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Home My WebLink About5764-zFOlll~ NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. Z. ~11!f3 ..... Date ........... .lfa~ ..... 11 .... , 1973 . THIS CERTIFIES that the building located at 1~,.0~/,..off. }tickol~r Ave.. Street 8/~ 6oose Bay Est Map No ............. alockNo .......... LotNo.. ~ .... $0,u.th0~a .... ~'~;.. ....... conforms substantially to the Application for Building Permit heretofore filed in this office dated ............ h~aXt..P?.., 1972.. pursuant to which Building Permit No. dated ........... t~ar...2'?... , 1972.., was issued, and conforms to all of the require- merits of the applicable provisions of the law. The occupancy for which this certificate is issued is The certificate is issued to .. 0~c.,..t:{¢>y~.~. BP.ae~:~D¢c.g..' ..... (~/1~¢.~. .................. (o~vner, lessee or tenant) of the aforesaid building. Suffolk County Department of E(ealth Approval UNDERWRITERS CERTIFICATE No.. P~e,,,:,. exist,;:l.~g ................................ HOUSE NUMBER..'1.2~.. H.~¢kC~bbegVO ................. : ........ : .................... Buddil' ' ~g Inspecto'lI''' / FORM NO. 2 TOWN OF $OUTHOLD !; BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N~ Y. BUILDING PERMIT L (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) pursuant to application doted ........................,~lM~tlt~ ...... 2~. ..... , 19.~.., and approved by the Building Inspector. Building Inspe~r FORM NO. ~ TOWN OF SOUTHOLD [~uildJng Deportment Town Clerks Office $outhold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF iOGCUPANCY instructions A. This application must be filled in typewriter OR ink, and sqbmitted in duplicate to the Building Inspector with the following; for new buildings or new usb: 1. Final survey of property with accurate location of all I~uildings, property lines, streets, and unusual natural or topographic features. 2. Final approvat of Hearth Dept. of water supply and sewerage disposol--(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, Multiple R~bidences and similar buildings and installations, a certificate of Code compliance from the! Architect or Engineer responsible for the building. 5. Submit Planning Board approval of completed site plan .requ rements where applicable. B. For existing buildings (prior to April 1957), Non-conforming uses, or bdildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, buildings and unusual natural or topographic features. 2. Sworn statement of owner or previous owner as to use, o}:cupancy and condition of buildings. 3. Date of any housing code or safety inspection of buildings or premises, or other pertinent in- formation required to prepare o certificate. C. Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land usg SB.00 3. Copy of certificate of occupancy $1.00 Date ................................................ New Building ...~,.cl.d..i...~.9..llOld or Pre-existing Building ................ i ........... Vacant Land ............................ Location Of Property ..~.~.~{`~.~.~.~.~q~f..~.~°.Av'.~`~....~'~.~...a~B.~.~Y.~.~..s..~ .................... Owner Or Owners Of Property ....D.~.~...!~,e,~?,~...,R,,9.,s,.e,-,~-b,,9.~.~. .................................................................... Subdivision XX · ................................................................ Lot No. xX Block No..~%XX.,. House No..1P~.lk,.~:zeke~ · Ave Permit No. [~'..6.brZ~ ........ Date Of Permit ~/.~,~./.~.2....Applicont .... ~:....}.I.,.a.~.t.....l.~.q ................................. Health Dept. Approval .... ~.~..~..~ ............................... Labor Dept. A~pproval ........ .~..t..E..: ............................... Underwriters Approval .............................................. Planning Boa/~d Approval ..~..~.*. ............................ Request For Temporary Certificate ........................................ Final!Certificate XXX Fee Submitted $ .,,~..:,,0.0. ......................... Construction on above described building anj~rmit meets oil a~plicable c,odei..~nd regulations. Sworn to before me this ................ day of ............................................ (stompor seal)-' Notary Public .................................... County FOI~M NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENI~ TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Exomined ~'~ ~-.~... '~ '~- Approved ........................................ , 1~) ........ Pemit No .... ~ ......... APPLICATION FOR BUILDING PERMIT Application No ..... .~...~,..~....