HomeMy WebLinkAboutTR-5924
·
TERMS end CONDmONS
Miro Radovich
t1Ie IUmittee
~:'>g at 400 Budd's Pond Rd.. Southold N. y~ as
pm o( «he coasideratioo lor the ü<>..~ o( «he Pe<mit does IIØdentaod and pœscribe to «he (01-
lowing:
1. That !be said Øoud of TtuSteeS and the Town 01 SouchoId ate rdeued from any and
aU damages, or claims for d.~, of IIÙa uisio&. clúecdy or ioditecdy as . ~ of OI1y opet-
adõn' performed ,.._at &0 chis peauIt, and «he IÚcI J>-onIl'IeewilJ, M Ids or __ ~
delead any and aU $II( ¡ MCS-/nlt/.tee! by ddtd.,utIa, and the said P.....klee .-.- faU liablIky
--wIdr respect th-, to !be ~Lote ""';'''¡''O of !be IIoard of TtuSteeS of !be Towq,d SouchoId
2. ThaI chis '-It is - ftUd fOt . pedocI of 24 mos. whld1 Is ()'rM: "I ~ &0 be the
eslimated time - requited &0 œmpIete !be wodc Inwlved, but shoa1d drmmstanccs WIaII1t, request
fOt 011 exteÐÅoo may be mode &0 «he Poatd at a bier Gate.
3. ThaI Ibis Petmil should be tetaI.aed iadeEl.aitely. or as loag as the said Pecmittee wishes
&0 "'.¡....;n the sttucture or project Involved, to provide evidence to anyone a>aœmed that 0D.ch-
«åatioo was ori&/.aaUy nf.caincd.
4. ThaI the wotIr: iawlved will be IIIbjcct to the ;~ &ad approoal of the JIoud or
Ia &gents, OI1d 11C>I1-ØnIp1l.~ with the pcovisioøs of !be o<igInori'>g appIicadoa, may be ausc for
CCWlalÍoa o( Ibis PemIit by œolutioo of the said Boud.
5. ThaI tbece will be DO Wll'elsoaable Interference with navigation as a result of the wotIr:
beœI.a auihorized.
6. That tbece shall be DO I.atecf_ with the right of the public to pass &ad .. doag
the beach bel1ieeG tJIsb &ad low water markJ. -
7. That II fuaue apcntioas of the Town of ~ rec¡aIre «he -r aad/or .........w.,
In «he Ioro"'ou of the wodc bcceI.a aadood>r rf, or if, In the "P'nIoo of ihe Poatd of T~ the _
wotIr: sbaI1 cause ....,.,......."'. obsttuœoo to feee uavigalÏoo, the said ~ will be rec¡uIred.
apoo. clue oodœ, to remove or aItec chis wodc ot project heteI.a staœd wiIbout ftJ'I' _. to the T_
- of Souchold. -
8. That the aid Boacd will be notified by the Permittee ot ihe ~ Of !be wodc aach-
odzed.
9. That the ¡>;.rm:.... will dJtaI.a all ocher pecmIa and ----" -ChIt may be required lap-
p.........."" to Ibis permit ~ _ybe IIIbjea to cevoIœ apot1 faJIare &0 obcaI.a-.
ë
Albert J. Krupski, presidene
James King, Vice-President
Artie Foster
Ken Poliwoda
Peggy A. Dickerson
e
Town Hall
53095 Route 25
P.O. Box 1179
Soutl\old, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES
72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN
APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO
SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE
PERMIT.
~QdO)rc \)
INSPECTION SCHEDULE
Pre-construction, hay bale line
151 day of construction
Yo constructed
/' Project complete, compliance inspection.
.
.
