. COUNTY ENGINEER NEAREST COLEMAN W. JENKINSAUP•T OF BUILDING CROSS-ST. FOR APPLICANT TO FILL IN DIT 0 yip GA?P--[CONST� P cE D-BY BUILDING STATISTICALSI•FICATION SEWER MAP- ADDRESS CLASS NO. DWELL UNITS BK G LOT NCI. � BLOCK USE ZONE MAP %7 O NO. TRACT -� - _ SPECIAL N0. OF SLOGS. CONDITIONS SIZE OF LOT NOW ON LOT USE OF ZXI,Tl LDC. SETBACK FROM OWNER 't NOL FRONT PROP. LINE OR - - (STREET) a TYPE OF EXISTING SETBACK HIGHWAY + YARD - TOTAL ADDRESS '` 7 / � (, HIGH Y W T FROM C L. CITY /��• !' `� �� + - ARCHITECT OR TEL. BLDG. SETBACK FROM . ENGINEER NO. SIDE PROP. LINE OF (STREET) TYPE OF EXISTING SETBACK HIGHWAY + YARD = TOTAL ADDRy�E�1SS _1,724p7. fp LW.,lMAXu'0rw TE /'/ HIGHWAY WIDTH FROM C.L. LU NJJTp�kACTOR • �I NOLIC 7 Z NO CORNER CUTOFF YES �' NO CITYCrZA '� `Ic - / SEE REVERSE SIDE FOR SPECIAL'APPROVALS C DESCRIPTION OF WORK NEWA ALT REPAIR-4 DEMOLISH SQ.FT. NO. OF NO. OF SIZE STORIES FAMILIES USE OF STRUCTURE oll SIGNATUREOF C�/�Ye4_G¢�td�� _5(m ✓icL; v v/\ i9 APPLICANT VALUATION$ C� X00 APPROVALS DATE INSP l6dolo SIG MATURE P.C. Q�Q p� PMT. FOUNDATION, LOCATION ..:..� F.EE$ /V ✓ FEE$ / FORMS, MATERIALS a � FRAME, FIRE STOPS,' 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING BOLT AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT. DUCTS 9UILDING CONSTRUCTION. I CERTIFY THAT. IN DOING THE WORK AUTHORIZED HEREBY-I WILL NOT EMPLOY ANY PERSON IN VIOLA- LATH. INT. ��12 TION OF THE LABOR CODE OF THE STATE OF CALIFORNIA RELAT- _ ING TO WORKMEN'S ENSATION INSURANCE. LATH. EXT. v SIGNATURE OF HOUSE NUMBER COR- PERMITTEE ARE AND POSTED / A ADDRESSCffr 1 N A L. 7 J`J 1 JOHN F. LEWIS. PRINCIPAL STRUCTURAL ENGINEER PLAN CHECK VALIDA ON - cK. M.O. CASH _ PERMIT VALIDATION . CK.. M.D CASH L,C6 8 O 8.4% APR 17 2 3 D- 1 .8 O.0 i - a 1 .8 2-% 'RPR 2.4 _1 D 3"6: 0 75A6AA CE#909 9.67 / / ,•L APPLICATIO FOR B DING PERMIT L� COUNTY OF LOS ANGELES BUILDING :.,AER1#RTMENT OF COUNTY ENGINEER ADDRESS BUILDING AND SAFETY DIVISION LOCALITY JOHN A. LAMBIE, COUNTY ENGINEER COLEMAN W. JENKINS, SUPT OF BUILDING NEAREST.;., . CROSS&.-' FOR APPLICANT TO FILL, IN DISTRICT NO. GROUP TYPE CE D BY ` O�NO.?! CONST- Print or type only) BUILDING STATISTICAL CLASSIFICATION SEWER MAP ADDRESS CLASS NO. g& KDWELL,UNITS BK G LOT NO. .f�� BLOC * USE ZONE MAP NO. O TRACT g0ga ` SPECIAL NO.OF BLDGS. CONDITIONS SIZE OF LOT NOW ON LOT USE OF EXISTING BLDG. n LDG.SETBACK FROM EL. FRONT PROP.LINE OF -(STREET) TYPE OF EXISTING SETBACK HIGHWAY + YARD - TOTAL ADDRESS !i[GliWAY WIDTH FROM C.L. CITY + - U ARCHITECT O TEL. SI DG ROP.LIN FROM ENGINEER NO. SIDE PROP.LINE OF (STREET) T•YPEOFEXISTING••SETBACK HIGHWAY } YARD = TOTAL ADDRESS - HIGHWAY WIDTH FROM C.L. TEL. + _ kCONTRACTOR- NO. LIC. C= CORNER CUTOFF YES ❑ NO V ADDRESS NO. C cm CITY CLASS SEE REVERSE IDE FOR SPECIAL APPROVALS DESCRIPTION OF WORK. �Q LL z DD ALTER REPAIR DEMOLISH SQ. FT. NO. OF NO. OF SIZESTORIES FAMILIES USE OF STRUCTURE SI NATURE APPLICAN VALUATION S ?j .APPROVALS DA'T'E INSPECTOR'S SIGNATURE P.C. PMT. / FOUNDATION: LOCATION d2 FEES FEFORMS, MATERIALS 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION FRAME: FIRE STOPS, BRACING,'BOLTS Zp AND