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1249 NE 91 Terr (4)/ : Permit No Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of work. Owner's Name and Address. - -.. / Street- . Registered Architect and /or Engineer Employing Plumber's Name PFa 1 .74 -- — 2 /j • 1 No, Street.. 42 .- , Location and Legal Description Lot Bloch Street and Number where work is to be performed —No State work to be performed and purpose of building (By Flews) __ ..___.. - -. New Building Remodeling Addition Size Septic Tanl c _ - -• ----- - - - - -- — - - - -- T Ype of Tank —_ Amount of Permit $ MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Feet of Drain Tile._._ _Dist. Feet of Tank or Drain Field from Well_ -_ Nature of Water Supply: City — Well. — __.__._.__. , ____._..-.Size of Soakage Pit (Signed) _ The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5988, Compiled General Laws of Florida Perinanent Supplement, and has com- plied with the provisions thereof, and will require similar compliance from all contractors or sub- contractors employed by him in the work to be performed under this permit; and will post or cause to be posted' for inspection on the site of the work such public notice or notices as are required by the Act. The undersigned agrees to employ only such sub - contractors, on work to be performed under this permit, as are licensed by Miami Shores Village. (Signed) Repairs No. of Stories Street Capacity Gals. Plumbing Inspector. Muter Plumber. STATE OF FLORIDA, COUNTY OF DADE. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acicnowledgrents, personally appeared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the ._..___...... . . .. ............ .. ....._ -.. of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all fads therein by him stated are true. My Commission Expires Notary Public, State of Florida , NOTE: A re- inspection fee of *1.00 will be made when tares re-inspection is mede•neoessary by hnpruper notice for inspection, or faulty materials and /or workmanship. CATCH OASIH FLOOR DRAIN ORINKIN* FOUNT' NS 1...:4',I4, t o A /') 4,i4/0 TOTAL FIXTURE[ CLOSET[ BATH TUBS SHOWERS LAVA- TORIES SINK[ SLOP 5114K1 LAUNCH' Tugs URINAL[ CONTR. I LST IST CHICK /-f . Ai J .2. G _ :9, 7) SEPTIC TANK SEWER CONN. DRAIN FIELD 5OAKA0[ PIT G TRAP SOLAR HEATER DRIP WELL SPRKLR. S SWIM'O POOL CONTR. '- LIST CHECK / : Permit No Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of work. Owner's Name and Address. - -.. / Street- . Registered Architect and /or Engineer Employing Plumber's Name PFa 1 .74 -- — 2 /j • 1 No, Street.. 42 .- , Location and Legal Description Lot Bloch Street and Number where work is to be performed —No State work to be performed and purpose of building (By Flews) __ ..___.. - -. New Building Remodeling Addition Size Septic Tanl c _ - -• ----- - - - - -- — - - - -- T Ype of Tank —_ Amount of Permit $ MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Feet of Drain Tile._._ _Dist. Feet of Tank or Drain Field from Well_ -_ Nature of Water Supply: City — Well. — __.__._.__. , ____._..-.Size of Soakage Pit (Signed) _ The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5988, Compiled General Laws of Florida Perinanent Supplement, and has com- plied with the provisions thereof, and will require similar compliance from all contractors or sub- contractors employed by him in the work to be performed under this permit; and will post or cause to be posted' for inspection on the site of the work such public notice or notices as are required by the Act. The undersigned agrees to employ only such sub - contractors, on work to be performed under this permit, as are licensed by Miami Shores Village. (Signed) Repairs No. of Stories Street Capacity Gals. Plumbing Inspector. Muter Plumber. STATE OF FLORIDA, COUNTY OF DADE. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acicnowledgrents, personally appeared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the ._..___...... . . .. ............ .. ....._ -.. of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all fads therein by him stated are true. My Commission Expires Notary Public, State of Florida , NOTE: A re- inspection fee of *1.00 will be made when tares re-inspection is mede•neoessary by hnpruper notice for inspection, or faulty materials and /or workmanship. LIST CHECK Permit No Size Septic Tank______ Feet of Drain Tile Date--- - `_ Application is hereby made for the approval of the detailed statement of the plans and specifications herewith sub tted for the building or cther structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of work. e Owner's Name and Address g i '' L' L _ Registered Architect and /or Engineer __ __ __— 7-7' Employing Plumber's Name erg ` — " "...1 4�/ ' " ° -- / -' �' — i No. Stree (7 l Location and Legal Description Lot Bloch Subdivisi Street and Number where work is to be performed —No -, i , - = Street Amount of Permit $ STATE OF FLORIDA, } is. COUNTY OF DADE. MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT State work to be performed and purpose of building (By Floors) _ _ New Building — ____________ _______ Remodeling __ __— Addition Type of Tank _ _____Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: City —Well __________________Size of Soakage Pit ( Signed)._ The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations a an /employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Sup a ent, and has com- plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed b ma in the work to be performed under this permit; and will post or cause to be posted' for inspection on the site of the work such public notice or notices as are required by die Act. The undersigned agrees to employ only such sub- contractors, on work to be performed under this permit. as are licensed by Miami Shores Village. (Signed)_ Repairs No. of Stories.. ........ . ...... ... Street . _L �..- -- . Capacity Gals--- ---- -- - -- -- - - -- reef) > � °L e My Commission Expires Notary Public, State of Florida ing Inspector. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the __ _________ _ of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts therein by him stated are true. NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made • necessary by improper notice for inspection, or faulty materials and /or worlonanship. CLOSETS T BATH L SHOWERS T LAVA- S SINKS S SLOP L LAUNDRY C ( l CAT H F FLOOR D DRINKING T TOTAL CONTR. p p� _ CHICK - _ - -- SEPTIC S SEWER D DRAIN S SOAKAGE G GREASE S SOLAR D DEEP S SPRKLR. S SW IM'G CONTR. / / Permit No Size Septic Tank______ Feet of Drain Tile Date--- - `_ Application is hereby made for the approval of the detailed statement of the plans and specifications herewith sub tted for the building or cther structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of work. e Owner's Name and Address g i '' L' L _ Registered Architect and /or Engineer __ __ __— 7-7' Employing Plumber's Name erg ` — " "...1 4�/ ' " ° -- / -' �' — i No. Stree (7 l Location and Legal Description Lot Bloch Subdivisi Street and Number where work is to be performed —No -, i , - = Street Amount of Permit $ STATE OF FLORIDA, } is. COUNTY OF DADE. MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT State work to be performed and purpose of building (By Floors) _ _ New Building — ____________ _______ Remodeling __ __— Addition Type of Tank _ _____Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: City —Well __________________Size of Soakage Pit ( Signed)._ The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations a an /employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Sup a ent, and has com- plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed b ma in the work to be performed under this permit; and will post or cause to be posted' for inspection on the site of the work such public notice or notices as are required by die Act. The undersigned agrees to employ only such sub- contractors, on work to be performed under this permit. as are licensed by Miami Shores Village. (Signed)_ Repairs No. of Stories.. ........ . ...... ... Street . _L �..- -- . Capacity Gals--- ---- -- - -- -- - - -- reef) > � °L e My Commission Expires Notary Public, State of Florida ing Inspector. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the __ _________ _ of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts therein by him stated are true. NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made • necessary by improper notice for inspection, or faulty materials and /or worlonanship. MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT P , .. cz^�3t No -- -• -- - -- Date - --- -�' - -= -- - ° - _= -�'- -- - - -- Application is he:eby n acre for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of work. Lootion and Legal Description Lot Blodr Subdivision.- Stye: t and Number whero work is to be performed —No.__ vt .�_... __ ...... Street-_ . - State work to he performed and purpose of building (By Fl oors)_ ._ ---- _--------------- __._.____ /44 ' /..? , s .- Ow er's Name and A ddress- - -f =! l �.. , �% .- - =- ��1-- ��_ - -- _ No.. -_ - - -- `? •� Street /.i1, . Registered Architect and /or Engineer..______..__._.__._ � _.