Albert J. Krupski, President
James King, Vice-President "'-;
Artie Foster
Ken Poliv,,·oda
Peggy A. Dickerson
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631i 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
May 26, 2004
Mr. Miro Radovich
400 Budd's Pond Rd.
South old ,NY 11971
RE: 400 BUDD'S POND RD., SOUTH OLD
SCTM#56·5-18
Dear Mr. Radovich:
The Board of Town Trustees took the following action during its regular meeting held on
Wednesday, May 26,2004 regarding the above matter:
WHEREAS, MIRO RADOVICH applied to the Southold Town Trustees for a permit
under the provisions of Chapter 97 of the South old Town Code, the Wetland Ordinance
of the Town of Southold, application dated April 26, 2004, and,
WHEREAS, said application was referred to the Southold Town Conservation Advisory
Council for their findings and recommendations, and,
WHEREAS, a Public Hearing was held by the Town Trustees with respect to said
application on May 26, 2004, at which time all interested persons were given an
opportunity to be heard, and,
WHEREAS, the Board members have personally viewed and are familiar with the
premises in question and the surrounding area, and,
WHEREAS, the Board has considered all the testimony and documentation submitted
concerning this application, and,
WHEREAS, the structure complies with the standards set forth in Chapter 97 of the
Southold Town Code,
2
.
.
WHEREAS, the Board has determined that the project as proposed will not affect the
health, safety and general welfare of the people of the town,
NOW THEREFORE BE IT,
RESOLVED, that the Board of Trustees approve the application of MIRO RADOVICH to
replace the existing bulkhead within 18" using vinyl sheathing, with the condition that
during construction, the pilings are removed, the sheathing and the whalers are
installed, and the pilings are re-installed, and all as depicted on the plan prepared by
Miro Radovich dated June 28, 2004.
Permit to construct and complete project will expire two years from the date the permit
is signed. Fees must be paid, if applicable, and permit issued within six months of the
date of this notification.
Inspections are required at a fee of $50.00 per inspection. (See attached schedule.)
Fees: $50.00
Very truly yours,
~. f 9- ~··7'1"'.l· ~.
Albert J. Krupski, Jr.
President, Board of Trustees
AJKllms
.
.
Telephone
(631) 765-1892
Town Hall
53095 Route 25
P.O. Box 1179
Southold. New York 11971-0959
CONSERVATION ADVISORY COUNCIL
TOWN OF SOUTHOLD
At the meeting of the Southold Town Conservation Advisory Council held Tuesday, May
11, 2004, the following recommendation was made:
Moved by William Cook, seconded by Don Wilder, it was
RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL of the
Wetland Permit application of MIRO RADOVICH to replace the existing bulkhead within
18" using vinyl sheathing and pilings of CCA material.
Located: 400 Budd's Pond Rd., Southold. SCTM#56-5-18
The CAC questions the street drain going through the bulkhead.
Vote of Council: Ayes: All
Motion Carried
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Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Albert J. Krupski, President
James King, VicewPresident
Henry Smith
Artie Foster
Ken Poliwoda
Telephone (631) 765-1892
Fax (631; 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use Only
(
Coastal Erosion Permit Application
--Wetland Permit Application ,.- Major
Waiver/Amendment/ han,ges
_...-Received Application: I./. 10
~eceived Fee:$
..-eompleted Application
_Incomplete
_SEQRA Classification:
Type I_Type II_Unlisted_
_Coordination:(date sent)
~AC Referral Sent ~ t\I{
"""'pate ofInspection .'f1J" Joy
_Receipt ofCAC Report:
_Lead Agency Determination:
Technical Review:
~ublic Hearing Held ,'51Jft1/r::fi_
Resolution:
Southold Town
Board of 1rustees
/
d ~~ ~S1~ l!
ID)I~ ~ ~ ~ \:j >;1 D
I~ APR"
Name of Applicant
11, í?D
A loll/S
R4!J0 t//c H
ÞONlJ ¡¿on-/)
.
S OuT -"-oL0
Address 4r.;rtJ
~(. '/ II <17 (
Phone Number ( ) (".3/ - ?foSt9¡ I:J..
~
(~~
~ \)f\\ -/
-J-J.
Suffolk County Tax Map Number: 1000- oS-éa -05-0/%
Property Location:
4&0 ßú~/J5. POA.J/'J fOA/)
i¡
streets, and location)
S; OL-<. T H-oL ¡)
·0 - ~--
AGENT
(If applicable)
Address:
Phone:
.
.
Board of Trustees Application
GENERAL DATA
Land Area (in square feet): / / ¿; '1' F/:
Area Zoning: K.;Ç> ,,'!) ~ 714 ¿
Previous use of property: P.CS (. b FtJ T14-L - ¡¿ €"c 12 <5',4 Tlc:?M4l..
