HomeMy WebLinkAboutTR-5070
Albert J. Krupski, President
James King, Vice-President
Henry Smith
Artie Foster
Ken Poliwoda
.
~ffol~,
(~.~\
Q ~o
en ::æ:
~ ~
~. ""
~Q, + ~~<:s
Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 11971
Telephone (516) 765-1892
Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
October 28, 1999
Mr. & Mrs. Howard S. Michelsen
860 Rabbit Lane
East Marion, NY 11939
RE: SCTM~3l-l8-l8
Dear Mr.& Mrs. Michelsen:
The following action was taken at the Southold Town Board of
Trustees Regular Meeting on October 27, 1999.
RESOLVED, that the Southold Town Board of Trustees approve the
request for a Transfer of Permit ~31-18-18 from Hazen Cook to
Howard & Valerie Michelsen.
If you have any questions, please contact our office at 765-1892.
Sincerely,
t2a~./~. /~.~.
Albert J. Krupski, Jr.
President, Board of Trustees
AJKllms
Board Of Southold Town Trustees
SOUTHOLD, NEW YORK
PERMIT NO. $0'70 DATE: Oct. 28. 1999
HOWARD & VALERIE MICHELSEN
ISSUED TO ...... .... . . . . . .
Autl10rizutinu
Pursuant to the provisions of Chapter 615 of the Laws of
the State of New York, 1893: and Chapter 404 of the Laws of the
State of New York 1952: and the Southold Town Ordinance en-
titled "REGULATING AND THE PLACING OF OBSTRUCTIONS
IN AND ON TOWN WATERS AND PUBLIC LANDS and the
REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM
LANDS UNDER TOWN WATERS;" and in accordance with the
Resolution of The Board adopted at a meeting held on .. Ckt. 27.. .
19 99, and in consideration of the sum of $ 100·00 paid by
Howard & Valerie Michelsen
East Marion
of N. Y. and subject to the
Terms and Conditions listed on the reverse side hereof,
of Southold Town Trustees authorizes and permits the following:
Grandfather Permit for an existing deck. stairs. house and
shed.
all in accordance with the detailed specifications as presented in
the originating application.
IN WITNESS WHEREOF, The said Board of Trustees Iwre-
by causes its Corporate Seal to be affixed, and these presents to
be subscribed by a majority of the said Board as of this dðt.e.
//~,!!,ç;þ'
He y Smith (Is)
k-~~k~cL .
Trustees
.
.
.,.,~ r"'·r.\ ,r.'· f.,~ f." :r.," r., . ra> ..r. . f," r., f' ··r. . fa\' " . ,r., fa\.:r,\, fa ~ fa . IA . fA ',1' "I. . I' . I' \ " '1." 1.\' f. I" fa . f' ,,' IA" " I. f.', r. ',. ,.' '. 'A '. '. '. . I. " . 'A '., 1 .
TERMS and CONDITIONS
Howard & Valerie Michelsen
The Permittee
residing at
patt of the
lowing:
860 Rabbit Lane, East Marion N. y~ as
consideration for the issuance of the Permit does understand and prescribe to the fol-
1. That the said Board of Trustees and the Town of Southold ILIe released from any and
aU damages, or claims for damages, of suits arising directly or indirecdy as a result of any oper-
ation performed pursuant to this permit, and the said Permittee will, at his or her own expense,
defend any and all such suits Initiated by third parries, and the said Permittee assumes full liability
with respect thereto, to the complete exclusion of the Board of Trusrees of the Town of Southold
2. That this Permit is valid for a period of N / A mas. whir:h is considered to be the
estimated time required to complete the work invohed, but should drcnmstances warrant, request
for an extension may be made to the Board at a later dare.
3. 1110t this Permit sÞ.ould be retained indefinitely, or as long as the said Permittee wishes
to maintain the structure or project involved, to provide evidence to anyone .concemed that auth-
orization was originally obtained.
4. That the work involved will be subject to the inspection and approval of the Board or
its agents, and non-compliance with the provisions of the originating application, may be canse for
revocation of this Permit by resolution of the said Board.
5. That there will be no unreasonable interference with navigation as a result of the work
herein audlorized.
