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Home My WebLink About11306-Z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-31910 Date: 10/16/06 THIS CERTIFIES that the building FARM BUILDING Location of Property: 18275 (HOUSE NO.) County Tax Map No. 473889 Section 115 MAIN ROAD (STREET) Block 2 MATTITUCK (HAMLET) Lot 10 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated JULY 25, 1981 pursuant to which Building Permit No. 11306-Z dated APRIL 3, 1981 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 FARM BUILDING. The certificate is issued to HENRY RUTKOSKI & WF (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. 3008869 10/02/06 PLUMBERS CERTIFICATION DATED N/A Rev. 1/81 Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 6 " ~ APPLICATION FOR CERTIFICATE OF OCCUPANCY (7(_ ' This application must be filled in by typewriter or ink and submitted to the Building Department with the fOllOW' ~ A. For new building or new use: I. 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 2/1 0 of I % 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. 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, building and unusual natural or topographic features. 2. A properly completed application and 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 - $.25 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 Date. c!J e-:f (, ClG New Construction: v Old or Pre-existing Building: ( check one) 04 rTl7'CJ0K::.. Hamlet Location of Property: RD / House No. R6~ log Street Owner or Owners of Property: lie n/ ~ </ ( Suffolk County Tal' Map No 1000, Section . IL v -r (o:..>.!' k ~ . f / ,5;' Block J- Lot /I Subdivision Filed Map. V 8'( Applicant: l'--r Underwriters Approval: Lot: Permit No. I! ~ 0 ~ z::. Date of Permit. ~ f)"u,f~ Health Dept. Approval: Planning Board Approval: Request for: Temporary Certificate 0<> Fee Submitted: $ .:L <) ::.-- ~ ~\,\\,O ~C Il\S-q Final Certificate: v- (check one) I~~ Applicant Signature FOB!\[ NO. I TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL, SOUTHOLD, N. Y. BUILDING PUMIT (THIS PERMIT MUST BE KEPT ON THE pREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N'? 11306 z Date ..........................4!.:r.:.......l.........., 19.f?t Permission is hereby granted to: /-Iv. , 'I 'J;.,-t fr (1 <>.-A.. . ..............................................................................0 --.-" i;j / :'.,y f r r- ::::::::::::::::::jh;.:f.~::(:~;:;:1::::::E~1.:::::::::::::/~:> S ,J- to ......!i.'../.~...0............A.........t:.!.:.{.~.L1.......... ..~!;?.t..;.!..!,..!>.LIY...~.:........................................... ................................................................................................................................................................ at premises located at ..................!..~.:::..?.~~I~.b!..~::.....E.Et:..~?................................................ f1 ^ -rr I -r(I( 1'/ ........................................................................................................................~....................................... ................................................................................................................................................................. County Tax Map No. 1000 Section ......../.!..::~..... Block ..........:~:-o...... Lot No. .Lt.:!...!....!.... JV"/ :.)'5 8/ pursuant to application dated .................................................:;'....., 19........, and approved by the BuildIng Inspector. .r- IS- Fee $........................ " .-, ~/ , ", /' / c.-^-~' - .-.. ..,.-'." /' 1'1&;/ .7/:'::4;/, ,-[,/1 ................................;(.............................................. Building Inspector Rev. 6/30/80 @].@] I BY THIS CERTIFICATE OF COMPLIANCE THE I ~ NEW YORK BOARD OF FIRE UNDERWRITERS ~ ~ BUREAU OF ELECTRICITY ~ ~ 40 FULTON STREET - NEW YORK, NY 1 0038 ~ I CERTIFIES THAT il'i, ,) -I ( I ~ Upon the application of upon premises owned by ~ ~ ~ ~ HENRY RUTKOSKI HENRY RUTKOSKI ~ ~ 18275 MAIN RD 18275 MAIN RD ~ I MATTITUCK, NY 11952 MATTITUCK, NY 11952 I ~ Located at 18275 MAIN RD MATTITUCK. NY 11952 ~ ~ ~ ~ Application Number: 3008869 Certificate Number: 3008869 ~ ~ . . . 