Intended use of property: R.l=--S I I) ~7.J Tl4L - e."çc..f2¿:.477 ~il ¡
Prior permits/approvals for site improvements:
Agency
Date
/
,
----
...y.- No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a governmental agency?
1 No_ Yes
If yes, provide explanation:
Project Description (use attachments if necessary):
R¿?P¿,4C.¿:-M é7J T g vJ.t: .+Et:lb COI.J$ Tl2v<.c T,'nJ
¡<¡II IV Fec,A-ir tJ F (Ç)L/J <O/J~. ÜS,.'P6- IItMý I 5/lfE77~[r
A-µþ P; ¿¿=.s "'- CA- /!1'¢T?=R,,'A-l.. ,
I
.
Board of Trustees
.
Application
WETLANDffRUSTEE LANDS APPLlCA nON DATA
Purpose of the proposed operations:
f<. ED LA é' 2M t:AJ'
I
/3uh /~
<2 L h A ë-rz.:R. I 0 {¿¡¡. n:=!J
( ON~r~ut"rrì"Ai
/í/ /µ rí20Vt
P, tALl:::. l~)) Gt:>-.J$.--rPÁA ~ 7'/cP".}·
Area of wetlands on lot:
//0 square feet
I/;o %
.
Percent coverage oflot:
Closest distance between nearest existing structure and upland
edge of wetlands: feet
Closest distance between nearest proposed structure and upland
edge of wetlands: 291(;/' feet
Does the project involve excavation or filling?
~
No
x
Yes
If yes, how much material will be excavated? (J cubic yards
How much material will be filled?------11 ;;..
cubic yards
Depth of which material will be removed or deposited:
tIJ
feet
Proposed slope throughout the area of operations: 0 '"
Manner in which material will be removed or deposited:
r/¿¿ /~ c7 r -:; PA t::.,Ç ßJ;Z"TZ<.J.,F~ 7?vo
I
6¿.,- 4-' fh.,4J).s; tth Ú~_ Aa:- 1) ,Dµ6 Al ~ t¡ 0 lI.sl S; .
Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by
reason of such prop6sed operations (use attachments if appropriate):
7 ~ úJ,'¿ ¿ Å$' N~ ¿- Fr-¿:-c.r
.
.
617.20
APPENDIX C
STATE ENVIRONMENTAL QUALITY REVIEW
SHORT ENVIRONMENTAL ASSESSMENT FORM
for UNLISTED ACTIONS Only
( To be completed by Applicant or Project Sponsor)
2. PROJECT NAME
1= pLAc.EMÐJ7 B
SEQR
PROJEÇT 10 NUMBER
PART 1 - PROJECT INFORMATION
1/20
3.PROJECT LOCATION:
$OL<.TUoLþ
1. APPLICANT I SPONSOR
Municipality
County
S (.... Frot...t<
4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks ate· or provide map
400 t?::,<AD/)'S. Po,,",þ R,.b. SOG.T.¡(oL~ tV.\(, / / "'11
5. IS PROPOSED ACTION: D New D Expansion
Modification I atteration
6. DESCRIBE PROJECT BRIEFLY: R ~-pL.4<:.éc"ñ1 €7Jr e, L... Lk !-h:-'ì4-/) éOAJS7RUc. 7,'0.,) I"i)"
oj F/!DIoJ7 ,oF r¡ff-oLb e>N~. Us ' Ai&- t/,;¡JVL S!lEFT/'.u, CÜ!:Jc..~S-ðD'
7f1X/~,' P¡L..NCr .T.O,#CCA '6 F~7 n>C""",,,74.e., ~//X'//J(/~/C<.J~~-¡e.:;;,
.A-i->)> ~<-..TTI3ÚJO:::',> ~//J«/~q..' CC,tJ I11/fIl:---G'.,4.¿. 4"XG1/X/J/Ó_!>Mtf,v
/tvl) 1'J1" 34 rr¿ç/è.c>!). /lit. Á3;oLTS ~ tñ4t.r4,t/r"k---j) .578" .
1/2 ~<-t~,£: YUf, <P,ç .>/?x/j w¡{¿ &=c...r.!=?> 7>:> P4p//)<£ 77fe ,cht.c..
