HomeMy WebLinkAbout21192-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPA~RTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No Z-22117
Date JANUARY 21, 1993
THIS CERTIFIES that the building
Location of Property 2675 HOBART AVE.
House No.
County T~ux Map No. 1000 Section 64
Subdivision
ADDITION
SOUTHOLD, N.Y.
Street Hamlet
Block 5 Lot 32
Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated JANUARY 19, 1993 pursuant to which
Building Permit No. 21192-Z dated JANUARY 20, 1993
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 DECK ADDITION TO EXISTING OWE FAMILY DWELLING AS APPLIED FOR
~ AS PER ZBA Ai~PROVAL ~4147.
The certificate is issued to
DONALD E. FAHEY, JR.
(owMer)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE NO. N/A
PLUMBERS CERTIFICATION DATED N/A
// ~'uilding Inspector
Rev. 1/81
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
$OUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N-°N.o 21193Z
Date .........Z.~ .....................
/
Permission is hereby granted to: /o/ _
.....
.......................... z ........... ~ .................. ~ ...... ~Z~
................................................... ~...~iv~ .................... ~ ...... zz ............ .~ ............. ~
~v~,~ ...... ~ .......... ze~ .......... ~ ....... ~....~ ....... ~g ............................ Z ....................
ot premises I~ated at ................. ~ ................. ~ .......................... ~: .............................................
......................................................... ,.....~~e.~ .............................................
..................................................... ................................ ::::::::::::::::::::::::::::::::: .........
co~.~ zo~ ~ov No. ~0o0 s.~t~o. .... ~.~ .......... ~ ....~ ........ ~ot No ......... W~ .......
~.~, ,o ~,,.~,,o. ~,~ ..................... l/~.2 ................ , ,~..2~ ~,~ ~,o,~ ~, t~.
/
Buildln~ Inspector.
Fee $.., ...~...."~..'.,..~.. .......
Rev. 6/30/80
Form No. 6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
This application must be fillgd in by typewriter OR ink and submitted to the building
inspector with the following: 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 1% 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.
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 a 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 - $5.00 over 5 years - $10.00
4...Updated Certificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00
Date ..... /~. L. g~.f.? .........................
New Construction ........... Old Or Pre-existing Buildi~g.....~.
.........
Location of Property ....................
House No. Street Hamlet
.
ty
)nwer or Owners of Proper .... .. .~...
· -
]ounty Tax Map No 1000, Section .......... Block ................ Lot.. . .............
;ubdivision .................................... Filed Map ............ Lot ......................
~ermit No ................ Date Of Permit ........ cant ...........................
{ealth Dept. Approval .......................... Underwriters Approval ....................
~lanning Board Approval ........................
:equest for: Temporary Certificate ....
'ee Submitted: $ ......... ~. ...........
... ................
APPEALS BOARD MEMBERS
Gerard P. Goehringer, Chairman
Serge Doyen, Jr.
James Dinizio, Jr.
Robert A. Villa
Richard C. Wilton
Telephone (516) 765-1809
BOARD OFAPPEALS
TOWN OFSOUTHOLD
January 15,
Mr. and Mrs. Donald E. Fahey,
15 Jodi Drive
P.O. Box 777
Eastport, NY 11941
Jr.
SCOTT L. HARRIS
Supervisor
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (516) 765-1823
Telephone (516) 765-1800
Re: Applo No. 4147 - Deck Variance-Hobart Ave, Southold
Dear Mr. and Mrs. Fahey:
Please find attached a copy of
determination rendered at last
concerning your variance application.
the Board's findings and
night's public hearings
It will be necessary for you to return to the Building
Inspector and any other agencies which may have jurisdiction on
this project for issuance of appropriate permits or other
documents. A copy of this determination has been forwarded to
the Town Building Department. Also, the Suffolk County
Department of Planning has jurisdiction under the Administrative
Code of Suffolk County which governs projects within 500 feet of
the sounds, creeks, estuaries, county lands, county roads, etc.)
and we have transmitted copies of this file for their
determination or waiver accordingly.
Very truly yours,
w~lski
Enclosures
Copies of Decision to:
Southold Town Bdilding Department
Suffolk County Department of Planning
APPEALS BOARD MEMBERS
Gerard P. Goehringer, Chairman
Serge Doyen, Jr.
James Dinizio, Jr.
