HomeMy WebLinkAbout18446-z FORM N0. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No Z-18541 Date NOVEMBER 6, 1989
THIS CERTIFIES that the building ACCESSORY
Location of Property 935 WELLS AVENUE SOUTHOLD N.Y.
House No. Street Hamlet
County Tax Map No. 1000 Section 63 Block 7 Lot 17.11
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated AUGUST 7, 1989 pursuant to which
Building Permit No. 18446-Z dated AUGUST 31, 1989
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 FENCE & DECK AS APPLIED FOR.
The certificate is issued to EDWARD KOWATCH
(owner)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE NO. N-095102 - SEPTEMBER 30, 1989
PLUMBERS CERTIFICATION DATED N/A
tel./
Building Inspector
Rev. 1/81
° FORM IQ0. A
T01NN OP 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)
N° ~ 8 4 r-F U Z Date ....~~~.r 1911..
Permission is hereby gra to to:
~ :~-:3.~..
.~~~i~.'s~...::........~~.7~....p..
to ..C;~~~.~...~ .....~1... ..Ri
..'.i~~.'r~:.
~f
of premises located at
County Tax Map No. 1000 Section ..........~A..~...... Block Lot Na......~
pursuant to application dated 19.s~.~., and approved by the
~~/O
8uifding inspector.
D/._
Fee
ilding or
Rev. 6/30/80
r ~
TOWN OF 50UTIIOLD
BUILDING DEPART?(ENT
TOWN HALL
SOUTIIOLD, NEW YORK 11971 .
~f ~ 765 - 1802
D ~C~ 2 ~ ~ A PL CATION FOR CERTIFICATE OF OCCIIPANCY
BLDG. DEPf•
N
DATE.. _ iO.. $9.....
NEW CONSTRUCTION .Y.,.q.OLD OR PRE-E%I/S~TING BUILDING......VACANT LAND..___...
Location of Property...l~~...(~~k~S,._l:J;?c;KV~___,..,,_~®a,~~c,~..e~.,,.~•~,_,\lq~~
NOUSE NO. f STREET HAMLET
Ovner or Owners of Property.~C.J,49gC~.V..~yy~-~,~__,_.._.
County Taa Map No. 1000 Section/~do`o63) Block Lot' . ~ ~ ~
1 ~ .
Subdivision Filed Map ........Lot........
Permit No. /~J.Ti~ ...Date of Permit .~31~~./. „Applicant .~Q~e~.f' V?s~S ~w~
111 .
health Dept. Approval Underwriters Approval.._...........
Planning IIoard Approval
Request for Temporar!%y~~--Certificate Final Certificate Y
Fee Submitted: $„Q~;l~„=.,,,.......
APPLICANT... /LW~~. ,q-LLl.G,v=c•-~.............
rem- 10/14/88
mac. 385~~
Co 18w~
r ~ ~
L
FORM NO. 6
TOWN OF SOUTHOLD
~ BIIILDING DEPARTMENT
TOWN HALL
765 - 1802 ,i
- APPLICATION FOR CERTIFICATE OF OCCUPANCY INSTRUCTIONS
A. 'This application must be'',filed in typewriter OR ink and submitted to the'$uilding
Inspector with the folloying; for new buildings or new use:
1. Final survey of property with accurate location of all buildings, pkgperty lines,
streets, and unusual gatural ar topographic features.
2. Final approval of 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 solder used in system contains less
than 2/10 of IZ lead.!i
5. 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.
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:
I. Accurate survey of property showing all property lines, streets, buildings and
unusual natural or topographic features.
2. A properlq completed application, a consent to inspect signed by the applicant
and a certified abstract of title issued by a title company which shall
show single and separate ownership of the entire lot prior to April 9, 1957.
If a Certificate of Oc'~cupancy is denied, the Building Inspector shall state the
reasons therefor in writing to the applicanC.
3. Date of any housing code or safety inspection of buildings or premises, or other
pertinent information Fequired to prepare a certificate.
C. For Vacant Land CerCificatte of Occupancy:
1. An application for vacant land Certificate of Occupancy shall be submitted,
and a certified abstract of title issued by a title company showing single and
separate ownership of the entire lot prior to April 9, 1957 shall also accompany
the application. If a''Certificate of Occupancy is denied, the Building Inspector
shall state the reason$ therefor in writing to the applicant.
D. FEES:
1. CERTIFICATE OF OCCUPANCY - New Dwelling $25.00, Additions to Dwelling $25.00,
Alteration to Dwel}Lng $25,00, Swimming Pool, $25.00. Accessory building $25.00
Addition to Accessbry buildings, $25.00 -'Businesses $50.00.