G. That there shall be no interference with the tight of the public to pass and repass along
the beach between high and low water marks.
7. That if fucure operations of the Town of Southald require the œmoval and/or alterations
in the location of the work herein authoriud, or if, in the opinion of the Board of Trustees, the
work shall cause unreasonahle obsrructlon to free navigation, the said Permittee will be requhed,
upon due notice, to remove or alter this work or projecr herein stated without expenses to the Town
of Southold.
8. That the said Board will be notified by the Permittee 01 the completion of the work auth-
orized.
9. That the Permittee will obraiu aU other permits and consents that may be required sup-
plemental to this permit which may be subject to revoke upon failure to obtain aaøte.
.
,T7::'-..:':"l;:;.?-~
j':c¡,\lfFOl~ -"e
..".5::)11" '1 t'f2..'~,
.:~ ~_';c
..~ -,. '.
'f':::' ~,....
"'- :...:..,
1'I - ~ ',',
,lei.) ;;e:::'
S~ ""þ
"~~ ~j,
'" ßß ~ '-- .jr
~.~ ~,""
-~"Q, + ....~ .~i'
~'- l' "1')
~::;-~:o...£,:;:;:;.p1-'-'-
.
Albert J. Krupski, President
James King. Vice-President
Henry Smith
Artie Foster
Ken Poliwoda
Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 11971
Telephone (5161 765-18'12
Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTH OLD
Office Use Only
Coastal Erosion Permit Application
---Wetland Permit Application
~Grandfather Permit Application
---Waiver/Amendment/c~~es
~eceived Application:' 7t¡t¡
eceived Fee:$ /00-
~ompleted Application ~/~qq
Incomplete
SEQRA Classification:
Type I Type II Unlisted
Coordination: (date sent) ----
.". CAC Referral sez:t: q {~~~~
ate of Inspect~on: Qq
Receipt of CAC Report: .
Lead Agency Determination:
Technical Review:
,,-public Hearing Held: IOI.?ltJq
Resolution: .
rr-::.;;-:-:--- h T - .
I,: 11 ' ,
II! 'r'c",
Uii.
UI SEP 2 3 !999
L__
TOV\J!\; C~i~ ~::~J"~' ':";
._--~._~-.. .
Name of APPlicantJ.\ tI\N Ov-rcJ S. ~ V C\\V\ f ) ~\(.".h~<;1l..vì
Address~\oU ~~bVn\ ~<J
ç "',' ~ "'-<, ~ ~'\ \\\~~ "-,, 151 \; ~Î i ? \, ~ 3
Suffolk County Tax Ma~ Number: 1000 - 3..l.=.1 -
Property Location: ~ \g \J YïZ.<>.. ~ \,¡ \ ~ ~ ~. \ ç, ~ $; 1 ~ N \ ~ ,'1\ \.,~
LILCO Pole #, distance to cross streets, and location)
AGENT:
( I f applicable)
Address:
Phone:
FAX#:
1
eard of Trustees APPlicat~
GENERAL DATA
Land Area (in square feet):
Area Zoning:
Previous use of property: '\ ~rcO, ,ð Q-v::);\CV\
Intended use of property: '\~ '::~, c\ ~.t, o.Á
Prior permits/approvals for site improvements:
Agency
Date
No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a
governmental agency?
~NO
Yes
If yes, provide explanation:
Project Description (use
.~ ~ '^ ç'v-1- '" oJ
<; \--. E' , d.
~m
attachments if necessary):
\'^ ~\d\\"\( df'c..-k Sfo..\(S ~O\A.>V""\--
ð ) )
OL. .,,~ \'9.), \, V 1r <i "'~ "+ 1 (()..n~í -:YQ{ íT\\ t- ~ 3 \ - \ '¡(-\ ~
\-\ CL'1 º- \\ C nn'{... \\j \-\.0 uX'l. \ r\.. "t \ h,~ ,\ 9- \'{\ ¡ ( \\ (l \:::.e I'L"
2
~d of Trustees APPlicati0tIÞ
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations:
Area of wetlands on lot:
square feet
Percent coverage of lot:
%
Closest distance between nearest eXisting structure and upland
edge of wetlands: feet
Closest distance between nearest proposed structure and upland
edge of wetlands: feet
Does the project involve excavation or filling?