Robert A. Villa
Richard C. Wilton
Telephone (516) 765-1809
BOARD OF APPEALS
TOWN OF SOUTHOLD
ACTION OF THE BOARD OF APPEALS
SCOTT L. HARRIS
Supervisor
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (516) 765-1823
Telephone (516) 765-1800
Appeal No. 4L47:
Application of DONALD E. FAHEY, JR. for a Variance to the
Zoning ordinance, Article IIIA, Section 100-30A.3 for approval
of existing deck constructed almost 20 years ago. This deck,
under the current zoning regulations, does not meet the required
rear yard setback for a substandard parcel in this R-40 Zone
District. Location of Property: 2675 Hobart Avenue, Southold,
NY; County Tax Map Parcel No. 1000-64-5-32.
WHEREAS, a public hearing was held on January 14, 1993 and
at said hearing all those who desired to be heard were heard and
their testimony recorded (no opposition was received); and
WHEREAS, the Board has carefully considered all testimony
and documentation submitted concerning this application; and
WHEREAS, the Board Members have personally viewed and are
familiar with the premises in question, the present use and zone
district, and the surrounding areas; and
WHEREAS, the Board made the following findings of fact:
1. The premises in question:
(a) is a parcel of land situate along the north side
of a Hobart Avenue, approximately 96 feet easterly from Old
Shipyard Road, Hamlet and Town of Southold, and contains the
following existing nonconformities under the bulk schedule of
the current zoning code:
lot area at approximately 4,400 sq. ft.
lot width (road frontage) at 50 feet
690+- sq. ft. of livable floor area
front yard setback at 24'8"
rear yard setback at 20+- feet;
(b) is improved with a single-family dwelling
structure and a very small accessory metal shed located in the
rear yard at the northeast corner of the property and wood fence
along or near the property lines;
Page 2 - Appl. No. 4147
Mat~er of MR. AND MRS. DONALD E. FAYEY,
Decision Rendered January 14, 1993
JR.
(c) is located in the R-40 Zone District as adopted
in the Master Plan revisions dated January 10, 1989.
2. By this application, appellants have requested approval
of a 12-3/4 ft. wide by 10-1/2 ft. deep open, low level deck
addition located in the rear of the existing dwelling, as more
particularly shown on a survey map dated November 6, 1992
prepared by Rampart Surveying, P.C.
3. It is noted for record purposes that the deck was built
about 20 years ago (without a building permit), and is not out
of character with the lots and buildings existing in this
residential area.
4. Article XXIV, Section 100-244B requires a minimum rear
yard setback at 35 feet.
5. The amount of relief requested by this application is a
reduction from the existing nonconforming setback at 20+- feet
to 16'9" at its closest point to the rear property line.
6. The need for this relief would not be alleviated if the
subject deck construction were to be located in any other manner
on the premises.
7. In considering this application, the Board also finds:
(a) that the deck has not been and is not adversely
impacting the essential character of the neighborhood;
(b) that the variance will not in turn be adverse to
the safety, health, welfare, comfort, convenience or order of
the town, or be adverse to neighboring properties;
(c) that the construction under consideration
involves an open deck addition, as exists and shown in the
photographs submitted by the applicants {not to be enclosed or
roofed - except by formal application), and the grant this
variance does not cause or create an increase in any dwelling
unit density pertaining to this property or cause a substantial
effect on available governmental facilities;
(d) that there is no other alternative feasible for
appellants to pursue;
(e) in considering all of the above factors, the
interests of justice will be served by granting the relief
requested and as conditionally noted below.
Page 3 - Appl. No. 4147
Mat~er of MR. AND MRS. DONALD E. FAYEY, JR.
Decision Rendered January 14, 1993
Accordingly, on motion by Member Goehringer, seconded by
Member Dinizio, it was
RESOLVED, to GRANT approval of the open deck construction
as requested under Appl. No. 4147 (Donald E. Fahey, Jr.) as
more particularly shown on November 6, 1992 survey submitted
with the application, and SUBJECT TO THE FOLLOWING CONDITIONS:
1. The deck remain unroofed and open, as requested and as
exists; {There shall be no permanent enclosure of the deck
addition (plexiglass or otherwise), other major alteration or
placement of a roof - without further ZBA approvalS;
2. The deck not be enlarged or expanded, without further
ZBA approval.