113Dlo BDC ~ @! Section: Block: Lot: BUilding Perml~ " .., : ns11 ~ ~ ~~~v ~ ~ Described as a occupancy, wherein the premises electrical system consisting of ~ ~ electrical devices and wiring, described below, located in/on the premises at: ~ ~ First Floor, farm barn, Outside, ~ ~ A visual inspection of the premises electrical system, limited to electrical devices and wiring to the extent detailed ~ ~ herein, was conducted in accordance with the requirements of the applicable code and/or standard ~ ~ promulgated by the State of New York, Department of State Code Enforcement and Administration, or '6ther ~ ~ authority having Jurisdiction, and found to be in compliance therewith on the 2nd Day of October, 2006. ~ ~ Name OTY Rate Rating Circuit I.Ym< ~ ~ Miscellaneous ~ ~ as built-1981 ~ ~ ag bam-storage-shop ~ ~ Panels I 100 8 ~ ~Wir~gand~k~ ~ ~ Outlet 6 0 Fixture ~ ~ Fixture I 0 Incandescent ~ ~ Fixture 5 0 Flourescent ~ ~ Outlet 14 0 General Purpose ~ ~ Receptacle 8 0 General Purpose ~ ~ Switch 9 0 General Purpose ~ ~ :::::~:~nspection, of the delineated electrical installati:, ~etermined2t~=: obvious h"::~Sc::~ present and the installation is believed to ~ ~ be in comformance with the applicable reference standard for the estimated period of construction of the premises wiring system. ~ I seal I ~ I of I ~ ~ ~ I This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated. I @].@] .-' !i3()0~ ((~~~ " 7f1IIP'" . _ ~ ~~ ~~.~ 765-1802 BUILDING DEPT. y INSPECTION [ ] FOUNDATION 1ST [] ROUGH PLBG. [ ] FOUNDATION 2ND [] I~LATION [ ] FRAMING [0INAL [ ] FIREPLACE & CHIMNEY REMARKS: /l1 ('pt.. b-. @,k- , , ~- '7 ~ ~ t!~ tJZ~rJ;- - ~~ ~ . DATE -1..,..-.'/.-/ 'Pc_ -/- 7/-,-~/v 1<(>", Ctl:'-~ ~ -r~ -;:;"""" 1~('tI ? tJ..""..r.--~"~ ": ........e......., FORM NO.1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined.. _. .~....~ 19 f7 Approved .. _7:~..!, 19. f(r.ermit No.. .e.!.~.~ 7 //3010 Application No. . . . . . . . . . . . . . . . Disapproved alc .. ..... ............................ ....................................~/....../~ .. .. ~4-t'.. )v. . ! .. .. ..~. . ~. (Building Inspector) ; APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Date 71 J,...s::. . . .. . . . ., 19 ~l a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Buildi Inspector, with 3 sets of plans. accurate plot plan to scale. Fee according te schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public strer or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this apr cation. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon apprc;al of this application, the Building Inspector will issue a Building Permit to the applicant. Such pem 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 Occupan 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 t Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein describe The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and admit authorized inspectors on premises and in buildings for necessary ins ections. ... .... ..... ... .~~. ........ (Signature f applicant, or n:une, if a corJt-Qration) Rd..- \ Bo><. lof?:.../JJf.~...tU...~. (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or build, ~ ............................... ... .......... ...... .... ................. ....................... Nameofownerofpremises . ../~.. ... ..~~. ...................,'............ . . . . . . . . j (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. ............. .... .......................... ... (Name and title of corporate officer) Builder's License No. ......................... Plumber's Licens~ No. ........................ Electrician's License No. ...................... Other Trade's License No. ......... _ . . . . . . . . . . . I. Location of land on which proposed work will be done. ............................................... /' . . .n.OX. .1.9.~... .R.<1.. (.. .r.~~T>. .1.Y.{.~:.v... .((~............ .(11.t;I-;1:.T.t.~.'<;-;K.......... House Num ber Street Hamlet County Tax Map No. 1000 Section Block Lot. .. ... ... . .. ... . . Subdivision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Filed Map No. .............. Lot.............. (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ................................................................... b. Intended use and occupancy ... E. 4. G.