No
Yes
If yes, how much material will be excavated?
cubic yards
How much material will be filled?
cubic yards
Depth of which material will be removed or deposited:
feet
Proposed slope throughout the area of operations:
Manner in which material will be removed or deposited:
Statement of the effect, if any, on the wetlands and tidal
waters of the town that may result by reason of such proposed
operations (use attachments if appropriate):
3
P·~6·~L2!8;ï-;--~:t! 12 . .
.. I I
PROJECT 1.0 ,'I U,',i a ¡:::::¡ 51 ì.21 SEC
Append;.;; C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSiVI ENT FORM
Far UNLlS7ED AC710NS Only
PART I-PROJECT INFORMATION (10 be comolered ~y .-\opJicant or PrOject SDonSOrJ
I 1 APPLICANT SPONSOR I 2. .:JROJE:-:- '~Ar.1E
I
J. PROJECT l..OC.; ¡ION:
Munlcloality Cûunt'{
,. PRE':;SE LùCA TION (Street aQQress ana roaQ rntersec:lons, prominent lanamarKs. erc., .:¡r ;:Hovlae ,ìlap)
-
5. IS PROPOSED AC7!ON:
.. ONew o Expansion o MoaifiGallonl31!eratlon
;. DESCRIBE ?ROJEC-:" BAIEFL Y:
1 AMOUNT OF LJ..ND AF¡:ECTEi:J:
fnl!ially acres Ultimatelv acres
J. 'NIL!... ,:::;ROPtJSED AC7¡QN C'::MPL':' ','VITH Ð:ISï!NG ZONING OR CTHEÑ :::XIST¡NG ~ND USE ::1ES7ri!C7':CNS?
I 2Yes UNo If ~~o. describe orie/ly
I
,
I ,. WHAT IS ?AESENT LANO US~ IN VICINITY OF i=lAOJECT"
- ~ rnaustrlal C Cùmmerclal U AgriCUlture - -
I !.......: Resldenllal ~ ParK/Forest/Ooen space '-...; Other
Gesc:lbe:
10. DOeS ACTION INVOLVE A ?~FlMIT APPAOVAL. OR FUNDING, ,'lOW OR ULiIMAiEL"f FROM ANY OTHER GOVE?.NME\l7'AL AGENCY (F::DE!=IAL,
5T,1. TE G~ LOC~L)?
DYes DNo If yes, list agenCYIS) and permrllapprova1s
':r-
11. DOES ANY ASPECT OF THE ACTlor~ HAVE A CURRENTLY VALID PEMMIT OR APPROVAL?
DYes· DNo !f yl!S, list aqef"lcy name anQ permIt/approval
12. AS), RESULT OF PROPOSED ACTION WILt. :XISTING PEMMIT/APPROVAL ¡:¡EQUIRE \10DIFIC.;ìICN?
DYes r: No n.
I CEíHIF'( THAT THE INFORMATION PROVIDED ~eOvE 15 TriUE:O THE 3ESï Or "-IY r{NCWl=CGE
Applicant/sponsor "ame: D..¡te:
SIgnature:
I If the action is in the Co"stal Area. and you are a state açency, complete the
I Coastal Assessment Farm before proceeding with this a'i.~essment
OVER
! ,
I
-
:,: .::;:: .:.c -:..:'~ :., .....::.:._ .;,:, ~
.=~~"=' -
....._...."1_. I
--:; --=E2'-'_L'::
--
::'"';'"" :,~f-::= :'.
c -O_c .
,- -
: : ".!$. _ _cr,::'ni.l~~
',"1e .~""~"'" ::':ce~g 'lflC J:O? 'r-~ ::''':L_
:":'.-
:J..:.r:.- :1_:::.'J'JI,:;':~I".~:=:<7;"·
,'J '5
'¡ '::::._ - _r, -j'
, ~s
:.0
_, .'IIL__ :"'::-:C,'~ =lE.:'::':',::: :::'::?;:{~J;.,'EJ ::¡E.·,IE'N':'S ==C'IIC:::':'
-:;a', ~e slJ::e'sec~o;: :y ~nc[:-.er nvG¡v~a ]çenc·/.