2. Certificate of Occupancy on pre-existing dwelling - $100.00.
3. Copy of Certificate of Occupancy - $5.00 - over 5 years - $10.00
4. Vacant Land Certificate of Occupancy - $20.00
S. IIpdated Certificate of Occupancy - $50.00
6. Temporary Certificate of Occupancy - $25.00 Residential
$SO,QO Commercial
reps',. ~~'il
,10/14/88
I
THE NEW YORK BOARD OF FIRE UNDERWRITERS ~={~k
1~f7,3,~93 BUREAU OF ELECTRICITY
88 JOHN STREET. NEW YORK, NEW YORK 70038
Date if Fi~T~~Pi,(1;3'i '~~'1.91f C) /lPPlicotian No. on file ~'~~'~~1~9f ~
THIS CERTIFIES THAT
only the electrical equipment as deacrihed 6ebw and introduced 6y the applicant named on the afwve appJicotion numher in the premises of
~~,was.3~s; ,1, xa?~r~•rc~b v~+~ u~;3rr.~ r~v~:o. ;~atr~t'xnz,rs, ra.~,
? ]st F'l. ? 2nd FY. .Section Block Lot
in the followinK' location; ? Basement {7f3`f°
uas examined on 5~~3~TfSflf{f,h '1. i5 ` 1'i)Y c) and found to 6e in emnplionre with the requirements of this Board.
FIXTURE ECEPTACLES SWITCHES FIXTURES RANGES COOKING DECKS OVENS DISHWASHERS EXHAUST FANS
OUTLETS INCANDESCENT FIUORESCENi OTHER AMT. K W AMT. K. W AMi K.W AMi. K.W AMT. H P
1 z I.
DRYERS FURNAC@ MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIME CLOCKS ggLL UNIT HEATERS MULTI-OUTLET DIMMERS
AMi. K. W. On H. P. GAS N. P. AMT NO. A W. G AMi AMP. AMT AMPS TRANS. AMi. H. P SYSTEMS AMi WAiiE
NO.OF FEET
1. 1~ t. ACJ
' SERVICE DISCONNECT NO.OF S E R Y 1 C E
AMi. AMP TYPE METER ~ 4W I ~ 3W ] % ~W 3,e' 4W NO. OF CC COND A W G. NO OF HbIEG A W C' NO Of NEUTRALS A. W G
EQUIP. PER9 OF CC.COND OF HELEG OF NEUTRAL
OTHER APPARATUS:
c.z~.c.:3:_.~
~(S1I'fk1F1:CN<r iD~(31,1 Thal car^ti.T4aaf,~
cGYe,rs cc,rrl~~lt~~rzr~m ~,C Chea d~~t.e c~E
anspertioTt Giti,y. blc~carasa cl,~ LlftlJZ7tl~;L
PYIYX. Y'{anrnenx~ iG i.u adv~.~af~:p a, t~,
haver ~reL~n~,T,t test end/e~x rta~l~tarw
Imac1E? 3>y a t111a1.1. f. i.e~ pF,T s1?n..
. - ~~~~E~ V
Gk,3fY IJORQSR3. 11:CC,.#2341, 1, G~~~~
&2t) f•St)Na.~LL LN.
I CC3Tt:}30GY1E, NX. 11935 GENERAL MANAG@R
i'1
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 credentials.
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
Ise ~ e~: ~~~n.:, q c~,~rM~ur~ ~
H
FOUN7ATION (1st)
FOU?JDATIO?J ( 2nd ) m ~
2.
z ~
o~
ROUGH FRAME &
PLUMBING ~O
a
N
H
3 . x'
m ~
co
H
I77SULATIOPI PER N. Y. ~
STATE ENERGY
CODE
j
.y
r
4. ~ y
FINAL ~O ,3
I o
l ~ tY1
ADDITIONAL COMMENTS: x
~1 p ~ ~ ,
U v
,o
/ C. _ ~
c~ (~d
x \
'a ' .C.
H
~
9
y W
H
O
m
a
• r\
_ H ~
b
Rl
b
H
+u; ~ G f
~ ~ ~ 765-1802
BUILDING DEPT.
1 NSPECTION
[ ]FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] IN ULATION
[ ]FRAMING [ FINAL
REMARKS:
Y
DATE INSPECTOR
i I r i ! I i I i I •I ~ ~ r ( '
j~ l i , I; I i i i
I ~ i ~ I I I I I
i I I ~ I j ~ ~ i I i~ i I I ; r
III II ~'III~I~I
I I I I I ~ j l j l I l l j ~ r
I ~I ~Illl~.{~I~_I
__r ,
{ ~
i '"'y-f r-I ~ I i r ~ I
r
I , ~ I \ I I- , I i
i
~ i I i r
I 1~ ..f I~ I I ~ l I I 5.