/?;,~T2<JéF/V' rt-<Jo ß<--<.¿¡c. 1-k74-ð Gc>..-.- .rr£<-<c ,,'...-<./
7. AMOUNT OF LAND AFFECTED:
Initially , ~ acres Ultimately' to acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS?
~es D No If no, describe briefly:
~AT IS PRESENT LAND USE IN VICINITY
~ReSidential D Industrial D Commercial
OF PROJECT? (Choose as many as apply.)
DA9riCUlture D Park I Forest I Open Space
DOther (describe)
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING,
AGENCY (Federal, State or Local)
(g]ves D No If yes, list agency name and pennit I approval:
NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL
)¡. ~ C, ø F NY P""7e"',"r !>=?1P,dtfr
11. DOES A~SPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
DYes ~NO tf yes, list agency name and permit I approval:
PROPOSED ACTION WILL EXISTING PERMIT I APPROVAL REQUIRE MODIFICATION?
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Applicant
Date:
Signature
.3
Ifthe action is a Costal Area, and you are a slate agency,
complete the Coastal Assessment Form before proceeding with this assessment
.
.
PART II - IMPACT ASSESSMENT /To be comnleted by Lead Aaency)
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.47 If yes. coordinate the review process and use the FULL EAF.
DYes DNO
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 If No. a negative
declaraUon may be superseded by another involved agency.
DYes DNo
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible)
C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pattern. solid waste production or disposal,
potential for erosion, drainage or flooding problems? Explain briefly:
I
C2. Aesthetic. agricultural, archaeological, historic. or other natural or cultural resources; or community or neighborhood character? Explain briefly:
I
C3. Vegetation or fauna. fish. shelffish or wildlife species. significant habitats. or threatened or endangered species? Explain briefly:
I
C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain brieny:
I
C5. Growth, subsequent development, or related activities likely 10 be induced by the proposed action? Explain briefly:
I
C6. Long term, short term, cumulative, or other effects not identified in C1-C5? Explain briefly:
I includ¡n;;- charras in use of either Quantilv or tvoe of enemv? Ex lain brießv: I
C7. Other i,n;;-acts
I
D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL
ENVIRONMENTAL AREA (CEA)? (If yes, explain briefly: I
DYes D No I
E. IS THERE. OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If ves explain:
DYes DNO I I
PART 111- DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, importanl or olhelWise significant. Each
effect should be assessed in connection with its (a) setting (I.e. urban or rural); (b) probability 0/ occurring; (c) duration; (d) irreversibility; (e)
geographic scope; and (f) magnitude. If necessary I add attachments or reference supporting malerials. Ensure that explanations contain
sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked
yes, the determination of significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA.
Check this box if you have identified one or more potentially large or signifICant adverse impacts which MAY ocœr. Then proceed directly to the FUl
EAF and/or prepare a positive declaration.
Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed actio
WILL NOT result in any significa[lt adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi
determination.
Name of Lead Agency
Date
Pnnt or Type Name of Responsible Officer In Lead Agency
Tilfe of Responsible OffICer
Signature of Responsible Officer in Lead Agency
Stgnature of Preparer (If different from responSJble officer)
.
.
NOTICE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEES. TOWN OF SOUTHOLD
In the matter of applicant:
MJJ?O fA 1)01/1 c ¡..¡-
SCTM# /1"52/0 -(?~0 ·-OS-eYe
YOU ARE HEREBY GIVEN NOTICE:
1. That it is the intention of the undersigned to request a Permit from the Board of Trustees
to: ? ç- fLo+c-G" 13 ú..l t::.1-l=-,..y¡ Co AJ.5 re¿<.e 'T1 0;<..1 .
2. That the property which is the subject of Environmental Review is located adjacent to
your property and is described as follows: D . J
r::> l-- UC Ik 1<'H> Co.u srh1 c no
3. That the project which is subject to Environmental Review under Chapters 32, 37, and/or
97 of the Town Code is open to public comment on: . You
may contact the Trustees Office at 765-1892 or in writing.
The above-referenced proposal is under review of the Board of Trustees of the Town of South old
and does not reference any other agency that might have to review same proposal.
OWNERS NAME: ~~"¿..//c~
MAll..ING ADDRESS: - l /'oul) /) ,
ScOt'",,7~Lj Nfj /I!~/'
PHONE#: {;, I -r ~I
Enc: Copy of sketch or plan showing proposal for your convenience.