VOTE OF THE BOARD: Ayes: Messrs. Goehringer, Dpyen,
Dinizio, Villa and Wilton. This resolution was duly adopted.
lk
GERARD P. GOEHRINGER,,CHAIRMAN
APPEALS BOARD MEMBERS
Gerard P. Goehringer, Chairman
Serge Doyen, Jr.
James Dinizio, Jr.
Robert A. Villa
Richard C. Wil~on
Telephone (516) 765-1809
BOARD OF APPEALS
TOWN OF SOUTHOLD
January 15,
SCOTTL. HARRIS
Supervisor
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
F~x (516) 765-1823
Telephone (516) 765-1800
Mr. and Mrs. Donald E.
15 Jodi Drive
P.O. Box 777
Eastport, NY 11941
Fahe¥, Jr.
dAR I 9 I993
Re: Appl. No. 4147 - Deck Variance-Hobart Ave, Southold
Dear Mr. and Mrs. Fahey:
Please find attached a copy of
determination rendered at last
concerning your variance application.
the Board's findings and
night's public hearings
It will be necessary for you to return to the Building
Inspector and any other agencies which may have jurisdiction on
this project for issuance of appropriate permits or other
documents. A copy of this determination has been forwarded to
the Town Building Department. Also, the Suffolk County
Department of Planning has jurisdiction under the Administrative
Code of Suffolk County which governs projects within 500 feet of
the sounds, creeks, estuaries, county lands, county roads, etc.)
and we have transmitted copies of this file for their
determination or waiver accordingly.
Very truly yours,
Linda Kowalski
Enclosures
copies of Decision to:
Southold Town Building Department
Suffolk County Department of Planning
APPEALS BOARD MEMBERS
Gerard R Geehringer, Chairman
Serge Doyen, Jr.
James Dinizio, Jr.
Robert A. Villa
Richard C. Wil~on
Telephone (516) 765-1809
TO WNOFSOUTHOLD
ACTION OF THE BOARD OF APPEALS
SCOTTL. HARRIS
Supervisor
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (516) 765-1823
Telephone (516) 765-1800
Appeal No. 4147:
Application of DONALD E. FAHEY, JR. for a Variance to the
Zoning Ordinance, Article IIIA, Section 100-30A.3 for approval
of existing deck constructed almost 20 years ago. This deck,
under the current zoning regulations, does not meet the required
rear yard setback for a substandard parcel in this R-40 Zone
District. Location of Property: 2675 Hobart Avenue, Southold,
NY; County Tax Map Parcel No. 1000-64-5-32.
WHEREAS, a public hearing was held on January 14, 1993 and
at said hearing all those who desired to be heard were heard and
their testimony recorded (no opposition was received); and
WHEREAS, the Board has carefully considered all testimony
and documentation submitted concerning this application; and
WHEREAS, the Board Members have personally viewed and are
familiar with the premises in question, the present use and zone
district, and the surrounding areas; and
WHEREAS, the Board made the following findings of fact:
1. The premises in question:
(a) is a parcel of land situate along the north side
of a Hobart Avenue, approximately 96 feet easterly from Old
Shipyard Road, Hamlet and Town of Southold, and contains the
following existing nonconformities under the bulk schedule of
the current zoning code:
lot area at approximately 4,400 sq. ft.
lot width (road frontage) at 50 feet
690+- sq. ft. of livable floor area
front yard setback at 24'8"
rear yard setback at 20+- feet;
(b) is improved with a single-family dwelling
structure and a very small accessory metal shed located in the
rear yard at the northeast corner of the property and wood fence
along or near the property lines;
Page 2 Appl. No. 4147
Matter of MR. AND MRS.~ DONALD E. FAYEY,
Decision Rendered January 14, 1993
JR.
(c) is located in the R-40 Zone District as adopted
in the Master Plan revisions dated January 10, 1989.
2. By this application, appellants have requested approval
of a 12-3/4 ft. wide by 10-1/2 ft. deep open, low level deck
addition located in the rear of the existing dwelling, as more
particularly shown on a survey map dated November 6, 1992
prepared by Rampart Surveying, P.C.
3. It is noted for record purposes that the deck was built
about 20 years ago (without a building permit), and is not out
of character with the lots and buildings existing in this
residential area.
4. Article XXIV, Section 100-244B requires a minimum rear
yard setback at 35 feet.
5. The amount of relief requested by this application is a
reduction from the existing nonconforming setback at 20+- feet
to 16'9" at its closest point to the rear property, line.
6. The need for this relief would not be alleviated if the
subject deck construction were to be located in any other manner
on the premises.