I
r
I
F i i ~ I I 1 ~ ! i i~ /~vr
r'
':fit r I I I - .f1 ~ I I ' i i 1 ~ I ^/'~i i~ / ,I •
I I I t I I ~ i I l i ~I.
I
r
~ I ~ ~ ~ ~ ' '
t; I o l r I ~t' ~I
i '
i I I i 1 1~ i '~I 1? ~ I I ~ I I , ~ 111 ~
i
I I ~ bR. ; s' r. ~ i i { ~ ~ ~ 'i ! ; r ~ t ~ 7
' ~ I <r; ~ t' ~ I ~•j ~ ~ 7
`e~~' y~r ~Q~(j~ I r I~1
S• I' I I I I i I j ~11~~'~ ! i r I I I 6
':i
.
I
I
c~~ r r .
~ ~
r
~ ~ r I
r
J , .
r ~ r ' I ~
• , i
I I 1 I
I r r I . r ~ _ _ r r
LIIJII.y1.Wlr.\~'4nrlr~i Lru1..11:1~0111114 Ur.1:rI41JIIf IOII lh:f lql i.i4N9 w-•_M~~-_~~4iT~~ ~w
I ~~~'S?5~2-- v
y ~ ~ppQCY1R11ERSCERfIF~~ Z.
REQUIRED vuU-I,,.` w ` Itlr CI
1 'M L
' Dce ~R:in 5~9
MEDtAT
I' Olen Jp ~UPOSE O p~~.C~O.F~ Oi~', itiY l;t^,'1
ON C E
I~, BEFORE rPWq~q
IV
~ / ' 0
2e
~ I ,
lIL.tD ~s2~ ~
I ,~U ^ m r ~y`~
I IF.• _ ~
~Y~j ~ I ~~y36 9 ~ OG
_ I zE~~ ~ 9Ecu~~ 'f ^
p l ~ 3•=.~, -cam I
1 ,
Q j Q .eor?a ~ )U
I 1 ~ C Ili D? OJ Ys\ ~
S• \ / Q
ENCLOSE POOL TO CODE i 5
j UPON COMPLEf10N ~^c'~F t~ v" % ~
j 9EFORE P'WATRR" r^'' ^ ~ ~ \ u
i ~ ~ ` ~ `
• L /
' I
I I / \ I /
' SURVEY FOR
y ®°8 EDWARD J. KOWATCH 8 MARY H. KOWATCH -
6&.1?~ 99~" LOT U, °MAP OF SOUTHOLD GARDENS° Mu~Y 1B; ise6
y~$ ~ AT SOUTHOLD DATE SEPT. 28, 1982
' ~ ~~~^R A TOWN OF SOUTHOLD sLALE~ I"=ao'
~rsd. RRR ~~~888 SUFFOLK COUNTY, NEW YORK No. e2-sa'r
F xUtMUTHOR12E0 ALTERITION OP AOOITIOx TO THIS GUARANTEE
~~r~l~~° qpF I ~ SURVEY 6A VIOLATION Or SECTION )2090F THE
Ppm .d' p ' G`+ xrw YORK sTATE EoucATIOX LAw LHILA SONS E COMPANY
6 ~ xCOPl E4 OF TN6 SUgvEY MOT BEAPMG TN[ UMp
EDW 1f' A~' ATCH
SUP VEYOR'S INKED SEAL OP EMBOSSED SEAL SMall 6 OgN OL j,
NOT BC COXSIDERED TO BE A V1LID TRUE COPY
MGUAPAMTEES INOIUTED NEPfOM SXLLL flUN ONLY TO y( YV j E
MEA EPA N D A (Ty. {T THE PEflSDH FOfl WHOM TNC SUINEY IS PPEPARED `
1f~; f, qx0 W NIS BEHALF TO THE TTLf <ONPWT, OOVGX- . ;~E`.
x ME•B. DM I 5 URGE CF WgTER~ MIM °UBLIC_ NENTPL AGENCY qND LEXOING INSTITUTION LISTED y ~Y"5%,~.