<.. ~ . . . . .s. -f.-,.~ P-It-'! e. . . . . G .1.;-. <;1.,1' , . .. . .. . . . . . . . . . . . . . . , 3. Nature of work (check whic/1 applicable): New Building ..~... Addition.. ... . . ... Alteration .......... Repair ......... '(1' . Removal. . . . . . . . . . . . .. Demolition .. 4j-' / ;:.: . . Other Work. . (D~~~ri;~i~~; : . EstImated Cost. . . . . I ~.l? .0. .C? . . . . . . . . . . . . . . . . . . . . . . . . . Fee . . . . . . . . . . . . . . . . . . . . . . . . . . -.. . . . . . . . . . . (to be paid on filing this application) '. If dwelling, number of dwelling units. . . . . . . . . . . . . .. Number of dwelling units on each floor. . . . . . . .. . " . . . . If garage, number of cars ........................................................................ ,. If business, commercial or mixed occupancy, specify nature and extent of each type of use fA-fl-..>4....S-I:<. r.l'l-.te- .C! ld J Dimensions of existing stmctures, if any: Front. . . . . . . . . . . . . . . Rear .............. Depth............... Height ............... Number of Stories. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dimensions of same stmcture with alterations or additions: Front ................. Rear.................. Depth. . . . . . . . . . . . . . . . . . . . . . Height . . . . . . . . . . . . . . . . . . . . . . Num ber of Stories. . . . . . . . . . . . . . . . . . . . . . L Dimensions of entire new construction: Front. . .(.. . . . . . . . . .. Rear............... Depth. . . . . . . . . . . . . . . Height ............... Number of Stories. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . ). Size of lot: Front. . . . . . . . . . . . .. . . . . . . .. Rear...................... Depth ...................... J. Date oT Purchase ............................. Name of Former Owner ............................. I. Zone or use district in which premises are situated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . '. . . . . . . . . . . . . . . . . . 2. Does proposed construction violate any zoning law, ordinance or regulation: ........:....................... l. Will lot be regraded ............................ WiI! excess fill be removed fr.om p~mises: Yes No +. Name of Owner of premises k-t-I ~.y. . . n.....rr./<..o.f~.iAddress .~II..;.jJ.. R.! . M. ",""-.I.t':'Phone No. :z..r 0; .'. <J. ~ ~. J. Name of Architect ........................... Address. . . . . . . . . . . . . . . . . . . Phone No. . . . . . . . . . . . . . . . Name of Contractor. . . . . . . . . . . . . . . . . . . . . . . . . . Address. . . . . . . . . . . . . . . . . . . Phone No. .. . . . . . . . . . . . . . PLOT DIAGRAM Locate clearly an distinctly all buildings, whether existing or proposed, and, indicate all set-back dimensions from roperty lines. Give ree and block number or description according to deed, and show street names and indipte (hether terior or corner ]0 / - .., I D \ (00 () - I) - "- - . \ C,v -{ S' -+ ~ .(C f>- G;- -- J ..;.. L-(o't ~.t4+O ~ I -ql I lI) \ <::l - --- ----- ~ ~- -- \ , t , IT( ~ 0, pr-o puS'" J (3dJ , II .~ fI), \ \) \ t '- ( l') ~3 J i "\ ! ~ i IV ~QA.("<:' ~ II 0 I ~ I <.b ~ . L "- ~ ~ ~ S.S .... .........................................-.. being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) Jove named. e is the . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Contractor, agent, corporate officer, etc.) f said owner or owners, and is duly authorized to perform or have perfonned the said work and to make and file tllis Jplication; that all statements contained in this application are true to the best of his knowledge and belief; and that the .ork will be performed in the manner set forth in the application filed therewith. worn to before me)hj; .... .. ..c??~.? .-::. '.' ... day;f.. .~~.., 19.<f'! otary Publi , .. .'-,-;-(~..,. ?'~unty f\ 1___ Il , . JUDITH T. TERRY \ tf ~ tt~ Notary POU3b44IiC9'6S.3tar: fOfl ,NkEWCoYO~'" ... .......................................... No. 52. . .. u o. un . . . . Commis~ion Expires March 30, 1 .' (SIgnature of applicant) fh>i;'/'/ ~I'e, ''?