~.. ........... INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and ~ubmitted 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, relationshi~ to adjoining premises or public streets or areas, and giving a detailed description of layout of property must be drawn on diagram which ~s part of this application, c. The work covered by this application may not be commenced before issuance df Building Permit. d. Upon approval of this application, the Building Inspector will issue a Buildin~ Permit to the applicant. Such permit shall be kept on the premises available for inspection throughout the work. e. No building shah be occupied or used in whole or in part for any purpose w~atever until a Certificate of Occupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuane~ of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, SuffolJ~ County, New York, and other applicable ~aws Ordinances or Regulations, for the construction of buildings, add tons or alterations, or for removal or demolition, as herein described. ~he applican'~ agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections. .............. (Signature of applic~t', or name, if a corporation) (Address of applicant) State whether ap~pl~,~ant,is owns, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ........ ....... ............................................ ...................... Nam~E~ owner of premises .... ~--' ';~¥".~.....,,~,,~,,~.c~,...,~,.~~ ........ If applica~s a corporate, signatur~ of duly aut~rized officer. (Name and title of~porate officer) 1. Locat on of and on wh ch proposed work w be done Map No ....... ~ Lot No ........... Street and Number ...... ~.: .... ~ . .. ¢' / / f' ¢' ' / Municipality 2. State existing use and occupancy of p~mises and intended use and occ4pancy of proposed construction: a · ' "-'¢ ¢'¢ · Ex~st~ng use and occupancy ......................... :~ .................... ,: ....................................................................... b. I ntendeduseandoccupancy ..~.~.~.,~. ~ ....................... ....................................................................... Nature of work (check which applicable): New Building ....................... Addition .................... ~ Alteratio~ ............... Repair ......................... Removal ......................... Demolition ........................ Other Work'. ................................... (Description) 4. Fsdmated Cost ............................................... Fee ................................................................................................. {to be paid on filin§ this applieationl $. If dwelling, number of dwel~n~ un,ts ................. ~umber of dwellin~ un,ts on each floor ......................................... If ~ara~e, number of cars ............................................................................................................................................ ~. If business, commercial or mixed occupancy, specify nature and extent of e~h type of um ..... .: .............................. 7. Dimensions of e~istin~ structures, if any: Front ..~. ................~ear ........................... Depth ................................... Height Number of Stories ....... , ...... ~ ................................. ~ ............................ ........................................................... ~,~ ~ o Dimensions of same structure with alterations or additions: Front .......................... Rear ......................................... Depth ............................................. Height .................... , ..................... Number, of Stories ............. ,......~ .................... 8. Dimensions of entire new construction: Front ......................... Rear ............................ Depth ................................. /.:' :., .,~/& Height ................................. ~ ............... Number of Stories .... ~ .................................... ~ ............... ~ ............................ 9. Size of let: Ffent ...................................... Rear ..................... ~ ................... Depth .................................................. Height , . '? Number of Stories ~IZ. ~ J ~ ~,-- , : ,/~- ~, 10. Date of Purchase ..................................... Name ef For,~er O~ner .~. .......... ~ ........................................................... 1 1. Zone or use district in which premises are situated ................................................. , ................................................... 12, Does proposed ~onstru~tio~ violate any zoning law, ordinance or regulation: ............................................................ 13, Will lot be re~aded .......................... ~,~ ...... Will exce~s fill be.removed from premises: [ ] Ye~ [ ] No 14, Name of Owner of premise~ ....................................................................................................................................... (Address) (Phone No.) Name of Architect · '.: ,:.1,.; ~ /. , ~ /~ I! ~0 ,.~ ~ I-t o ~ ~ b - .~ ~1 0 '"7? ....... : .............. : ................. ..................................... ....... i:. ............. Name of Contractor ................................................................................................................................................... (Address) (Phone No.) PLOT DIAGRAM Locate c early and d st net y .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 wheth- er interior or corner lot. STATE OF NEW YORK, ) SS co U N::~-~':O F ................. . ...................... ...................... ~.~./.~;;.