HomeMy WebLinkAbout29283-Z FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-29440 Date: 04/30/03
THIS CERTIFIES that the building ACCESSORY
Location of Property: 1500 MT BEULAH AVE SOUTHOLD
(HOUSE NO. ) (STREET) (HAMLET)
County Tax Map No. 473889 Section 51 Block 3 Lot 2 .14
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated APRIL 10, 2003 pursuant to which
Building Permit No. 29283-Z dated APRIL 11, 2003
was issued, and conforms to all of the requirements of the applicable
provisions of the law. The occupancy for which this certificate is issued
is ACCESSORY INGROUND SWIMMING POOL WITH FENCE TO CODE AS APPLIED FOR.
The certificate is issued to JOHN GREENE
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
ELECTRICAL CERTIFICATE NO. N-625504 12/08/83
PLUMBERS CERTIFICATION DATED N/A
Authorized Signa re
Rev. 1/81
FORM NO. 3
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Hall
Southold, N.Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
PERMIT NO. 29283 Z Date APRIL 11, 2003
Permission is hereby granted to :
JOHN GREENE
1500 MOUNT BEULAH AVE
SOUTHOLD,NY 11971
for
CONSTRUCT AN INGROUND SWIMMING POOL WITH FENCE TO CODE AS
APPLIED FOR. (REPLACES BP #12705-Z)
at premises located at 1500 MT BEULAH AVE SOUTHOLD
County Tax Map No. 473889 Section 051 Block 0003 Lot No. 002 . 014
pursuant to application dated APRIL 10, 2003 and approved by the
Building Inspector to expire on OCTOBER 11 , 2004 .
Fee $ 150 . 00
Authoriz Signat re
ORIGINAL
Rev. 5/8/02
FORM NO. f
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
M, 12705 Z Date �. .....;�................... 19R"
Permission is hereby granted to:
................
.............................................
to .. 1 F^ 4.11 sACY....�?^�.. f....... *!C... ....it
.SP ......0-�....................
U ...q.�................................ ........ ...... .... ....... ..............................................
of premises located at .............. M ..............
.................................................................................................................................................................
..................................................................................... . . ....................................... ......
...................
County Tax Map No. 1000 Section ,— ��..)........... Block ..... `�............ Lot No. �. ..a....�...........
pursuant to application doted ..... ..... ..................... 1911-, and approved by the
Building Inspector.
r
Fee $ .42-1...�..x?..i...........
Ril.fh-
Building Inspector
Rev. 6/30/80
Form No.6
TOWN OF SOUTHOLD 76 S
BUILDING DEPARTMENT
TOWN HALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
This application must be filled in by typewriter or ink and submitted to the Building Department with the following:
A. For new building or new use:
1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or
topographic features.
2. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of I% lead.
5. Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate
of Code Compliance from architect or engineer responsible for the building.
6. Submit Planning Board Approval of completed site plan requirements.
B. For existing buildings (prior to April 9, 1957) non-conforming uses,or buildings and "pre-existing"land uses:
1. Accurate survey of property showing all property lines, streets, building and unusual natural or topographic
features.
2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is
denied, the Building Inspector shall state the reasons therefor in writing to the applicant.
C. Fees
1. Certificate of Occupancy-New dwelling $25.00, Additions to dwelling$25.00,Alterations to dwelling$25.00,
Swimming pool $25.00, Accessory building$25.00, Additions to accessory building $25.00, Businesses $50.00.