7. In considering this application, the Board also finds:
(a) that the deck has not been and is not adversely
impacting the essential character of the neighborhood;
(b) that the variance will not in turn be adverse to
the safety, health, welfare, comfort, convenience or order of
the town, or be adverse to neighboring properties;
(c) that the construction under consideration
involves an open deck addition, as exists and shown in the
photographs submitted by the applicants {not to be enclosed or
roofed - except by formal application), and the grant this
variance does not cause or create an increase in any dwelling
unit density pertaining to this property or cause a substantial
effect on available governmental facilities;
(d) that there is no other alternative feasible for
appellants to pursue;
(e) in considering all of the above factors, the
interests of justice will be served by granting the relief
requested and as conditionally noted below.
Page 3 - Appl. No. 4147
Matter of MR. AND MRS. DONALD E. FAYEY,
Decision Rendered January 14, 1993
JR.
Accordingly, on motion by Member Goehringer, seconded by
Member Dinizio, it was
RESOLVED, to GRANT approval of the open deck construction
as requested under Appl. No. 4147 (Donald E. Fahey, Jr.) as
more particularly shown on November 6, 1992 survey submitted
with the application, and SUBJECT TO THE FOLLOWING CONDITIONS:
1. The deck remain unroofed and open, as requested and as
exists; {There shall be no permanent enclosure of the deck
addition (plexiglass or otherwise), other major alteration or
placement of a roof - without further ZBA approval};
2. The deck not be enlarged or expanded, without further
ZBA approval.
VOTE OF THE BOARD: Ayes: Messrs. Goehringer, Doyen,
Dinizio, Villa and Wilton. This resolution was duly adopted.
lk
GERARD P. GOEHRINGER, CHAIRMAN
FORM NO. 3
TOWN OF SOUTItOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N.Y.
NOTICE OF DISAPPROVAL
Date. December 16, 92
.......................... 19 .....
To D.ona.ld E. Fahey, Jr.
P.O. Box 777
Eastport, N.Y. 11961
PLEASE TAKE NOTICE that your application dated DECEMBER 14, . 99.2.
for permit to FOR A DECK ADDITION
267.5 HOBART AVg. SOUTltOLD, NEW YORK
Location of Property ..............................................................
House No. Street Ham/et
County Tax Map No. 1000 Section ... 66 Block 5 Lot 32
Subdivision ................. Filed Map No ................. Lot No ..................
is returned herewith and disapproved on the following grounds ...............................
INSUFFICIENT REAR YARD AS SKI FORTH IN THE BULK SCHEDULE FOR RESIDENTIAL
DISTRICTS UNDER Tltli R-40 ,ZONE. ACTION REQUIRED BY THE ZONING BOARD OF
APPEALS.
B~ i~d i n9 Inspector
RV 1/80
Examined ............. · .,' :
Disapproved a/c .....................................
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1803
INSTRUCTIONS
BOARD OF HEALTH .........
3 SETS OF PLANS ..........
SURVEY ...................
CllECK ....................
SEPTIC FOaH
CALL ..........
}fAIL TO:
Date'.B.¢Ce( .ae . /."/. ., ,9 .&.
a. This application must be completely filled in by W!bewriter or in ink and submitted to the Building Inspector, with 3
!ets 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
)r areas, and giving a detailed description of layout of property must be' drawn on the diagram which is part of this appli-
:ation.
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 issued a Building Permit to the applicant. Such permit
;hall be kept on the premises available for inspection throughout the w6rk.
e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy
;hall 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
3uilding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
~egulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described.
['he applicant agrees to comply with all applicable laws, ordinances, buiJ, d'hxg~ode, housing cod~e.~and~regula~nd to
tdmit authorized inspectors on premises and in building for necessary insp~
- · · · ....
' 77.7... N,.Y:./.
. (Mailing address of applicant)
gtate whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
· 0 to/~ e/'c_ . APP~tOV,E:D AS NOTED
.......................................
~ame of owner of premises
............................... I ............. 'FEE: ',_:.1' ~' ~ ~' · By:~"ilP" 't~x"4</·
' ' (as on the tax roll ar latest aNi~V BUILDING DEPARTfvIENT AT
if applicant is a corporation, signature of duly authorized officer.
..
(Name and title of corporate officer)
Builder's License No .....................
Plumber's License No ........