~> .................... being duly sworn, deposes and says that he is the applicant above named. He is the ................................................................................................................................................................................................................. (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have p0rformed the said work and to make and fil0 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 JUI)ITR T BOKEN set forth in ~, a lication filed -~. / No*.9¢¥ 1,~jbhc, Stale o{ i'&:w York .,/ ':':-,/? -: · Notary Public//(..... ,: : ................. : ...... ~O/d'~. ,'/' ~'~/"': ........................................ ~ .......................................... (Signature of applicant) ~roz~z No. l TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Approved 'x ~ 19 ........ Pemit No Application No. ~'~ &' c/ ~ Disapproved a/c .~ .............................................. ..................... ....... :,' ........................ APPLICATION FOR BUILDING P~RMIT Date ......... ~ ....................................... 19 ............ INSTRUCTIONS a, This application must be completely filled in by typewriter or in ink and ?bm~tted in triplicate to the Building Inspector, with 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. PIct plan showing location of lot and of buildings on premises, relationshil~ to adjmmng premises or public streets or areas, an giving a detailed description of layout of preperty must be drawn on diagram whi(~,h is part of this application. o. The work covered by this application may not be commenced before issuance d~' Building Permit. d. Upon approval of this application, the Building Inspector will issue a Buildin~ 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 wl~atever until a Certificate of Occupancy shall have been~ granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuane~t of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffo[l~ County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as here~in described. ~he applicanl~ agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectS, rs on premises and in buildings for necessary inspections. ........................ i ................ /": ........... .............. (Signature of applica~-f, or name, if a corporation) (Address of apphcant) State whether applicant j.s owner, lessee, agent, architect, engineer, general contra¢l~or, electrician plumber or builder. If applican)-b a corporate, signature of duly aut~'~ed officer. ¢~" ~6~ 1. Location of land on which proposed work will be done. Map No.: ........ i' .......... Lot No ........................... ¢¢ ................. Street and Number ~ / / :' ,/ ~ / Municipality 2. State existing use and occupancy of premises and intended use and occ~pancy of p~oposed c~nstruction: a. Ex~stmg use and occupancy ....................... ; ........... ;~,~ .................... ~; ...................................................................... b. Intended use and occupancy 3.. Natu~re of work (check which applicable): New Building ....................... Addition ...~ ...... AIt~i.9~; .......?.. ..... Repair ......................... Removal ......................... Demolition ........................ Other Work ..~.C-). ~..~...~...~..i~.~. ~.!. (Description) 4. Estimated Cost .........~....~...~..; .~...d. .................. Fee (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 ..~.¢2...~. ........ Rear ..... ~....O. ............... Depth .~./~. ........................... Height ...... ./.'...-~... ............................................. Number of Stories ......~.~.~ ............................................................. Dimensions of same structure with alterations or additions: Front ....~...~.. ............... Rear ....-~....~. ................................ Depth ........ .-~.....~.. ............................ Height ....../..%~... ............................. Number of Stories ....~....~.....~.. ........................ 8. Dimensions of entire new construction: Front .....~.~.. ............ Rear ..... ~..~ ............... Depth ...~..~...~ .................... Height ...... ./...~..'~..~ ................................ Number of Stories ......~....~.....~. ....................................................................... 9. Size of lot: Front ..... L..O.....~. ..................... Rear ....... /....~....~... ...................... Depth .~...~.....'~.....'...~... .......................... .................................................... Number of Stories ..../.. ............................................................................... 10. Date of Purchase ..... ../..~.....7'.../. .................. Name of Former Owner .....~..../~....~..?...~...~......?....~...(.~..v...~....~.. .......................... 11. Zone or use district in which premises are situated ....~J......~..../...~....T'z~./.f.,..-~.. ......................................... ' .................. 12. Does proposed construction violate any zoning law, ordinance or regulation: ..Z~.~. ................................................ 13. Will lot be regraded .... ~...