2. Certificate of Occupancy on Pre-existing Building- $100.00
3. Copy of Certificate of Occupancy-$.25
4. Updated Certificate of Occupancy- $50.00
5. Temporary Certificate of Occupancy-Residential $15.00, Commercial $15.00
Date. 0�J�/g�D3
New Construction: X Old or Pre-existing Building: (check one)
Location of Property: 15,60 Mo�,x�t� ga.� /�j ryu" : u
House No. Street Hamlet
Owner or Owners of Property: ( r a,d- A
Suffolk County Tax Map No 1000, Section l 5, 1 Block 3 Lot 2 1 y
Subdivision Filed Map. Lot:
Permit No. Date of Permit. Applicant:
Health Dept. Approval: Underwriters Approval:
Planning Board Approval:
Request for: Temporary Certificate Final Certificate: >C (check one)
Fee Submitted: $ 2S•
pp scant Satu
�c..4 3 7 7 � �s� _--
co �2: agy6 `f
�= 10M M8 THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
�M9 83 JOHN STREET, NEW YORK, NEW YORK 10038 1a� �
Date UeQBmUer of 1983zw
Application No.on file 243=/83
I' THIS CERTIFIES THAT
N 625504
only the electrical equipment as described below and introduced by the applicant named on the above application number in the premises of ..
Mr. John Green, Mt. Beulah AveNxte, Southold, N.Y.
in the following location; ❑ Basement ® Ist Fl. ❑ 2nd Fl. Ga f OUt►side Section Block Lot
was examined on Neer 28, 1983 and found to be in compliance with the requirements of this Board.
f�
�- FIXTURE ECEPTACLES SWITCHES FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS
OUTLETS INCANDESCENT.FLUORESCENT M uY
i.�. VA AMT. K.W. AMT. K.W. AMT. K.W. AMT. K.W. AMT. H.P.
` DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIME CLOCKS gLL UNIT HEATERS MULTI-OUTLET DIMMERS
,..� AMT. K.W. OIL H.P. GAS H.P. AMT. NO. A.W.G. AMT. AMP. AMT. AMPS. TRANS. AMT. H P SYSTEMS
NO.OF FEET AMT. WATT$
20
3
SERVICE DISCONNECT NO.OF S E R V I
AMT AMP TYPE METER C E
EQUIP. 1,92W 1 0 3W 3,B'3W 3,f'IW NO.OF CC.COND. A.W.G. NO.OF HI-LEG A•W.G.
-T- PER B OF CC.COND. Of HI•LEG NO.OF NEUTRALS OF EN UTRAI
r..
OTHER APPARATUS:
r
1-4.F.C.I.
(SWIM, pool) This certificate covers
Heaa>I31aEI of uauieual calaplianoe at the date of inspection only.
envir mMts it is advisable to have frequent test and/or repairs
ma& by a qualified person.
A.C.R. Electric Corp.
53-A Lamar Street
West BAbylon, N.Y. 11704 Lic. 171
..
GENERAL MANA
'-
Per
This certificate must not be altered in any manner••return to the office of the Board if incorrect. Inspectors may be identified by their entials.
-= COPY FOR B ILDING DEPARTMENT.THIS COPY nF CFRTICIi%A-rC ILSL'IO-r•.O%T
TEL. 765-1802
e�FFU(K�� TOWN OF SOUTHOLD
OFFICE OF BUILDING INSPECTOR
P.O. BOX 728
N TOWN HALL
SOUTHOLD, N.Y. 11971
DATE: Julyll , 1986
APPLICANT:
Dear:
While reviewing our files I find that your expired
pool permit � (P has never been finalized. Kindly return
the enclosed application with a check for $5 .00 . Also, please
call and arrange for a final inspection so that we may issue
a Certificate of Occupancy on the above pool and complete
this outstanding file.
Yours Truly,
\(L �� wc-Z4 4�L oe—
Victor Lessard
Executive Adminstrator
OCCUPANCY OR
USE IS UNLAWFUL
WITHOUT CERTIFICATE
OF OCCUPANCY
TEL. 765-1802
c�VEfan TOWN OF SOUTHOLD
OFFICE OF BUILDING INSPECTOR
P.O. BOX 728
N TOWN HALL
p Off. SOUTHOLD, N.Y. 11971
December 8 , 1987
Terence Green
Mt . Beulah Ave .
Southold , N .Y . 11971
Dear Mr . Green :
I am writing to you about your permit for an
inground pool and fence . Please be advised that the
permit has expired and you have not passed the final
inspection .
When I did the inspection I found that the fence
was not installed according to what was submitted on
the application . Also any doors from the house and gar-
age will be required to be self closing and self latch-
ing and a minimum of 40" off grade .
