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Home My WebLink About17292-z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. _ CERTIFICATE OF OCCUPANCY No Z-23040 Date JUNE 14, 1994 THIS CERTIFIES that the building ALTERATION Location of Property 220 BROADWATERS ROAD CUTCHOGIIE, N.Y. House No. Street Hamlet County Tax Map No. 1000 Section 104 Block 10 Lot 7 Subdivision Filed Map No. Lot Noy. conforms substantially to the Application for Building Permit heretofore filed in this office dated AUGUST 4, 1988 pursuant to which Building Permit No. 17292-Z dated AUGUST 4, 1988 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 ALTER & INSTALL NSW PICTDRE WINDOW AS APPLIED FOR. The certificate ie issued to ANDREW CARLIN & WIFE (owner) of the aforesaid building. ' SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A UNDERWRITERS CERTIFICATE NO. N/A PLUMBERS CERTIFICATION DATED N/A Building Inspector Rev. 1/81 Fosai xo. s TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT CfHIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) l N fl ~ 17 2 9 2 Z Date ...lw!~/~~M:.4: 19. Permission is hereby granted to: ' ......................P....~....................................... a~ ~ ~ ~j ~ at premises located.•.at fib...... !xq.!~?....~:..........~.,..... ...-..'~1., County Tox Map No. 1000 Section ....1..4`f........... Block Lot No......~.~............ pursuant to application dated 19l..B...., and approved by the Building Inspector. Fee Building Inspector Rev. 6/30/80 `J/A~i ~ ~ Ga 9%sL_~9/6~ v"/ f~ ~ arr~ ui 4c~-~ c-~r~i.~r~.G ~'r .~c~l .~S'7~ G~i Form No. 6 v _ TOWN OF SOUTHOLD ~G e2 C..~.~C'~~ BUILDTOWNDHAARTMENT p:.¢ ~r~ i1~~ G,~yy~il/erd~-j.. w~ APPLICATION FOR~CERTIFZCATL OF OCCUPANCY/ ~ A. This application must be filled in by typewriter OR ink and submitted to the building inspector with the following: foY new building or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural oY topographic Features. 2, Final Approval from Health pep C. of water supply and sewerage-disposal(S-9 form). '&,ED 3. Approval of electrical installation from Board f Fire Underwr t k, Swore statement from plumber certi ying t at the solder used in system CanCains less than 2/10 of 1R lead, S. Commercial building, industrial building, multiple residences and similar buildings and installations, a oerCificate 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, atreet8> building aY:d unusual natural ar topographic features. 2. A properly completed application and a consent to inspecC signed by the appliaarit. • If a Certificate o£ Occupancy is denied, the Building Inspector shall state Che reasons therefor in writing to the applicant. C. Fees • 1, Certificate of Occupancy - New dwelling $2S,D0, Additions to dwelling $25.00, Alterations to dwelling $25.00, Swimming pool $25.00, Accessory building $25.OD, Additions Co accessory building $25.00. Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Buildinc - $100.00 3. Copy of Certificate of Occupancy - $20.00 4, Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $/1/,/5J.00, C mmercial $15.00, Date ,4.~~ . •New Construction., Old Or P existing i1 .n Location of Property... , , , , , ,~-~::~lL:+l:/~~:-w-~ House No . . Stx'eet ~ amlet Onwer or Owners of Property... ~ County Tax Map No 1000, Section.., lA~......Block,,.,lK.,..,,,,,Lot ..............f`....... Subdivision ....................................Filed MaP....,.......Lot........... Permit No ....D/a~~e Of Permit................Applicant............................. Health Dept, Approval....?