HomeMy WebLinkAbout33067-Z
FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-32527 Date: 08/10/07
THIS CERTIFIES that the building STORAGE ADDITION
Location of Property: 4200 KENNYS
(HOUSE NO.)
County Tax Map No. 473889 Section 54
RD
(STREET)
Block 4
SOUTHOLD
(HAMLET)
Lot 3
Subdivision
Filed Map No.
Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated
MAY 29, 2007 pursuant to which
Building Permit No. 33067-Z
dated
JUNE 4, 2007
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 STORAGE ADDITION TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED
FOR.
The certificate is issued to DINA & VITO MOLES
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
N/A
ELECTRICAL CERTIFICATE NO.
N/A
PLUMBERS CERTIFICATION DATED
N/A
Rev. 1/81
r~- .~
I .
,
I AUG-g 7
I , I
. APPLICATION FOR CERTIFICATE OF OCCUPANCY I L_.,,__ ..... i I
This application must be filled in by typewriter or ink and submitted to the Building Departm~nt wrTgih6ro1;IT\~i~i.-o'L-J
Form No.6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HAU,
765-1802
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 nses, 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
I, 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, Ollf'tl-C r
New Construction:
s~ (M{~)
Old or Pre-existing Building:
L'fJtJO ~/Vey'S lIP
House No, Street
07. LEJi>7
(check one)
Sbt n/tJu)
Hamlet
Location of Property:
Owner or Owncrs of Property: J':-Io 1- 61,vi/ tUolFS .
Suffolk County Tax Map No 1000, Section ~ as-fBlock ~ 6c.ttJO Lot rf}-:3 i ~
Subdivision
r itTif; g~' z,
Date of Permit.
Filed Map,
(p f Lr/01_ Applicant:
Lot:
)tV! €=<;.
Planning Board Approval:
P;n
Underwriters Approval: J //,4-
-- '''''(
--- ~
Final Certificate: (check one)
Permit No.
Health Ocpt. Approval:
v/el
-Uk
Request for: Temporary Certificate
Fee Submitted: $ J(;r{)
n
~.I:J\1\
eo C 3,;)5;1 '7
FORM NO. 3
TOWN OF 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)
4, 2007
PERMIT NO.
33067 Z
Date JUNE
permission is hereby granted to:
DINA & VITO MOLES
7 KLARMAN COURT
HUNTINGTON,NY 11746
for :
CONSTRUCT A STORAGE ADDITION TO AN EXISTING ONE FAMILY DWELLING
AS APPLIED FOR. THIS PERMIT REPLACES BP # 19386
at premises located at
4200 KENNYS RD
SOUTHOLD
County Tax Map No. 473889 Section 054
Block 0004
Lot No. 003
pursuant to application dated MAY
29, 2007 and approved by the
Fee $
50.00
Building Inspector to expire on DECEMBER
ORIGINAL
Rev. 5/8/02
J~38f.cZ
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1 ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING I STRAPPING [] FINAL
[ ] FIREPLACE & CHIMNEY [] FIRE SAFETY INSPEcnON
[ ] RRE RESISTANT CONSTRUC11ON [ ] FIRE RESISTANT PENETRAnON
REMARKS: ~ ~ ~ -I:i-
fl ~~ ~~~
j/~ rl. ~~~-'
DATE S r-~I - C '1
INSPECTOR .~~
:'l:::LD I;;S~;::C71(J:J
1 . .
4
FO~IDATION (1st)
-----
\.
II
FOUNDATIOIJ
(2nd)
2.
ROUGH FRAME &
PLUMBING
3.
IIJSULATION PER N. Y.
STATE ENERGY
CODE
4.
FINAL
IIlJ,',7E 'I
COMMENTS
::J
. .