.
.
Albert J. Krupski, President
James King, Vice-President
Artie Foster
Ken Poliwoda
Peggy A. Dickerson
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
BOARD OF TRUSTEES: TOWN OF SOUTHOLD
---------------------------------------------------------------
In the Matter of the Application
of
___~!!]:)__~~_1l~Jc\______________________________
COUNTY OF SUFFOLK)
ST ATE OF NEW YORK)
AFFIDAVIT OF POSTING
I. f1\RO ,::::\\J)J1/1CH , residing at
40C :ßL\b~' '::> PONÌ) t~ P.
SOLlïNCLt> I'~"-I
being duly sworn, depose and say:
1111\
That on the 14 day of M t\ ~ ' 2001f; I personally posted the property known as
'-¡liC 6\,tj)'b'-'> rO,'ID RD. ~",OVllHÙL-:D N'i tlq'll
by placing the Board of Trustees official poster where it can easily be seen, and that I have
checked to be sure the poster has remained in place for eight days prior to the date of the public
hearing. Date of hearing noted thereon to be held ~. I N'\n ~ ~~ -
on or ab t ~
Dated: i.IC,N/CRt-., \ II..\. MA-Y ~Y:
(£ignature)
Sworn to before me this
I t.f day of f1f1i 2004-
~lJ¡~í{? 1Æ7
DEBORAH A. McCRAY
Nocary pubUc. State 01 New 'ftIttc
No. 01 MCS073323
Qualified In Kings ~
CommJIIIion Expirea F~ 24, (J¡¡ "J
.
.
Board of Trustees Application
County of Suffolk
State of New York
/Þfi /Zo ~ dltY/c /<I BEING DULY SWORN
DEPOSES AND AFFIRMS THAT HElSHE IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE
TRUE TO THE BEST OF IDSIHER 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 VlRTIÆ OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS
APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR
REPRESENT ATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE
PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION.
~12-~~
,y Signatøre
SWORN TO BEFORE ME TIDS ¡;;¿I-tv DAY OF M1\-RCH
,2012Ï-
1t1 ;;;AÀ~/ j 'f)~ ~
Notary Public
DeBORAH R. McCAA'i'
NotarY Public, Slate 0' New '/tØ
No. 01 MCS073323
QUI!lified ~ Kings Coun\f 02 0 j)"7
eommisalon ExpIIN feb, 24,
.
.
APPLICANT/AGENTIREPRESENT A TIVE
TRANSACTIONAL DISCLOSURE FORM
The Town ofSoutbold's Code of Ethics Drohibits conflicts of interest on the Dart of town officers and emolovees. The Durnase of
this fonn is to orovide infonnation which can alert the town ofoossible conflicts of interest and allow it to take whatever action is
:::::a;:oid same. K 4 b 0 /¡ C fI M t' 'fZ-o
(Last name, first name, middle initial, unless you are applying in the name of
someone else or other entity, such as a company. If so, indicate the other
person's or company's name.)
NAME OF APPLICATION, (Check all that apply.)
Tax grievance
Varianee
Change of Zone
Approval of plat
Exemption ITom plat or official map
Other / A. I
([f"Other", name the activity.) i.AI?r ~ Þ
Pe:~h/-r ~¿'U3--77,",J
Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee
of the Town of Southold? "Relationship" includes by blood, marriage, or business interest. "Business interest" means a business,
including a partnership, in which the town officer or employee has even a panial ownership of (or employment by) a corporation
in which the town officer or employee owns more than 5% of the shares.
YES NO --+-
If you answered "YES", complete the balance of this form and date and sign where indicated.
Name of person employed by the Town of Southold
Tide or position of that person
Describe the relationship between yourself (the applicanr/agenr/representative) and the town officer or employee. Either check
the appropriate line A) through D) andlor describe in the space provided.
The town officer or employee or his or her spouse, 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 non-corporate entity (when the
applicant is not a corporation);
_C) an officer, director, partner, or employee of the applicant; or
_D) the actual applicant.
DESCRIPTION OF RELA TrONSHIP
~~~:ediliis~daY~~ 2001
Print Name ../ 7, ....v r iJ.