~~vjj. .................Underwriters Approval....•..................,~ Planning Board Approval •,S~./7 Request for: Temporary Certificate.........,. Final Certicate „ ..vv~~,,y~ ~0 Fee Submitted: .z4t/',,,,,,,,,,,,,,,,,,,,,,, 1 ~Rt,,. ~28L S9L 9tiS ~~dH NMO1 O~OH1f70S WHEb:[L b5. 6Z J,HhI eo ~ a3 o N~ .nn,~~,..m .-1~LD If:SP~CTiUt+ ~~UAiE ~ %OMMEN7° 'ti ti 7 . ~ ~ a nom. H Y FOUNDATION (1st) c FOUNDATIOW (2nd) m - - ! z ROUGH FRAME & o -PLUMBING ti H 3 . m y IIJSULATIOP7 PER N. Y. • • STATE ENERGY CODE x } FIidAL o ADDITIOIJAL COMMENTS: x~' ' x ro N H .L m '.F y o -Q z o ~ Z • r.._ x d m -o H 765.1802 BUILDING DEPT. INSPECTION [ ]FOUNDATION 1ST ( ] ROUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [~RAMING [ ]FINAL REMARKS: D~ ~ / 1,~ ~ ~.~2 l t I 4 DATE ~ INSPECTOR ~ i • /3ro.r~' G?,~ris Cove 70' -Sp's 7~i9,eu • R3 ca>•Ir~ a w,'~c Po Dex iio5 to: 17 pm ,ZJ..O ~Z ro Ad WK~'Gr5 RaR $e~}I.old y $ec loy - w ~ ~ , r Lo+p 182. ~ ~ ~ t , _ J 7 Ui di~~ rr~S~DOyQ~g~~ ~o~ ~ xCCii ~W-. ~p m aD~ a ` ~ ~g ~~~~o~W n w a p~i~ O Q"~~~roD~m ~ O m } ~ 3w ~ / xr 47 p mb ~ ~«.,.,..»„~.Q ~ Q r n-~iy~ ~r~n~~ ~s -t 8 ,Sh~~O, ti h t'~7 3z' 3~' ~ti' ~ ~ New w,r~ow zo 6c 1.5fn~lca ~ ~ T6,y wr+l I 3~ ~ 31~ S bo 7~ p "t 8 . .(J/OAC~w.ry rvs IZOnc~ . row ~ c° ~ o S ~ z N o A S ~ ~ J 4 N N 1 A N n ~ ~ ~ i 1 s G ~ c W a w ? ~ ~ , l/+ r'CO r T ~ ~ ti ~ S N N c ~ s cn y _ n V, ~ ~ 3 6- t ~ ~ ~ ~ r ~ N ~ ~ n, V ~ X O N Z 1 N n ~ s 6' h~ n y\ 3 n S n o ~ gS'~ z g ~ 0 N ~ N w 3 L ~ v ~ ^ r o 5 O 1 ~ O ~ C S N ~ ~ 5 G £ J ~ C ri A ~ a D N ~ a o e z e r oti F s r N ti 'a + ~ 2~° ~ ~ ~ a O p J ~ ~ ~ t ~ v 3 INSPECTORS UFFO( (516) 765-1802 I{'C VICTORLESSARD,Principal ~G SCOTT L.HARRIS,Supervisor CURTIS HORTON, Senior = y~ Southold Town Hall VINCENT R. WIECZOREK, Ordinance y P.O. Box 1179, 53095 Main Road ROBERT FISHER, Assistant Fire ty Southold, New York 11971 Building Inspectors Oy • ~ Fax (516) 765.1823 THOMAS FISHER 4J~1 ~ ~aO~ Telephone (516) 765-1800 GARY FISH OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD October 30, 1990 Andrew J. Carlin 220 Broadwater Road Cutchogue, N.Y. 11935 RE: Building Permit #13903-Z (SUnroom & Deck) #16792-Z (Stove) #17292-Z (Alteration) Premises: 220 Broadwaters Road, Cutchogue N.Y. Suffolk County Tax Map #1000-104-10-7 Dear Mr. Carlin: During a review of our files, it was noted that the above building permits have expired and Certificates of Occupancy have never been issued. According to the Code of the Town of Southold Article XXVIII 100-281 and 100-284 a building permit is needed for any alterations or additions to an existing dwelling, and it is unlawful to occupy said dwelling until the Certificates of Occupancy has been issued. Please contact this office as soon as possible so that we may clear up this matter. Thank you for your cooperation in this matter. Very truly yours, SOUTHOLD TOWN BUILDING DEPT. Victor Lessard, Principal Building Inspector VL:gar INSPECTORS 7n (516) 765-1802 r r U~ F ~(I~ SCOTT L. HARRIS, Su visor VICTOR LESSARD, Principal ~5 y ~Q Pn CURTIS HORTON, Senior ~ti % Southold Town Hall VINCENT R. WIECZOREK, Ordinance ; . /~~,`.