Please comply with these regulations within 30
days or a new permit will be required . When you have
corrected these things please call our office for a
reinspection . Thank you .
Yours truly ,
Thomas Fishep
TF :hdv Building Inspector
OF PROPERTY
�(► f tAOr • SU2YL°YFrO FOIZ
TERRY F 6P-8EN
scaie: 5C2 '= l" AND
tJOHN GREENE
Suff. Lo. tdx parcal: AT
----f9jx--' l000 -oSl-3- Pt. oft 60UTH0LD
A26A: 40,009 Ja. rT, R's t1JsFOL/C Go. , al. Y.
y }. /�� c / j w� f M
L� MIAUTKOMZEn ALTVATION 00 ADDITIO. C UONO n i re d" 7 o V. V. tile. �j Jf lHourostCe
V f0 1N1< SUf VET IS A VIOLATION Of
h Co.tovnd to Southold davinga dondc
.r EDuuur. -.A.:., 43 QUYVd t/6� +`/O V. 3• /3f1. I
Q THE acr �l .1
:A „.
; �4I?E�/GAG �//I tilTt1 Yt, R C.
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TO Of A
OUAM,,lf S I -AI a SMAIt RUN
ONLY To TH- , .A IH, SUWET LJcenscd Lord •S�rveyor�
IS RRE;A.Uc A H.* _ lIr IU THE
TITLE COlAFn ... q A -lCY AND GYl t
LENDING IkS 11.T }. 'v AND
THE ASSIG 15 F 1 : --DING MSTV
-ON.GUARAKTEIS A— .pT TMWIRAIIU I
TADDITIONAL INSTHUl1ONS OR SURSEQUEM-•5. ,
LOT 6 "NOT. $EL/L.AN AClt65 "
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--------- ----- 9 Sas'- �--- .
INSPETO
(16) 765-1802 �$UFFOL,S CO
O
VICTOR LESSARD, Principal SCOTT L.HARRIS,Supervisor
� y` p
CURTIS HORTON, Senior y Southold Town Hall
VINCENT R.WIECZOREK, Ordinance p P.O.Box 1179,53095 Main Road
ROBERT FISHER, Assistant Fire d,� 0!� Southold, New York 11971
O� �0
Fax(516) 765-1823
Building Inspectors Telephone (516) 765-1800
THOMAS FISHER
GARY FISH
OFFICE OF BUILDING INSPECTOR
TOWN OF SOUTHOLD
ORDER TO REMEDY VIOLATION
Date: January 20 , 1993
TO: Mr. John Greene
125 East 63rd Street-Apt. 7B
New York, New York 10021
PLEASE TAKE NOTICE there exists a violation of:
Zoning Ordinance - CHAP. 45
Other Applicable Laws, Ordinances or Regulations
at premises hereinafter described in that:
USING AN INGROUND SWIMMING POOL WITHOUT THE ISSUANCE OF
A CERTIFICATE OF OCCUPANCY
In violation of CODE OF THE TOWN OF SOUTHOLD, CHAPT. 45-15
YOU ARE THEREFORE DIRECTED AND ORDERED TO comply with the
law and remedy the conditions above mentioned IMMEDIATELY
The premises to which this ORDER TO REMEDY VIOLATION refers
are situated at: 1500 MT. BEULAH AVE. SOUTHOLD, COUNTY OF
SUFFOLK, NEW YORK
SUFFOLK COUNTY TAX MAP #1000-51-3-2. 14
Failure to remedy the conditions aforesaid and to comply with the
applicable provisions of law may constitute an offense punishable
by fine or imprisonment or both.
Gar Fish,
Building Inspector
encl.