X SLPF CD TP%MAP p3i 00 SEC TIDN oG3 BLOCK ~-LOT OITII NEPEON~ ANO TO THE PSSIONEES DF TXE LEMbIN4 M N ~'~5+~ ,
NTN[RE IRE MJ OWELLINBf WITHIN 100 FEET D° 1X15 PROPf PTY INSTIiVTIOx. OWRPNTEES PPE x0T TPAIISFEPPBLE Y+S::
OTNEP THAN THOSE 9NOWM NEPEON. TO ADDITIONAL INSTITUTIONS OP SUBSEOUENL O uw c
M TXE WITEn SUPPLY 11p 3fWADC D15{OIAL 4YSTEM f(N TXIS RESIDENCE OWNERS `
x DISTANCES SHDWN NEPEON FPON PRDPEPTT LIMES mF JI, y<' p`~
WILL CONFORM TD THE SigMWnD50F TNC 3VFF0.K COUNTY DEHRTNLNT TO EXISTING STpVGNRE9 ITE FOP A9£UFI[ tS 0, 124 a
OF NGLiM SfMICO, PURPOSE ANO APE NOT TO BE USED TO ESTI3USM °jOryA ,xEEN -
AI°LIGAMT' PROPERTY LINES Oq FOP THE ERECTION OF FCNCES / I EK6
AODPESS ~'y
TEL YaUfVG & YOU~!G AOOTSaTRAl~GER AVENUE
i RIYERHEAD, NEW YORK
•+MON VMENT ~=PIPE x
su BDiv1910N MPP FILED Ix THE OFFICE OF THE CLEflx or 6VFIOLY. CouNrr ~ % ALDEN W.YOUNG, PROFESSIONAL ENGINEER
ON MAY T+ 19)s As FILL X7.8012 } AND LAND SURVEYOR N V5. LICENSE NO 128x5
HOWARD W. YOUNG LAND SURVEYOR
N TIF LOGTgM 0FW6LIW1+9EpIICTPNNI590 CE59P(IOLSfCP)SNWx HfflEMI NY LICLN$E NO a5R93
eqE FROM FIELD ODSfRVATIDNS NID OR CLTP OPTPIUrn rgnN OTYFeS
1flf DYNE IO<i X01 ))o
/ '
. r c r,.
}
BOARD OF HE.\LTH
3 SETS OF PL.1NS
FORM N0.1 SURVEY
TOWN OFSOUTHOLD CHECK
BUILDING DEPARTMENT SEPTIC roam
TOWN HALL
SOUTHOLD,N.Y.11971 NOTIFY 7 _ //..rr~~
• • . TEL.: 765-1802 CALL ~/.o`....... .
Examincd.~~`~9 19~~ l/ MAiL To: ,
\pprovtd ...~~~,f 191J./Permit No../. D. 7; ~c7.~ 12 (~7 R
Disapproved a/c . D IS l~7 15
AU6 ~ Q egg
-~Z . BLOC. oePT.
TOWN OF SOUTFIOLD
(Build' ,Inspector) "®°°"""'""'.°•-°°--~--n--~~--_-~.._,,
APPLICATION FOR BUILDING PERMIT ~)e
Date ~ - 15 .i~. r
INSTRUCTIONS
a. Tlus application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3
sets of plans, accurate plot plan to scale. Fee according to schedule.
b. Plot plan showing ]ocation 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 par[ 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 issued 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
Regulhtions, for the cons true ig~,,pf~~lal}pdings, additions or alterations, or for removal or demolition, as herein described.
The applicant agrees(.tb~~o~rt"~ly''"3~'i~H aljj ~pplicab7e laws, ordinances, building code, housin, code, and regulations, and to
" admit authorized inspectors r~r~;premis,@s and ilu;btlilding for necessary inspections. _ h -
- - !'~L,3t Ir\147 Yt.~t,` I ~s•) ~
_ Y-:
,'t' ' 't t' (Signature of applicant, or name, if a corporauon)
• t'.s,.;s;a ; ~ ~ ~Mailin~ address of applicant)
.
State whet//h°°er: applicant is owner, lessee; agent, architect, engineer, general contractor, electrician, plumber or builder.
C~ .,G
Name of ownet+ dEp`remise§' .:L :~F'~!~`?~"?'...K•~(~J?~ 1 ~ .
~ (as on the tax roll or latest deed)
If a licant is ~c,:a-tt. ! . i ~t
pp Ip ~t:pnsignature ofduly authorized officer.
.....1~-~'~'J~~....
(Name and title of c rate officer)
Builder's License No. .....~.~r.: ~ y ~ E"~ME~oATELY'•
Plumber's License No. $E
pgEO.~A~I~
N~~
Electrician's License No . .
Other Trade's License No . .
1. Location of land on which proposed work will be done .
skNS v`. ~U~~1;la~.~...~L~
...~.i.3~ `
house Number Street. ~ Hamlet
County Tax Map No. 1000 $CChOn C0C"3,. Block ..Q , . , , , • , • , Lot U ~ ~ : ~ , • , , , , , , .