~,~i ~C P.O. Box 1179, 53095 Main Ro ROBERT FISHER, Assistant Fire ~ ` ~ Southold, New York 11971 Building Inspectors ~ ~ ~.3;~~' ~ Fax (516) 765-1823 w ~ ~e ~ Telephone (516) 765-18 THOMAS FISHER z7> ~ GARY FISH "<<~AOl 1,~ ~`a OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD ORDER TO REMEDY VIOLATION Date: December 18, 1990 TO: Andrew J. Carlin, (Owner) 220 Broadwaters Rd. Cutchogue, N.Y. 11935 PLEASE TAKE NOTICE there exists a violation of: Zoning Ordinance CHAP. 100 Other Applicable Laws, Ordinances or Regulations at premises hereinafter described in that BUILDING PERMIT #12168 13903-Z 16792-Z & #17292 HAVE EXPIRED AND CERTIFICATES OF OCCUPANCY HAVE NOT BEEN ISSUED WHICH IS REQUIRED BEFORE OCCUPANCY OR USE. In violation of ARTICLE XXVIII CHAP. 100-281 and 100-284. 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: 220 BROADWATERS RD., CUTCHOGUE, COUNTY OF SUFFOLK, NEW YORK. SUFFOLK COUNTY TAX MAP #1000-104-10-7. 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. VINCENT R. WIECZORE , ORDINANCE INSPECTOR INSPECTORS Principal Building Inspector p~pS~FFO~k`'OG Curtis Horton h~ 2~ SCOTT L. HARRIS, Supervisor Senior Building Inspector o Thomas Fisher y x Southold Town Hall ~ P.O. Box 1179, 53095 Main Road Building Inspector ~ • `F Gar Fish ~?j a0~ Southold, New York 11971 Building Inspector ~ Fax (516) 765-1823 Vincent R. Wieczorek Telephone (516) 765-1800 Ordinance Inspector Robert Fisher Assistant Fire Inspector OFFICE OF BUILDING INSPECTOR Telephone (516) 765-1802 TOWN OF SOUTHOLD January 3, 1991 Mr. Rory Klinge Traditional Buildings & Restorations P.O. Box 203 Greenport, N.Y. 11944 Re: Building Permit #16792-Z (STOVE)- ANDREW CARLIN Premises: 220 Broadwaters Rd., Cutchoque, N.Y. Suff.Co. Tax Map #1000-104-10-7. Dear Mr. Klinge: During a review of our files, it was noted that the above building permit has expired and a Certificate of Occupancy has never been issued. According to the Code of the Town of Southold Article XXVIII 100-281 and 100-284 a building permit is needed for any construction of additions, accessory structures, alterations or new dwellings, and it is unlawful to occupy or use said structure until the Certificate of Occupancy has been issued. Please contact this office as soon as possible so that we may clear up this matter. Thank you for your cooperation in this matter. Very truly yours, SOUTHOLD TOWN BUILDING DEPT. Victor Lessard, Principal Building Inspector VL:gar /,f road G?M~~S Cove 70~ 7P~s 7~z9`sY RS carl,~ a w(~c ~ Po Dnx nu5 10:17 PM ,21o Iz roHd w,rfGrS jZnq~ , $e~ftiotd ~I `I Cv}~4aj,.t Sec l04 - lo- ~ y /~y~` Q } J i , ~ ~ ~ ^ A ~tN7b A<aN v-`, O m ;ti's S! T T. r tr m -i Ci ~ m ~ ry i rn :J 'J C :,i tri 2 O f~ p O J r= Gi ro a~ = ofy Win.. Z J~ 'G ~~~~c~tyzbmo~aq i ~ Cn ]7Cm ~mC> D c7 07S;r °4 +C ~yy~-ziaGT~ ~ o m i~ ® _ f7QQU127JS .~C) ~~UTA QY n A m< =p y ~2' pu). G ~°m~zroD ~ 2 O Oy 'ns0~ ZwR' D O ~m~N~~~-~r~n ~~~~3 ~ ~ e ~°z ~ y'v a a~ Z m G 0° ~o .i r w ~ (n 7R«~~1 L7 O my.. ~ ~ ~ y,~ ~ m C°y Q ~~HC ~ G A Z is• 'O ~ D ~ Cl~~O ~s' erg 3z' 3~' ~-v' N,ew window To QC 't~s~allc~! 'n 74~y wall 3~ ~ 3~ S too' ~o 8~ (//aAe~w.ffrv5 /2 once r o ~ s ~ c+a'a ~ r } r _ ~ } c £ 4 J N C ri ~ ~ 0 D a `0 a N R ~ > ~ O ~ Y Y-' S_ U1 ~ 0 L m~ ~ ~ V Y ~ ~ J N 2 + ry 1 D ~ _ O r ~ r a a v V+ N a ~ r ~ ~ y Q Y S r z w f o E s J ~ ~ n V y N ~ 0 A P N ~ ~ Tv ~ c = ~ ~ ~ G x ~ w ? R" 1/~ N A > N ~ + NC y ,c r ~ 3 N ~0 1 _ N E ~ s ~ ~ U ~ ~ S 2 R ~ L ~ ~ ~ ~ A v N N v, ~ a X ~ ~ ~ N r T' ~ s s x, h~ ,n n n n EG +o z o ~ N ti ~ w - 3 WSPECTORS (516)765-1802 VICTORLESSAAD,Principal OCJ~~fO~CO/, ~ SCOTTL.HARRIS,Supervisor CURTIS HORTON, Senior ~ ` ~ Southold Town Hall VINCENT R. WIECZOREK, Ordinance ti ~ P.O. Box 1179, 53095 Main Road ROBERT FISHER, Assistant Fire ~ ~ Southold, New York 11971 Building Inspectors tft ~ Fax (516) 765-1823 THOMAS FISHER • Telephone (516) 765-1800 GARY FISH ~/Ol ~ ,~vaO~ OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD ORDER TO REMEDY VIOLATION Date: December 18, 1990 TO: Andrew J. Carlin, (Owner) 220 Broadwaters Rd. Cutchogue, N.Y. 11935 PLEASE TAKE NOTICE there exists a violation of: Zoning Ordinance CHAP. 100 Other Applicable Laws, Ordinances or Regulations at premises hereinafter described in that BUILDING PERMIT #12168 13903-Z, 16792-Z, & #17292 HAVE EXPIRED AND CERTIFICATES OF OCCUPANCY HAVE NOT BEEN ISSUED WHICH IS RE UIRED BEFORE OCCUPANCY OR USE. In violation of ARTICLE XXVIII CHAP. 100-281 and 100-284. 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: 220 BROADWRTERS RD., CUTCHOGUE, COUNTY OF SUFFOLK, NEW YORK. SUFFOLK COUNTY TAX MAP #1000-104-10-7. 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. VINCENT R. WIECZORE , ORDINANCE INSPECTOR INSPECTORS ~ SU f FO(~ (516) 765.1802 Q C VICTORLESSARD,Principal ~O ~G SCOTTI,.HARRIS,Supervisor CURTIS HORTON, Senior = y~ Southold Town Hall VINCENT R. WIECZOREK, Ordinance H P.O. Box 1179, 53095 Main Road ROBERT FISHER, Assistant Fire ty Southold, New York 11971 Building Inspectors G • ~ Fax (516) 765.1823 THOMAS FISHER y~f Q`' Telephone (516) 765.1800 GARY FISH o'~ ~ ~Q OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD October 30, 1990 Andrew J. Carlin 220 Broadwater Road Cutchogue, N.Y. 11935 RE: Building Permit #13903-Z (Sunroom & Deck) #16792-Z (Stove) #17292-Z (Alteration) Premises: 220 Broadwaters Road, Cutchogue N.Y. Suffolk County Tax Map #1000-104-10-7 Dear Mr. Carlin: During a review of our files, it was noted that the above building permits have expired and Certificates of Occupancy have never been issued. According to the Code of the Tawn of Southold Article XXVIII 100-281 and 100-284 a building permit is needed for any alterations or additions to an existing dwelling, and it is unlawful to occupy said dwelling until the Certificates of Occupancy has been issued. Please contact this office as soon as possible so that we may clear up this matter. Thank you for your cooperation in this matter. Very truly yours, SOUTHOLD TOWN BUILDING DEPT. Victor Lessard, Principal Building Inspector VL:gar B0.\RD OF HE,\LTii FORMN0.1 3 SETS OF PL.1NS SURVEY TOWN OF SOUTHOLD CitECK BUILDING DEPARTMENT SEPTIC FOR:1 ~ ~ ~ ' TOWN HALL ~ ~ ~ ~ SOUTF{OLD, N.Y. 11071 NOTIFY ' ' TEL.:7G5~1302 _`pOCALL r,'j`5~ Examine 19°~ ,~IL T0 approve ~l"~?d'.. ~ . 19 Penn No. .L91. ~ G'~y r tt Disapproved a/c . ~D 41988 TOWN pF • DEPT. ' soumot.o (Building Inspector) APPLICATION FOR BUILDING PERMIT Date ~~j........., 15 INSTRUCTIONS a. Tltis 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 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 issued a Building Permit to the applicant. Such permit shall be kept on the premises available for inspection throughout the work. e. No building shalt be occupied or used in whole ar 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, NeAv York, and other applicable Laws, Ordinances or Reculations, for the construction of buildings, additions or alterations, ~r for removal or demolition, as herein described. The applicant agrees to comply with ail applicable laws, ordinances, buulding code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessa spllect' ris. ~(/yn (Sigtl,apP{icon a if a corporation) ~ - • j°.