~. ..................... Will excess fill be removed from premises: [ ] Yes [ ] No Name of Owner of premises ........................................... ............................................................. (Address) (Phone No.) Name of Architect ..................................................................................................................................................... (Address) (Phone No.) Name of Contractor ................ .~...~J~ ........ ,~..,.~...Y,~J..~........~.~..~..~......'~... ........... Z~.~... ......... ~....~. ......... (Addressl (Phone No.) 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 wheth- er interior or corner lot. STATE OF NEW YORK, ) SS COUNTY OF ......................................................) (Contractor, ~gent, corporate officer, ¢t¢.) of said owner or owners, and is duly authorized to perform or have performed ~e said work and to make and file this application; that all statements contained in this app cat on are true to the best of h s k~d~b,~C~,~l~)e~b,?.nd that the work will be performed in the manner set forth in the appJication fi~ed therewith. No. 52.0344963 f,u~o~k ~~ Comm,s '~P'res M~rch ~ ' - '~ ~~ (Stgnature o] appt~ntJ FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. Z.~I.~ ..... Date ........... !~ ...... ¶.'1 ..... , 1973.. THIS CERTIFIES that the building located at R~0 o¥,..off, lt.tei~O~. ~. Street ~ G~se Bay Est Map No ............. Block No ........... Eot No.. ~ .... ~U~0!d .... N,y... ...... conforms substantially to the Application for Building Permit heretofore filed in this office dated ............ ~..2~.., 1~2.. pursuant to which Building Permit No. ~Z.. dated ........... ~r...2~ .... , 19~2.., was issued, and conforms to ail of the require- ments of the applicable provisions of the law. The occupancy for which this certificate issued is ........................................ The certificate is issued to .. Pr....P~.r, Ro~.~nbe~g ....... ~e~. .................. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .................................... UNDHRWRITHRS CHRT~F[CATH ~o.. P~e~. ~st~ ................................ HO~SH ~U~HHR. ~.. ~ek~A~ .............................................. Building Inspector l~OIL~ NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N~ Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 5764 Z at premises located at ....JJ,e~J,..~J~,J~..ilJ.~l~,.~l'~,e~.~/IJlJ..iJ~JllllL.~&~...~,~.JJ ........ · ~.l~..~....~ .~,.~,~....ssavas~....s.z." - .......................................... i .................................... pursuant to application dated ........................~ ...... ~,~. ...... , 19.~1~.., and approved by the Building Inspector. Fee $....~ ~.*.0~. ........ FORM NO. 6 TOWN OF SOUTHOLD Building Deportment Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions X A. This application must be filled in typewriter OR ink, and submitted in duplicate to the Building Inspector with the following; for new buildings 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 of Health Dept. of water supply and sewerage disposal--(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installations, a certificate of Code compliance from the Architect or Engineer responsible for the building. 5. Submit Planning Board approval of completed site plan requirements where applicable. B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, buildings and unusual natural or topographic features. 2. Sworn statement of owner or previous owner as to use, occupancy and condition of buildings. 3. Date of any housing code or safety inspection of buildings or premises, or other pertinent in- formation required to prepare a certificate. C. Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land use $5.00 3. Copy of certificate of occupancy $1.00 New Building ...~..~..~,~. ,~,~.Q..ZlOId or Pre-existing Building ............................ Vacant Lond ............................ Location Of Property ~A~r~9~~A~Ye~G~s~e~s~ ...................................... .. Owner Or Owners Of Property ...,,g.~..~.....~..e.~....e.?.....~.,9.,s.,e.,q~...e..~..l~ ..................................................................... Subdivision ............ ~ ............................................... Lot No...~ ..... Block No..,T,~X... House Permit No. ~'..~.br?' ........ Date Of Permit ~.~,,~./.~.2....Applicant .... ~.......~.8,...~.~....[...~..q ................................. Health Dept. Approval .... ~.~..~..~. .............................. Labor Dept. Approval ........ .~..."..~..; ............................... Underwriters Approval .............................................. Planning Board Approval ..~..s~.; ............................ Request For Temporary Certificate ........................................ Final Certificate Fee Submitted S ......................... Construction on above described building ~/~p~_rmit meets all applicable c,ode.~,.~nd regulations. X Applicant..~..~.,.~ ....... Sworn to before me this (~- / '//~""~ //~c1~ // ................ day of ............................................ (stamp or seal) Notary Public .................................... County FOR,,~ ~0. ! TOWN OF SO~THOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. ........... , ........................................ , 19 ........ Pemit No .... ,............ ........ Disapproved o/c ..........,....-.........~.....~ ............. Application No ................................ APPLICATION FOR BUILDING PERMIT ........ 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 diagram which is part of this application. 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, Suffo[l~ 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, building code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections. (Signature of applic~(', or name, if a corporation) (Address of applicant) State whether applicant,Ls owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises .... ~',........~..~....~~....~. ................................................................ //// If applican~;j,s a corporate, signature of duly autl~brized officer. (Name and title of~'porate officer) 1. Location of land on which proposed work will be dgne. Map No.: .................... Lot No .............................................. Street and Number .~..~..~.....~...~..~.;....~./'/~_...~...~..~.~.'~ J/ / / [ ~/ / Municipality 2. State existing use and occupancy of pr~emises and intej~ded use and occupancy of proposed construction: a. Existing use and occupancy ............. ..~...~ ............................................................................................ b. Intended use and occupancy .~...~~, ~ ,4 .............................................................................................. 3. Nature of work (check which applicable): New Building ....................... Addition .................. ~ Alteratio~l ............... Repair ......................... Hemoval ......................... Demo ition ........................ Other Work .................................... (Description) 4. Estimated Cost ............................................... Fee ................................................................................................. (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 ~; ~ ' -~ ..................... Rear ..... .-i .................... Depth '~ .D /.-' O/V _ Height ........................................................... Number of Stories ....... ,,.....~ ................................. ~ ............................ /o Dimensions of same structure with altarations 0r,~lditions: Front .......................... Rear ......................................... Depth ............................................. Height ..................... ..................... Nu_rnber, of Stories ........................................ 8. Dimensions of entire new construction: Front ......................... Rear ............................ Depth ................................. Height ................................................. Number of St0rie. s .... ~ ................................................... ,~, ........................... B. Size of lot:~Frclnt,~ Rear ..................... ~2 ................... Depth ...~.. ............................................. Height .................................................... Number of Stories .................. ~ ..... ,...~. ..... ,, .......................................... 10. Date of Purchase ..................................... Name of F~er O~wne,?~)/,~ ./._.~..)..~..:~: ................ ........................................... 11. Zone or use district in which premises are situated ............................................ T'Y'~, ................................................. ,va-, 12. Does proposed construction violate any zoning law, ordinance or regulation: ............................................................ 13. Will lot be regraded '"-;""c""'~'~';"' ~/jtl exce, ss fill be,removed fr~rn premises: [ ] Yes [ ] No 14. Name of Owner of premises ....................................................................................................................................... (Address) (Phone No.) Name of Architect .................................................................................................................................................... Name of Contractor ................................................................................................................................................... (Address) (Phone No.) 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 wheth- er interior or corner lot. STATE OF NEW YOR K, ) SS CO UI'L~-Y'IO F ................................... ~ sworn, deposes and says that he is the applicant above named. He is the ................................................................................................................................................................................................................. (Contractor, agent, corporate 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 end, belief; ~and that the work will be performed in the manner JUDTTF-I T B~KEN set forth in the~am~ication filed therewith. Notary Pu blic~.. ..................... .~. .......................................... ~- ~:?c._ ......................................................... ~.. .......................................... (Signature of applicant} i