_"1,7t-,i f,,/,,-( f '3'iJ.w:.~..-,'-~ ,-- ~ l'<C ~ -.....('0 .......... . i~r(l . ~ Fen;'.1 NO. TOWN OF SOUTHOLD BUILDING DEPARTrvlENT TOWN HALL SOUTHOLD, ny. 11971 TEL.: 765,1302 Enmincd . _ . . . ~~. . . .3.~ 19 y,'7 . Approved. . . /?. .af _ . J. 19 . f7re rill it No. . . I:. .~.D (~ 2---- ,~ ~rI if Acectw:"- r:h~~ - 1/30k Application No. . . . . . . . . . . . . . . \).') c. 6' ~ Disapprove,l alc .. .,- ;--:-~. . . . . . . . . . . . . . . . . . . . . . . . . . . . '\ ............................ .~.... ... '>i'~" ')4~~ . - . . . . .,/ .";::'.:1"'-1'.<1,,",,.. r. . \..'. . . . T. . . . . . . . (Iluilding Inspector) INSTRUCTIONS 0() ~ ~ D,,, 71 hC H' 19 f APPLICATION FOR BUILDING PERMIT a. This :.ppiicotion must be co'"pldcly filled in by typewriter or in ink and submitted in triplicate to thc Bu,;, Inspcctor, with 3 sets of pbns, acclIntc plot pian to scak Fcc according tc schedule. b. Plr:t pl.1n (hawing loc::tioll of lot and of buildings on premises, r~btiOll5hip to adjoining premises or public st;-_ or :nC:1S, a1':o giving a detailed description of layuut of property must be dr<lwn Oil the diagram which is part of this ~l ' cation. c. The work covered hy this applicati'JI1 m:IY not be commenced before issuance of Building Pem] it. d. Upon upprc:ol of this applieation. th,; Building Inspector wilt issue a Buildlllg Pennit to the apolicant. Such pc' shall k kept on the premises available for inspection throughout the work. e. No buildi;]g sholl be oc;cu;:ied or used in whole or in pJl't for any purpose whatever until a Certificate of Occup,; sbll !lave bel';] granted by the Building Inspector. APPLICATION IS HEREBY ~1^DE to the Building Department for the issuance of a Building Pemlit pursuent to Building Zone Ordinance of the Town of SouthulJ, Suffulk County, New York, and other applicable Laws, Ordinul\c,. Regulatiol\s, for the construction of bllildings. additions or alterations, or for removal or demolition, as herein descri:' The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, 3"': admit allthon,;eJ inspectors on premises and in buildings for necessary inspections. ... .j!~~~~... .IL~.'......... (Signaturc(of applicant, or mme, if a corJt'lration) Q. ~ \ Be><- I o/]" .ffJ/.~:r..-"" .1.21( ../If(R..d~:~ (Mailing address of applicant) ~ <"' "'5 ~ s... :r 1'\J c -I A ~ 7.. State \l,'hetl1cr applicant is owner, lessee, agent, architect, engineer, general contractor, etectrici:1n, i.)lumber or buiLl ............. .tr.CV:.".'. Q:~......... ..,...................................................... . f Name of owner of premises ... jJ,'?,:, ""~. j' If applicant is a corporation, signature of duly anthorizcd oi'ficer. . . . .rl.<_Ax.~~>,l.___(:. . . . . . . . . . . . .. .. . . . .: . . . . . . . . . . . (as on the tax roll or latest deed) ............................................. . (Name and title of corporate officer) Builder's License No. ......................... Plumber's License No. ........................ EL:ctriciaIl'S License No. ...."................. Other Trade's License No. ..................... ]. Location of land on which proposed work wiil be done. .............................................._ . .D. 0X. .1. (,,)S . . . P. J. .{. . . r,S . :': I}l ~ ~J.. . ,{(r ~~ . . . . . . . . . . . . . (I:l.f':I-.1:T.'.'!':':-:. S-Jc;-; . .. .. . . . . . House Number Slreet Hamlet County Tax Map No. 1000 Section lJlock Lot.............,.. . Subdivision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Filed Map No. .............. Lot......,...,... (Name) 2. State existing uSe and occupancy of premises "Illl intended lIse and occupncy of proposed construction: a. Existing lIse and occupancy ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . , . . . . . . . , . . _ b. Intended use and occupancy ....F. fr-. '!. ~v;1.. . . . . . Y. !-'c R.-It'J ('. . . . ,Q .'-:-. <;1.1' ' . , , . , , . . , . . . . . , , . . . _ . 1. Nature of work (check whic!