______._ Employing Plumber's Name_y L_ v ' , i14. L..LJJ _.ci s l c_Lt `fa No.l '_ ��- - - -_ -� StreetLi. New Building__-- ______. ...... _...___ Remodeling- _ - -_ -- _ _____ Addition------- _._- .--- •- -___ -. Repairs No. of Stories Size Septic Tank__.. - .� Type of Tank ' a,_ Feet of Drain Tile___ _ :_ � � .__Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: City — Well._____ Size of Soakage Pit Amount of Permit $-- ...... STATE OF FLORIDA, r j as. COUNTY OF DADE. (Signed)_ Capacity Gals Plumb _ Inspector. The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has com- plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are required by the Act. The undersigned agrees to employ only such sub- contractors, on vlk Ad be per 9zm€ J under this pg;mit, as are licensed by Miami Shores Village. My Commission Expires Notary Public, State of Florida Master Plumber. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the___ of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts therein by him stated are true. NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made•neoessary by improper notice for inspection, or faulty materials and /or workmatlahip. rLO�pTv BATH TUBS SHDWERf LAVA. TORIES S SINKS SLOP SINKS LAUNDRY TUBS URINALS CATCH BASIN FLOOR DRAIN DRINKING FOUNT•NB TOTAL FIXTURES LI v Cmhcm SSPTSC: TANK SEWER CONN. DRAIN FIELD SOAKAGE PIT GREASE TRAP SOLAR HEATER DEEP WELL SPRKLR. SYSTEM SWIM'o POOL CONYR. LIST CHECK /f �` MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT P , .. cz^�3t No -- -• -- - -- Date - --- -�' - -= -- - ° - _= -�'- -- - - -- Application is he:eby n acre for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of work. Lootion and Legal Description Lot Blodr Subdivision.- Stye: t and Number whero work is to be performed —No.__ vt .�_... __ ...... Street-_ . - State work to he performed and purpose of building (By Fl oors)_ ._ ---- _--------------- __._.____ /44 ' /..? , s .- Ow er's Name and A ddress- - -f =! l �.. , �% .- - =- ��1-- ��_ - -- _ No.. -_ - - -- `? •� Street /.i1, . Registered Architect and /or Engineer..______..__._.__._ � _.______._ Employing Plumber's Name_y L_ v ' , i14. L..LJJ _.ci s l c_Lt `fa No.l '_ ��- - - -_ -� StreetLi. New Building__-- ______. ...... _...___ Remodeling- _ - -_ -- _ _____ Addition------- _._- .--- •- -___ -. Repairs No. of Stories Size Septic Tank__.. - .� Type of Tank ' a,_ Feet of Drain Tile___ _ :_ � � .__Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: City — Well._____ Size of Soakage Pit Amount of Permit $-- ...... STATE OF FLORIDA, r j as. COUNTY OF DADE. (Signed)_ Capacity Gals Plumb _ Inspector. The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has com- plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are required by the Act. The undersigned agrees to employ only such sub- contractors, on vlk Ad be per 9zm€ J under this pg;mit, as are licensed by Miami Shores Village. My Commission Expires Notary Public, State of Florida Master Plumber. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the___ of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts therein by him stated are true. NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made•neoessary by improper notice for inspection, or faulty materials and /or workmatlahip. Permit No -1- Owners Name and Address 2? Registered Architect and /or Engin Emplayi _g ( P�lttmbe�Q NaJo / 11 Location and legal DesrtipHon L,oif 3 i 3 �` 3e. L Street and Number where work Is to be performed —No MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of. Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of work. State work to be performed and purpose of building (By Floors )___ _ New Building. -_ - -- _ _ _.._._........_._ Remodeling— ____.. __.___..__ Addition.. _____ No/aZ(7 / - Street_ Repairs Date / ` Zez ..._ -- — — Street ._ st___ • - r1- C Block / Subdivision No. of Stories Size Septic Tank_ -Type of Tank_ Feet of Drain Tile_ ___ —Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: City—Well. Size of Soakage Amount of Permit $ My Commission Expires (Signed) plied with the provisions thereof, and will require similar compliance from all contractors or sub -con performed under this permit; and will post or cause to be posted' for inspection on the site of required by the Act. The undersigned agrees to employ only such sub-contractors, on licensed by Miami Shores Village. (Signed) Plumbing Inspector. The undersigned applicant for this building permit does hereby certify that he understands a(1d accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5988, Compiled General Laws of Florida Permanent Supplement, and hrr cnm- rs employ by him in the work to he work such publi. , .. _ . : 'cos as err to caned er • t, as are STATE OF FLORIDA, 1 COUNTY OF DADE. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take aclmowledgments, personally appeared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the .___ -- - _ --- ...-- -._... _ _ ... — ._ of the above described construction, that be has carefully read the foregoing application, and that be did sign the same, and that all facts therein by him stated are true. Notary Public, State of Florida Master Plumber. Y..- NOTE: A re- inspection fee of 11.00 will be made wham some miasmal= Y oade by improper notice far inspection. or faulty materials and /or workmanship. CLOSETS BATH TUEa aMOW[Ra LAVA• TORIES SINKS SLOP •INK[ LAUNDR Tuaa URINALS CA TC H eA[IN FLOOR DRAIN DRINKING FOYNT'NE TOTAL FItTURES CONTR. LIST CHECK SEPTIC TANK SEWER CONK. DRAIN FIELD SOAKAGE PIT G TRAP SOLAR HEATER DEEP WELL 5 SYSTEM SWIM•O POOL CONTR. LIST CHECK Permit No -1- Owners Name and Address 2? Registered Architect and /or Engin Emplayi _g ( P�lttmbe�Q NaJo / 11 Location and legal DesrtipHon L,oif 3 i 3 �` 3e. L Street and Number where work Is to be performed —No MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of. Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of work. State work to be performed and purpose of building (By Floors )___ _ New Building. -_ - -- _ _ _.._._........_._ Remodeling— ____.. __.___..__ Addition.. _____ No/aZ(7 / - Street_ Repairs Date / ` Zez ..._ -- — — Street ._ st___ • - r1- C Block / Subdivision No. of Stories Size Septic Tank_ -Type of Tank_ Feet of Drain Tile_ ___ —Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: City—Well. Size of Soakage Amount of Permit $ My Commission Expires (Signed) plied with the provisions thereof, and will require similar compliance from all contractors or sub -con performed under this permit; and will post or cause to be posted' for inspection on the site of required by the Act. The undersigned agrees to employ only such sub-contractors, on licensed by Miami Shores Village. (Signed) Plumbing Inspector. The undersigned applicant for this building permit does hereby certify that he understands a(1d accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5988, Compiled General Laws of Florida Permanent Supplement, and hrr cnm- rs employ by him in the work to he work such publi. , .. _ . : 'cos as err to caned er • t, as are STATE OF FLORIDA, 1 COUNTY OF DADE. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take aclmowledgments, personally appeared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the .___ -- - _ --- ...-- -._... _ _ ... — ._ of the above described construction, that be has carefully read the foregoing application, and that be did sign the same, and that all facts therein by him stated are true. Notary Public, State of Florida Master Plumber. Y..- NOTE: A re- inspection fee of 11.00 will be made wham some miasmal= Y oade by improper notice far inspection. or faulty materials and /or workmanship. fl i Lt.. STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT Applicant ;it "-- : A Permit Number i.: • ' - PART 11 - SYSTEM INSTALL TION INSPECTION AND FINAL INSTALLATION APPROVAL Installer f Proper tank legend: Yes r' ■ No Tank material ' Tank level: Yes , z No Tanks watertight: Yes �- ` No Tank size - -- gallons gallons gallons Proper tank outlet device: Yes , i , No Manhole or marker to grade: Yes No Drainfield Trench Absorption Bed Length Width Length Width Length _ feet x2= 2'feet & ) ft feet feet feet feet Length feet x ' - - ° — feet = - ft feet feet i feet feet Proper No. drainlines: Yes - No Beet feet ° feet feet Proper pipe separation: Yes - No Total = ft Total = ft Distribution box level: Yes No ! Y Systems located as permitted: Yes .✓ No Systems including plumbing stub -outs installed at proper elevation: Yes No Average depth to drainpipe invert from finished grade: `. v inches Maximum depth - Inches Average depth of drainfield gravel: _LL inches Minimum depth of gravel inches Proper gravel size: Yes / No Gravel is suitable quality: Yes No Backfill or fill material as required: (Quality) Yes No (Quantity) Yes No 1 Other findings ',/') -' , - Inspected by v . Tank Manufacturer / '4 a Date a , PART III - FINAL ILLATION APPROVAL Date a'` I `Approved by (■ COUNTY PUBLIC HEALTH UNIT AN APPROVED INSTAL ION DOES NOT GUARANTEE PERFORMANCE Note: Completed copies of this form will bk provided to \the applicant, installer and the building department. FIRS—H Form 4016, Feb 85 (Obsoletes previous editions which may not be used) (Stock Number. 5744 - 002 - 4016-0) Page 2 of 2