STATE-THAT. THE ABOVE ICORRECT AND AGREE TO COMPLY FURNACE: LOCATION, '•'- - WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT, DUCTS BUILDING CONSTRUCTITION. I CERTIFY TIFY THAT IN DOING THE WORK , AUTHORIZED HEREBY-1 WILL NOT EMPLOY ANY PERSON IN VI - ' TION OF THE LABOR CODE OF THE STATE O 'CALIF NIA REL LATH, INT. A ING TO WORKMEN' Ct�NSAT[ON IN AN ATH, EXT. SIGNATURE OF H USE NUMBER COR- PERMITTEE' RECT AND POSTED ADDRESS IN L' JOHN F. LEWIS. PRINCIPAL STRUCTURAL PLAN CHECK VALIDATION CK. M.O. CASH. _ PERMIT VALIDATION -CK. M.G. CASH ( .3'1 5 .• FEB 16 D- .6.0-0N- P WORKERS'COMPENSATION DECLARATION hereby affirm that I have certificate of consent to self APPLICATION FORBUILDING PERMIT insure, or a certificate of Workers'Compensation Insurance, or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.PC 975 58&mpany Republic Indemnity BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ® Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS LOCALITY NEAREST Date 11-1-86 Applicant Randol Roofing CITY Temple City zip 91780 CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one US Z(�NE MAP _ s1 hundred dollars($100)or less.) TRACT BLOCK LOT NO. / ( NO. TEL. — SPECIAL I certify that in the performance of the work for which this OWNER Harr Scheibel NO.448-299 CONDITIONS permit is issued, I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PR SSED BY V so as to become subject to the Workers'Compensation Laws. ADDRESS 10317 Olive CONST. ZONE r Date 9-5-86 CITYZIP ppcantSTATISTICAL CLASSIFICATION APT. CONDO. 16- NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. Exemption, you should become subject to the Workers' 4 ENGINEER NO. CLASS NO. DWELL.UNITS 111111 Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER NAP r� with comply with such provisions or this permit shall be deemed revoked. TEL' BK. PG, VALIDATION CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 529 E. Valley Blwif&.451937 VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY San Gabriel CLASS C-39 $ 2.629.00 , SQ. FT. NO.OF NO.OF CHECK License Number 451937 Lic.Class C-39 SIZE STORIES FAMILIES ONE Contractor Randol Roofing Date 9-5-86 DESCRIPTION OF WORK Re-roof house & NEW ❑ $ ❑ ADD E]I am exempt under Sec. a a e tt tt — / B.&P.C. for this reason glas shingles. ALTER REPAIR ❑ DA EL 2:Lz: �—� USE OF IN .DEMOL ❑ ' Date: EXISTING BLDG. SFD B Signature APPLICANT TEL. 1P OWNER-BUILDER DECLARATION PRINT NO. _ I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS Professions Code): PRESENT ❑ BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). 'S J5 4 1. 1 A REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for HFRN a o a o 0 1 the performance of the work for which this permit is issued 0 0 5 9 L 5 tSec. 3097, Civ. C.). a o05g256Lender's Name 0910-86 Permit Fee 48.75 Lender's Address r I certify that I have read this application and state that the Issuance Fee 10.50 above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee 59.25 and hereby authorize represe tatives of this County to enter upon th bo menti ned operty for inspection purposes. 9-5-86 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date ®s