> applicable): New DuilJing . .v.. . . . . . AJJition .. . . . .. . .. Alteration .......... Repair .............. Remonl . . . . . . . . . . . . .. Demolition ...,'.......... Other Work. . . . . . . . . . . . . . . . l1'ft / '). (Description) . EstllllateJ Cost. . . . . /(11 .CJ. Po . . . . . . . . . . . . . . . . . . . . . . . . . Fee . . . . . . . . . . . . . . . . . . . . . . . . . . ~ . . . . . . . . . . . (to be paid on filing this application) '. If dwelling. number of dwelling units. . . . . . . . . . . . . .. Number of dwelling units on each floor. . . . . . . . . . . . . . . . If garage, number of cars ........................................................................ I. Ifbusin.ess, commercial or mixed occupancy, specify nature and extent of each type of use rAfl......... s.+.... ..."'te- .t! Id J DllnenslOns of eXlstmg stmctures, If any: Front. . . . . . . . . . . . . . . Rear .............. Depth............... Height ............... Number of Stories. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dimensions of same stmcture with alterations or additions: Front ................. Rear.................. Depth. . . . . . . . . . . . . . . . . . . . . . Height. . . . . . . . . . . . . . . . . . . . . . Number of Stories. . . . . . . . . . . . . . . . . . . . . . l. Dimensions of entire new construction: Front. . .(,. . . . . . . . . " Rear............... Depth ............... Height ............... Number of Stories. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ). Size oflot: Front .... . . . . . . . . . . . . . . . . .. Rear...................... Depth ...................... l. Date of Purchase ............................. Name of Fornler Owner ............................. I. Zone or use district in which premises are situated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ) Does proposed construction viabte any zoning law, ordinance or r,egulation: ........:....................... L Will lot be regraded ............................ Will excess fill be removed frem wemises: Yes No I. Name of Owner of premises kN ~.y. . . ((.ur.-f::..oJ\C(Address .'(!i\..:.w. . ((<! . t'l~TY.I.t:'Ph'c>ne No. 2..1 tf. ... ':I.'"?--.':-. J. Name of Architect ........................... Address. . . . . . . . . . . . . . . . . . . Phone No. .... . . . . . . . . . . . Name of Contractor. . . . . . . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . Phone No. . . . . . . . . . . . . . . . PLOT DIAGRAM Locate clearly and distinctly all buildings, whether e>:isting or proposed, and. indicate all set.back dimensions from ,operty lines. GiVlreet and block number or description according to deed, and show street names and indicate Whether tenor or corner ]0 I / _ -, ) " I , I 0 0 D - ''''. - u' \ , I I \ \: G,J-.- Lr : {_ ~.~4+"' 5' -{ ~ ,f( A 6--€. 1 . - I I ~ I .~ , Ii \... V) II ~ I ii " ]! ~ I I '\\:' II ~ 'i !i , i' , ...-" I 0, ff), \ p\"'0 puS" J f3LJj \ l. -..l. 0\ ~ ->::! t '<" '0 ( t,3 ,. "\ " ~ "-ll ~ ~"-"...<:: o r:Lb \ ~~ ~i-c------:J ~. " , 'I S.S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) lOV'O named. e is the ...........................,..............4..................... ................... ...... (Contractor, agent, eorpornk officer, etc.) f said owner or owners, and is duly authorized to perform or have perfonned the said work and to make and file this lplication; that all statements contained in this application are true to the best of his knowledge and belief; and that the ark will be performed in the manner set forth in the application fileJ t,'erewith. worn to before me)~ ..... ...c??~..?......... day of. ...... ~~.., 19.cfl ~ ~~ olary PUbli?, .. .\-;-(~.\. /~<1-~unt\' ~~~~D'~;~_ T _:~~~o:~:?~ \ J/.:<~ 7, . ()~!F:.~ ~. . . . . . . . . . . . . . eommis~ion Exp.re' Mdrd, 3J, l~ (Signature of applicant) - r ", -:-1 I I V>W -Ic) :a; r t ~ ,I i I ! ~I I i I I II ~I , , , I I I I I I I I I I ! II I I ~. I I "'. 9 !ft lp 9 1\ I: , r-I ~ J "U :%J 2""' 0..... ~- ~s: 0_ ~:z 8)> 2:%J ~-< ~ ~o ~:%J 0)> ~:;: ~- mz Cl (fl .' ... I 1- 1-- '----1 ,- I -il'-'- !' -- :' Iv"""_""~~"",,,,,~,,~,", [-...------ 'i 1-" I 1"'-0"'"- I i, \ L ----j L.j --- (1 ! - .o- I: ------] ,: i I_~ - -- I : I I , --~~] -; , -=- .--- ---;' 1 r--- I I I 1" ! I, , I"~ 1 1'1 __._'___._____) F I , I' ! 1.1 _'- ____ o . 'Oy: .- , j 1----- - r - ii! ...:1 '---, - ;1-- . ,. . < ~ , I I -_.~ I .,...._ ,. , I