-.
JtIL.S';'":::=' -'::-:-::::;.'J5 '"
' "r:::=R. ~J.;::;,
-
'0.
] 1e-;':;';:".f3 ::::C lr-
'/~$
."0
:, :':L:L:J .;C7:Crl ;: :5i....L. N .Jr.NY .1oC'lE::SE. ':--:::·:,3 J,S~":C;..T:::J .'JI7"'-' -:...:: =·JL~':\I·l\."JG, ;.."1:>'Ners "':":"'{ -:e ":.3,nC'.VrI[:e'1 t eo:;r::lel
::::.tIS;lng llr ,:tJal.t',. ]ur~ac:'! )( ;rCl.:nd'Nare~ :va¡itl{ Jr ::L.3.n!lty, 1CIse e'I~IS. ~x:s::nG '~3:~iç ::a!:e~~s. :CI,C vas,e :r;:Ct:c:.:."': :r ~I~:
:Joter'\!lal 'cr :!ros,on. ::í3.lnaçB Jr "Iaocmq :rocl¿ms? ~~Claln :Jfle!!y:
c_
.J.estneIIC. :¡çnc:':ltuf:ö,I, JrC:':3èOIOqIC.3I, 11$,afIC, Jf ::HI'1~r la¡'..zr:11 )f ':'.1111.;(")1 ''!saurC2S; :>r ::;¡mmun'f'{ Jr -:elç:-:cct:1CCC ":;,-:~fac:è~'" ~:='';'L,'l
leç~~aIIQn ,Jr :auna. ·:SI"I. ;,-:eIHisn Jr Nllçll'e J:Jec:~s. ~ (;mric.Jn! 1aCI[ar~. :;r 7:-H~.3.fè!lea Jr "'!ncançe~~':I :;:ec:es"' ~:CI,;,tn Jrrall'{"
"'_, ~ .:::mmunl(·(·s IÓ!xls~:ng ;I!ans or ;0315 as 011l.::allv 'OCQteo. Jf J. cnange Ln usa or Intenslty:n 1.;se 01 ~ana or ':lIner natural reSQUfCS~? =.·{C .J n
:.5, '3row{n. ¡uaseauent :lÓ!veloament. Jr relaleo ac::vltles likelY '0 Je ,nouc.eo JY :ne :::rocosea aC:lcn" =.x:)13In JfTerlv,
_.:i, '_.:::nq 'erm. ¡ner; 'lÓ!f,~, ::.UTIulallve. Jf Jmer <3ttec:,S not ,Ce!lfrr,,~O ,n (:>::5? =."(;:]lall"l :;rrerl'!,
:l~~~ moac:.3 .jnC:..JClng ::-,ar1çes ,n 'Jsa 01 ~nner "Juantlty .,r :vçe Of "'!nerç;YJ? ::"'t;:Jlaln ::rlerly,
:ì. S -H=~E,:R S -:-....=;:::;E _::<::::'.:~.C 3E. :::NT;:;OVE?S'( :::rE~,=;) -:-0 ~'JT~,'.¡"ï';'i.. ~:\¡'=.=!Së ::.~ I;IRCNME,'lí;'L .',:P~C7S-:'
_ '~es
."0
f ·~es. ,¡xc!aln Jrteltv
.'ART Ill-DETERMINATION OF SiGNIFICANC:: ITa ~e camoleled oy .Agency)
INS7RUC--:-10NS: For ~3C:'l aQverse :!!fec: IdentJfie':l 3Ccve. C!etermine wnetl1er It IS sut)staruial, :arge, :mc:crtanc or otl1erNlse s¡çnific
:::aC:'1 ~ifec: S:10uIC ~e 3ssessed in c::mnecnon with ;ts (3) 3ettJng (i..~.. urcan or rural); (t:) ~robacl!ity of occ:J-.-wg; (c dU(2.tior
Irre'¡erslcilHy; :e geogracmc ,3c:Jce: ana {f} magmtude. If necessary, aod attac!'1ments or reterence sUPDoning materials. :'::1sure
~xClanatlcns c~nra.ln suttic:ent detail to snow that all re!e'¡ant aaverse impacts have been identified ana adeQUately accressec.