~:~..!a~F.. 5~~~~o/day (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, ge eral contractor, electrician, plumber or builder. ~on~fc<fc1`osL ' Name of owner of premises ~)rlL~.Yei^!, , • ~1r4 ;n • ~ v~7-C (as on the tax rpll or latest deed) ' ' If applicant is a corporation, signature of duly authorized officer. II (Name and title of corporate officer) Builder's License No. ~ ~~S/~ J-~L Plumber's License No . Electrician's License No . . Other Trade's License No . . Location of land on which proposed work will be done . t~u7c~a%!.°.~. house Number Street\ ~ ~ ~ ~ ~ ~ ~ Hamlet ~ ~ • ~ ~ ~ ~ ~ ~ County Tax Map No. 1000 $CCIIO? ......~~.y, Block l Lot . ~ .....`-#,~.g~~ Subdivision Filed t`lap o. . . (N:une) ;t Lot............... State existing use and occupancy of premises and intended use and Deco ancy of proposed construction: a. Existing use and Deco anc a( ~ ~ ,y P Y ~.'..`j b. Intended use and occupancy , , , ~rHUw ~ i _ i 3. Nature otwork (check which applicable): New Uuilding ' Repair licmoval . • Addition .Uterat' (1 Demolition OthcrlVork..•• 4. Estimated Cost , , , _ , , ~ Sa O • ~ (Dcscnption; • Fec.................................... (to be paid on liling this application) 5, If atragcnnumbcr of ~atsvclljng units , , , , , , , , , , , , , , , Number of dwelling units on.cach Cloor , , „a ~ . 6. 1f business, conuncrcial or mlixed occupancy, specify Hatay and extent of each t e oC use , , , • , , . • • . , , _ ; 7, H`ntft`sions oC ~xistim~ stntctures, if any: Front , ~ „ umbcro .Rear .la~.. Depth...-,3 r? f Stories . , / . ' ° ' ' ' ' ' Dimensions bf same struc(urd with alterations ~ • • ~ ~ • ~ ~ ' ~ • ' ' ' ' ' ' ' ' • Dcprtt . or additions: Front .Rear . ,Cp,S'„ • . • • , ~ lIcight . /d~ 8. Dimensi~nt etv cpristntctio • ~ " " " " " • • • • • Nurnber of Stories . ! • ~ " " " Height n: Front......... Rear . 'Number of Stories . ~ • ~ • ~ " " " " " • • • • Depth 9. Size of }ot: Front' ;•//f~ : • , L0. Date ofPurchlse Rear 7~ . Depth . ;5/0' S!/G ' . • • • ....Name of Pormer Owner • . 11. Zone or use district in which premises are situated . 1 Does proposed construction violate any zoning law, ordinance or regulation: , /L!U• • ~ ~ ~ • ' • • , • • • • • . 13. Hill lot be regraded ~ ~ ~ ~ • " " " " 14. Name of Owner of premises ;S, C wrl•; ~ • ~ ' ' ' ' • }Vrlt excess RI1 be removed from premises: Ycs N, Name of Architect I w'•~ • Address ,2,Z Q , Q,~gAdtianrl<.~ • , , ,Phone No. . Name of Contractor ~45~ .(~wh~ .c~,~. • .Address .......Phone No . ~ •gr• • .Address .IMP. ,Qoy, ~']o IS.Is this property logated within ••PhoneNo.~~¢:,tf~•?°'),,.. *If yes, Southold Town Trustees PeNrmit may bearequiredetland? *YES~C..NO.... PLOT DIAGRAh1 Locate clearly and distinctly all buildings, whether existing or proposed, and, indicate all set-back dimensions frpr. property lines. Give street and block number or description according to deed, and show street names and indicate whethc: interior or_Lc turner lot. I ~~2 ~1 ~`N~~-e ~ gY~QerS I~ . • j STATEpFNENY K, ~ =OU, OF. .~S'S .....i r above named(namc of individual signitjg contract) ~ ' ' ' ' being duly sworn, deposes and says that 1te is the applicant is is tltc li fsai (Contractor agent, corporate officer, etc.) • • ' ' ' ' ' ' ' ' ' d owner or owners, and is duly i;wthorizc to perform or h;tvc performed the said work and to m '~plication; that all statements contaiticd in this application arc true to tho best of his knowledge and belief; and [hat the ork wdl be performed in the manner set forth in the application lilud therewith. ~`c and file this ~~'orn to bctorc me this " .day of S l 19 v0 i' ~tar}• Public, , ' I• • County If11N~ ~ L McAt tMnIINMd M (Woulitlr / . OomnNMbn81y1rN rs,19~~v (Si^natureoC applicant)