(Cert. Mail)
INSPECTO
(516) 765-1802 �SUFFO(,�co
VICTOR LESSARD, Principal
tiy` Gy SCOTT L.HARRIS,Supervisor
�
CURTIS HORTON, Senior y Southold Town Hall
VINCENT R.WIECZOREK,Ordinance p P.O.Box 1179,53095 Main Road
ROBERT FISHER, Assistant Fire Southold, New York 11971
Fax (516) 765-1823
Building Inspectors Telephone (516) 765-1800
THOMAS FISHER
GARY FISH
OFFICE OF BUILDING INSPECTOR
TOWN OF SOUTHOLD
December 7, 1992
Mr. John Greene
125 East 63rd Street Apt. 7B
New York, New York 10021
Re: Building Permit #13024Z- SWIMMING POOL
Premises: 1500 Mt. Beulah Ave. , Southold
Suff. Co. Tax Map #1000-51-3-2.14
Dear Mr. Greene:
The above building permit has expired and a Certificate of
Occupancy has never been issued.
You are aware that you did not pass the final inspection
because the fence was not installed properly. We have requested
you to move the latches on the gates to the required 40" from
grade on the inside of the enclosure.
This is the fourth notice that you have received from this
office advising of the violation. Kindly contact this office
immediately so that we may clear up this matter and avoid any
possible legal action as this constitutes an unsafe condition.
I am returning check #200 in the amount of $25. 00 as it is
outdated. Please submit a new check and the enclosed CO
application.
Thank you for your anticipated cooperation in this matter.
Ver truly yours,
Gar li6i ,
Building Inspector
GJF:gar
encl.
(Cert. Mail)
gUFF0j,FcoG
y�
Town Hall, Main Road y x Fax (516) 765-1823
P. O.. Box Box 1179 Telephone (516) 765-1802
Southold, New York 11971
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
ORDER TO REMEDY VIOLATION
Date: March 18, 1998
TO: Mr. John Greene
1500 Mount Beulah Ave. Southold, New York 11971 PLEASE
TAKE NOTICE there exists a violation of :
Zoning Ordinance -CHAPTER 45
Other Applicable Laws, Ordinances or Regulations
at premises hereinafter described in that:
USING AN INGROUND SWIMMING POOL WITHOUT THE ISSUANCE OF A
CERTIFICATE OF OCCUPANCY.
In violation ofCODE OF THE TOWN OF SOUTHOLD, CHAPTER 45-15
YOU ARE THEREFORE DIRECTED AND ORDERED TO comply with the
law and remedy the conditions above mentioned IMMEDIATELY
The premises to which this ORDER TO REMEDY VIOLATION refers
are situated at: 1500 MT. BEULAH AVE. , SOUTHOLD, COUNTY OF
SUFFOLK, NEW YORK.
SUFFOLK COUNTY TAX MAP #1000-51-3-2 . 14
Failure to remedy the conditions aforesaid and to comply with the
applicable provisions of law may constitute an offense punishable
by fine or imprisonment or both.
c
Gary Fight
BUIL G SPECTOR
encl . (Cert. Mail)
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
}- TEL.: 765-1802
Examined .-".. ...^. . . . . a. , 19 3
x
Approved . b'e� ?ti . .a�. ., 144. Permit
Disapproved a/c
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Building Inspector)
APPLICATION FOR BUILDING PERMIT /
Date . . . . . �( 2. . . . . . . . .. 19 .
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building
Inspector, with 3 sets of plans, accurate plot plan to scale. Fee according to schedule.
b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets
or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli-
cation.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such permit
shall be kept on the premises available for inspection throughout the work.
e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy
shall have been granted by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described.
The applicant agrees to comply with all applicable laws, ordinances, buildingf, e,hou ' g code, and regulations, and to
admit authorized inspectors on premises and in buildings for necessary iifpccti, s. .
. . . . . . . . . . . . . . . . . . . . . . .
(Signature of applicant, or name, if a corporation)
(Mailing address of applicant)
State whether applicant is owner, lessee, a ent chitect, engineer, general contractor, electrician, plumber or builder.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Name of owner of premises t+,ti Co2�C € N�-
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Name and title of corporate {officer)
Builder's License No. . . i�.
�sPC�
S 0 � (-i-fC r e cc,:vad
Plumber's License No. . . . . . . . . c(a t Ps
Electrician's License No. . . . . . . . . . . . . . . . . . . . . . .
Other Trade's License No. . . . . . . . . . . . . . . . . . . . . .