C:'eCk: :hls box :f :Jou have ic'entifiea ene or ,'TIDre :oten{ aHv !arçe or significant aC'¡erS2 ¡mcac:s 'NhIC:1 ,'.1"':"
oc:~r, 7"hen 'Jrcc::eo üirec:!y ~o :ne ¡::UL~ =)..F 3.nC/or ;::;re~are a positive- dec araticn.
C~ec:< :nis :::ox 'f you 'ave ,je!ermrned, JaSed 'In the inicrmation and analysis 3.bo'le and any suooor(ji:
,jac'J~enta[lcn. :t1ar ;t:.e Jrooosea ;,c:jon WILL ,'JOT resutr In......3.11'.I significant acverS2 -?nvlrcnment21 imcac:
AND JrOlllce :n .3.;:~aC:1(:1enrs .3.5 necessarv, the ~easons 5uc:canlng tnlS determInation:
"''''''''- ',{ _,,~U ~ ,1:11("
....'nl JI ,~o:: ,-,.,TI.. )1 ·(c·,;;on\'OI<: ~/r,c'!r n ~...."a ~~"nC",
:'00:: 01 -<",D0(111010:: VII'Co!'
;,..nJn,,~ }I -<..<con"OI~ ':'t:'':~'.11 ..0::..10 '.;~n(y
>''(noi:''''O!' )I ...·.."..1.1r~' 'If ~":~~~"I ft1m It:soonl.O,O: J¡I'c~n
J"It"
o
.
-r:";:;:X~~>--
1"~\i~~"
:".' !::>\).~'"
/1,7§ ~\
i\':::' "" 1".
;~ Q :-c t,:
I~ en ~ ,~)'
H."-- -,Y
~c;:. ~e
~'A.. ___l/
" ""- !::>,"i>
~:Q./ .. ~~~é"'
-'-<':~--<zz;:;c.:};:~:J
.
Albert J. Krupski, President
James King, Vice-President
Henry Smith
Artie Foster
Ken Poliwoda
Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 11971
Telephone (516) 765·1~
Fax (516) 765-1823
-----------------------------------
IT~r;;ìD Œ [is f';-':'
11~r-'--
I nJ~. SEP 2 7 ¡qq,
'llY'·
L. I'"
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
BOARD OF TRUSTEES: TOWN OF SOUTHOLD
In the Matter of the Application
of
J:.JD11 \ or./!_ ~ _UoJe.r:1.L JDf çJ~l~n
COUNTY OF SUFFOLK)
STATE OF NEW YORK)
AFFIDAVIT OF POSTING
I;Jclv\<¿)~\(J-.-e.\~~, residing at.2rù \...~cl<"l~ ~~J ,
G\~ CN~<L. "'-\.A \ \ ~"fd.-
being dUly sworn,' depòse and say:
That on the da posted the
property known as ~ '\\ \ \ ~ '3 ~
by placing the Board of oster where it can
easily be seen, and that I have checked to be sure the poster
has remained in place for seven days prior to the date of the
public hearing. (date of hearing noted thereon to be held ~.';)'ì/ qqq
~f}:OD þ~ .
Dated: 9 \9-l{\"I"\
\,I~ ~\~
(s gnaturej
Sworn to before me this
a(ðday of.~ 199P
~~ ¡D, /)~
Notary Public ~
HELENE D. HORNE
NøI8ty Public. State of New York
No. 4961364
Qualified In Suffolk ~
Commlaalon Expires May 22, :;:¿ ¿7 <7
I
BO~ of Trustees Application 4IÞ
County of Suffolk
State of New York
"{o..\U\<-' ~Vv-.~~ x \~V->Ov-rcÁ .s. ~~\~ING DULY SWORN
EPOSES AND AFFIRMS THAT H /SHE IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE
TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL
WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION
AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES.
THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN
TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS
ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN
COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES,
THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY
TO INSPECT THE PREMISES I' CRNJUNCTION WITH REVIEW OF THIS
APPLICATION. ~~-uL'[\f"\~
'0~-0J \\"'-d'~~
\ - Signature
DAY OF #.
SWORN TO BEFORE ME THIS
~3
,19 1''1
\
--~- --
'--'
JOYCE M. WILKINS
NotaN rv Public. Stat& of New Vorl¡
o. 4952246. Suffolk Coun
Term Expires June 12 --, tv
. o<.Oú/
~~ IT
D<r'
II
II SEP i "' Ie, .
¡.;, ~
L__
TO"',"·
1...---.-,..--...
7
.
.
Telephone
(516) 765-18"\2.
Town Hall. 53095 Main Road
P.O. Box 1179
Southold. New York 11971
SOUTHOLD TOWN
CONSERVATION ADVISORY COUNCIL
A11he meeting of the Southold Town Conservation Advisory Council held Monday, October 18,
1999, the following recommendation was made:
Moved by Scott Hilary, seconded by Melvyn Morris, it was
RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL of the
Grandfather Permit Request of HOWARD & VALERIE MICHELSEN 31-18-18 for an
existing deck, stairs, house and shed, and to Transfer Permit #31-18-18 trom Hazen Cook to
Howard & Valerie Michelsen.
860 Rabbit Lane, East Marion
The CAC recommends Approval as long as the structures existed prior to 1971 and proof is
submitted.
Vote of Council: Ayes: All
Motion Carried
-
4IkPPLt~ANT 4IÞ
TRANSACTIONAL DISCLOSURE FORK
The Town of Sou~hold's Code of E~hics prohibi~s cønflicts of
in~erest on the par~ of town officers and employees. The
purpose of this form is to provide information which can
alert the town of possible conflicts of interest and allow
it to take whatever action is necessary ~o avoid same.
Last name, firs
you are applying in the
other entity, such
the other person's
indicate
YOUR NAHRt
NATURE OF APPLICATION! (Check all that apply.)
," ".
. 'I?~'¡'
,.'
.,-
Tax grievance
variance
Change of zone
Ap'p~~al of plat
Exemption from plat or official map
other
(If "other," name the activity.)
Do you personally (or through your cömpany. spouse, sibling,
parent, or child) have a relationship with any officer or
employee of the Town of Southold1 "Relationship" includes
by blood, marriage, or business interest. "Dusiness
interest:" ..eanR a bURineRR, including a partnerRhip. in
which the town officer or employee haR even a partial
ownership of (or employment by) a corporation in which
the town officer 7r em oyee owns more than 5% of the
shares_
YES NO
If you answered ·YES,· complete the balance of ~hiø form and
date and Rign where indicated.
Name of person employed by the Town of Southold
Title or position of that person
Describe the relationship between yourself (the applicant)
and the town officer Qr employee. Either check the
appropriate line A) through D) and/or describe in the space
provided.
rhe town officer or employee or his or her spouse I sibling,
parent, or child is (check all that apply).
A) the owner of greater than 5% of the shares of the
corporate stock of the applicant (when the applicant
is a corporation),
B) the legal or beneficial owner of any interest in a
noncorporate'entity (when the applicant is not a
corporation),
C) an officerl director, partner, or employee of the
applicant, or
D) the actual applicant.
DESCRtPTtON OF RELATtONSIltP
¡'
., ' . ~ ' ~. ,,' ~ ., .. .". _. .."..1,.. _ .. ..,~ .,
S"bo","~~ l;.;~~<;'.;¡;'·· .~
Signa~ure . .. _.. ~~.
Pr1n~ name~a\ed\C'~CW~\ï.~ìJW'V<-tS. ~~l~
. '. >. A'.'.'~J'~.' ,. Ii.', ,....".,.'1".,
t¡·-·'·~1(0~~..t,:,;{~t~~. ..;: ~ ,~.~?:."t:,~"t. ~rtl;õ?F;" . ¡ç\':..~.
. . :.' "~, '. ."', ~ ..'. i..j. :'A:'\~~ J!'~.'.~ :,_:,,-~>&;:, "~~o;"~