Electrician s,License No ...... : r/./.t. ...... '. 7
Other 'Trade s License No ...... . .~./.fi].. ..........
· Location of land on which proposed work will be'done· .
765-1802 9 AM TO 4 PM FOR THE
FOr. LOWING INSPECTIONS:
t, FOUNDATION TWO REQUIRED
FOR POURED CONCRETE
2. ROUGH - FRAMING & PLUMBING
3~ INSULATION
4 FINAL CONSTRUCTION MUST
BE COMPLETE FOR C.O,
ALL CONSTRUCTION SHAM. MEET
THE REQUIREMENTS OF THE
STATE CONSTRUCTION & ENERGY'
CODES, NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS
......................................................................... c 77¢oz.
House Number Street Hamlet
County Tax Map No. 1000 Section .................. Block '. ................. Lot ..............
.
Subdivision. ~0~.~.~F~... ~a¢.:... Filed Mbo ~o ........
(Name)
. State existing use and occupancy of prem~es and intended use and occupancy of proposed construction:
a Existing use and occupancy ~~d ~ '
b Intended use and occupancy Ke ;beoe
3. Nature of work (check which abplicable) New Building . . Addition ........ ':~l~eration '. .........
Repair ............ Removal ............. Demolition ............. Other Work ~Jl-D.
~' ~'~e~ ~sE ~ ~ (Des hptio )
4. Estimated Cost. ~ · ............ O~ ~ ' c n
'"~ ..... ,v, ....... Fee ......................................
' : (to be paid on filing this application)
S. If dwelling, number of dwelling~units .,...~/~ ...... Number o f dwelling nnits on ~ach floor .... O .......
. If garage, number of c~s ..... '.. ~/~ ..... ' .............................................
6. If business, commercial 0r mixe~ occupancy, specify nature and extent of each t e of use ..... ' '
7. Dtmensionsofexistingstmctur~s if any Front ~- / -~-- YP ~ ..~ .........
Height ............... Number of~to~es ~fqS~ '?Ee' ~0~e0[<~' ' ~0ge m ..............
D~ensio~,of same slmcture wLth alterati~s or.additions: Front
Denth FA~4S¢ ~'e¢ ~c~O .~'u~ve~ ................. Rear ................
e ~ N mbe f St ~ '
8. Dimensions of entire new eonst~etion: Front . . ~l .... o... Rear .............. De t .
Height ............... Num erorSto es'. .ee .......
9. Size of lot: Front ...... ~ .? .... ~. ' ' '~A' ' 76' 't .................. tD~ · '~'3 -/ .......
11. ~one or use d~stnct ~n whmh pre,m~ses are s~.tuated .... M~.SD'O W~ =m~, ....
12. ~oes proposed construction violhte any zonino'~ .... ~a; ..... ''' v',' '.' ....... [)25 ........................
13. 'Will lnt h~ r~o ~ A ~/~ ~ ~ ,~--, ......... ~,or regulauon: .... 1.~o . . .
..... '~ ..... 2' ~ .... ~. ·. Will excess fill be removed from premises' M ~ Yes
14. ~e o~ owner of premises /~.~.~A~.Add .... P~,~,~ ~ ..... ~/~, , ' ~
. _. or ..... Ir4: ,. ............... /. Address .......... Phone No.
15. ~s t~s property wlthSn 3.00 feet of a tZdal wetland?''~;;" ..................
xes ........ ~o .........
·If yes, Southold Tiown Trustees Permit may be required.
... ; PLOT DIAG~
Locate clearly ~d distinctly ~I lbuildNgs, whether existing or proposed, ~d. indicate ~1 et-back d~ensmns from
propeNy ~nes. Give street ~d block flumber or description accord~g to deed, and show street nines and indicate whether
Ntefior or comer lot.
¢TATE OF NEW./. YQgK, ' S
.... .~.0/'~0.1.'./. ~...L, w...[T.~ ~ ~ ................ being duly sworn, deposes and says that he is the applicant
(N~me of individual signin~ contract)
bove named. · . i' '.'
is the
i (Contractor agent corporate officer etc ) '
said owner or owners, ~d'is duly a;uthorized to perform or have,perfomed the said work and to m~e and file this
pplication; that all statements contained N this application are true to the best of his knowledge and belief; and that the
'ork w~l be perfomed in the m~ner sdt forth in the application filed therewith.
worn to before me this
. U~tlC,~_O~'~ ( /~ ~ _/(Signature ofapplicant)