1. Location of land on which proposed work will be done. l:S . 4,.VN `uL A 9` u Utf<J
. . . . . . .+. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.f:V.4nr+. . .kv�. . . . . . . . . . . . . . . . . . . . . . .lo ..11L 1
House Number Street Hamlet
County Tax Map No. 1000 Section . . . . . . .
fi . . . . . . . . . . . Block . . . . . . . . . . . . . . . . . Lot . . ".j. . . . . . . . . . . .
Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Filed Map No. . . . . . . . . . . . . . . Lot . . . . . . . . . . . . . . .
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy %-
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Intended use and occupancy . :% :: ^:na n �. . .i.`,D L. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Nature of work (check which applicable): New Building wt.,. . . Addition . . . . . . . . . . Alteration . . . . . . . . .
Repair . . � . . . . . . . Removal . . . . . . . . . . . . . . Demolition . . . . . . . . . . . . . . Other Work . . . . . . . . . . . . . . .
�► _ (Description)
4. Estimated Cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fee 7. . . . . . . . . . . . . . . . . . . . . . . . . .
(to be paid on filing this application)
5. If dwelling,number of dwelling units . . . . . . . . . . . . . . . Number of dwelling units on each floor . . . . . . . . . . . . . . . .
If garage,number of cars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use . . . . . . . . . . . . . . . . . . . . .
7. Dimensions of existing structures,if any: Front . . . .SS . . . . . . . . Rear . . . ; . . . . . . . Depth . .?5 . . . . . . . . . . .
Height . . . . . . . . . . . . . . . Number ofStories .
... . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . .
Dimensions of same structure with alterations or additions: Front . . . . . . . . . . . . . . . . . Rear . . . . . . . . . . . . . . . . . .
Depth . . . . . . . . . . . . . . . . " . . . . . Height . . . . . . . . . . . . . . . . . . . . . . Number of Stories . . . . . . . . . . . . . . . . . . . . . .
8. Dimensions of entire new construction: Front . . . .Yo. . . . . . . . . Rear . . . . Y.a. . . . . . . . Depth . . 7 ;=t . . . . . . . . .
Height . . . . . . . . . . . . . . . Number ofStories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. Size of lot: Front . . . ,'Av. . . . . . . . . . . . . . . Rear . . .!�'/ . . . . . . . . . . . . . . . Depth . ?.<` . . . . . . . . . . . . . . . . .
10. Date of Purchase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name of Former Owner . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11. Zone or use district in which premises are situated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12. Does proposed construction violate any zoning law, ordinance or regulation: . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .
13. Will lot be regraded . . . . . . . . . . . . . . . . . . . Will excess fill be removed from premises: Yes No
14. Name of Owner of premises i J < < . . . . . . . Address P"r SGA ' Rte` -�?411hone No. . . . . . .
Name of Architect N Addressi ! �. a < :� . Phone No.QV!
. . . .vo t `.. . . . . . . . Address.tl i ,: . Phone No.E r
Name of . . . .
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and,indicate all set-back dimensions from
property lines. Give street and block number or description according to deed, and show street names and indicate whether
interior or corner lot.
f
I
STATE OF NEW YO�R,K, S.S
COUNTY OF . . . . . T`.'. . . . . . . .
f,l<-;
. . . . . . . . . . . . :1 v f. . `. .. . . . . . . . . . . . . . . . . . . . . . being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
above named.
He is the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:2 �, v
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Contractor, agent, 6'8rporate officer, etc.)
of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this
application; that all statements contained in this application are true to the best of his knowledge and belief;and that the
work will be performed in the manner set forth in the application filed therewith.
Sworn to before�me this
. . . . . . . . . . .Jc . . .:. :. . . .day of. .�.5 c f T. .
Notary Public, ( ! �^Ls l.' e --`County
NeNLfS MOM,.
40?ARY PUBLIC,State of New
o..Wied in Suffoll Count/ . . • :• . • . . • . . • . . . . . . . . . . . .
No. 52-4648995 (Signature Of applicant)
GTmbf1Y?Feslra�MneN S0.14