Subdivision Filed flap No. Lot .
(Name)
State existing use and occupancy of premises and intended use and occupancy of proposed construction:
Q~1 ~Ar-~ I dwell ivy
a. Existing use and occupancy • • • • • • • • • • • • • • .
k 6c0.1u~-~J.PgIIV ~~~i~~id~'~gxttrat~4
b. Intended use and occupancy . ~ • • • • •
D t`cvC ~ rr t, ET~~ ~ ~ ~ ~ ~ writ aa+~:~ ta,g; '
E t
I
3. RNet air of work (check which applicable): New Building Addition , , Alteration
P Removal Demolition Other\Vork~W~.n-.1•"'~"~.
(Description)
4. Estimated Cost Fee .
5. If dwelling 6 (to be paid on filing this application)
units Nt~mbcr of dwelling units on each floor .
If gara,e, num ber of carswellin ~ . • • , • • • • . • .
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use , , , , , , , , , , , , , ,
g s.... cs,ifany: Front......... p
Hint} =sions of existin structu~ber of Stories , , , , , , , , , , • _ . ' '
Nu Rear De th
Dimensions of same structure with alterations or additions: Front Rcar . ~ ~ ~ •
t s~ . • • • • • . • • • ..',...Height . . Number of Stories .
' 8. D'me~°~nY d'f entire new construction: Front . Rear . • • ~ • ~ • • • • • • • • • ' ' '
Hcigltt . Number of Stories Depth .
9. Size of lot: Front ....(.94~ • Rear 2 ~ ~O .
10. Date of Purchase Yv,A; 1~,.... , , , , r "Q • • • • • • • • • • • . Depth
. ~ ...'~,>'l Name of Former Owner . SS.4v~k\A~ Ya. C?la'a;~l:n~s. .
1 1. Zone or use district in which premises are situated ' ' ' ' ' '
12; Does proposed constructio ~ mate any zoning law, ordinance or regulation: . H~ .
13: Hill lot be regraded . , \Vill excess fill be removed from premises: es No
14; Name of Owner of premises KOJWARd~ )Zgwbjcj-~. • • • Address .~t~$.w~0 ~ , AST Sµ (e ~'Z
Name of Architect ' ~ .Phone No. ~ , • , • , ,
...........Address ..Phone No.
Name of Contractor .-sUr~k~~?~?~, ,P~'•t•~ • • .....Address ..P~:3`~k. ,5~5, ,$k(, ,Phone No. X65; .fit,?y-
IS.Is this ro ert loc'
y ' P P Y ated within 300 feet of a tidal wetland? *YES....NO....
*If es Southold Towp Trustees Permit may be required.
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. '
I
~ CV O DATE: A PRO~EO AS ROTE ~
~ LA~w~~~'UL FEE: s~e.P, «
NOTI Y BUI DING A~PARTME
I' " ° ~ FO6t_OWING NM 1CTIONS: FOR THE
1, FOUNDATION - TWO REQUIRED
FOR POURED CONCRETE
2. ROUGH -FRAMING & PLUMBING
3. INSULATION
4. FINAL CONSTRUCTION MUST
BE COMPLETE FOR C.O.
ALL CONSTRUCTION SHALL MEET
7HE REQUIREMENTS Of THE N.Y.
STATE CONSTRUCTION 8 ENERGY
j CK70ES. NOT RESRONS18l''1<: FOR
I, OESIGN OR CONSTRUCTION ERRORS
i
sY
ss ~'E_
it
ST,1TE OF NE\V YORK,
COUNTrY,
wOF $
.l~r.^",.-rte .S
• • • • ~ • ' ' ' ' ' • ' ' ' ' ' ' ' • • • • • • being duly sworn, deposes and says Yhat Ite is ttte applicant
(Name of in si~nitig contract)
above named.
He is the 'I ,
(Contractor, agent, corporate officer, etc.) ~ • • • • ~ ~ • ' • • ' ' ' '
of said owner or otvncrs, and is duly'' authorized to perform or have performed the said work and to make and file this
application; that all statements contaijted in this application are tntc to the best of his knowledge and belief; and that the
work will be performed in the manner het forth in the application Gled therewith.
Sworn to before me this i '
.......day of/.,',• ~/~~_iT` 19
Notary Public, , ,~tJ""ji, !!4!'!!':/;~ , County
~p~ry,IDVCIt ..~a.-~-::-
Wp•;q6 (Signature of applicant)
Term 6~MM