.,,\jJ
~0l
;50>
o.J'lS'-
:;;;~
~tt
.
z-
o..c
'r
~
J
""
.. g.~
~
~ ~
~/o':l d};/ & --./. -:./ -< -L 4'11 /~~ ~
/ ~~:'AH'//'./?, . o-! ~
5")./-'/" /'Igd ~ ~ _?" ~ -i:rr- Wt JJ 'if"
-
,,~j:~ ~IYL:' 4~.fP".,Jtt.Y\"T:o'-~~~ ~
rro~~ ~ JJ f1.. ~/"~~ J. ~
?1.4>7 1 <U //(!f7 . 5.t~ A .,/.\ ..1.:",-"L )\)~ \ q/U/tJ~g ~
I~ITIONAL COMMENTS: /AArIL l'r'.A I ~ ~
f/ j'--- ~./ :. U\
.
.
.
, (,
. .
t>J
>< .......
"''50
H..........,
"':--c:
~
.. ~
;ffi
..
,
'x
t>J
".
c-
o-!
X
k
~
C
t>J
."
o-!
""
110
3
8')
J: ':,-"
'LOT AAEA - 13.8;Z~;S9. FT,
-_"(I''''~ .. .j)j.)....FilclIjI....' ___ '" lIa,
--"...'...-~~;;~- ","".---
1NIIlIlII!)1.....;1!I!'!"""""" 00i....., ........................... ,:
'~~.~"':~"c::!.cllli".,G1lIIll~
~~..~,,"'i......:1V,,:n.:~,'ia.A \GIQ'ICJft OF' IECIDI
'~~111!:....." :....!'~....<.:" " ,.
".~iIJ ,-'. 2~;igsi; '_41; ~y",.~~" "",,, ",'_,.e < "
iCi;,~ /JjtIJ:'~'''':4~~'-\~,~, ',.hJ7:~;':''''4'''';~;'''''.''::''''~;'''''',w,.." "
_':2;-~r V-:-'_~_:,J. I_;~."':'CIII:t":m:~1tII:......;\,..:,.....:,...
'.....:.'.--.'_...,..,~,'IIJ''''*~'........_..
~~.AMD,,"""'~',~:"""<ND:J.o,,1Ni:,~,~.,1tE_, .'
..-...'_4Jb.11/..... a!lli&.,"'.,:l'II'J~:,1D ~~.
.~~;-c, ,/77')~"~;::"::.'::;~;::':-i:YL:\':;~;;,,\".',i;)',">'-" ' ';. . -.:',
'a:flIDOP:}n_:~_.",,_-1HE.~',""""'.1M!D IrJL OR .
~__IIW.L'_.'CEI --....1O."..,"I"fU:eapt'(. .
~,
~
~
~
..
rfJ
:d
o
>
t:l
.'::: ;
04-397
/
+
X
~]( ~; ~ ;1~ ~ I'
I.. OEPT
, bl.U,.. '.
L-J!,_"VIII o.F sn, 'THO' '1_
SOUND
ISLAND
LONG
WATER liNE
MEAN HIGH
APPRO)(. , '47"1::
'O.."E N 38"01
N 41'31 ;-'
29.85
11_6-2003
,
, 88.65
-
z
(f) ~
q
o
~
G)
~
::l
o
l'1
tJl
q
VI
(j)
o
o
f1l
o
:;0
~
o
:;0
~
l'1
:;0
~
-'
.2:
""
(j
J:..
i5
J:
~
o
oj
(,;j
0"
:::lo
o
FT1 ~.
3::
$i
^
~
~
^
<-
o
1Il
l'1
-u
~
Z.
l'1
0-
(\)
-u
If
(l) ::l
...00
o ~.
-uO
t: C
<<l @
V1 ~
>-
('\:.1 ~
~. ~
~ (:;J
t! ~
~ 1.111
~"'='
lib l:J
06 ~
O~
(j) ~
y-
r::~
!,-J
tIl ...
~~
cl)
WOod
. deck
~
~
\
Cl
\
'"
o
o
VI
----
7.6'
-"
2.3.9'
. 16. l' -:.
CII
1 S7Y F; .
DWf:LL R ::J rt!Zz.~~fD
.32.5' ~
,3..9:, g~vt!1 d . ....-._ ...;;,a
, rA' .-,' nve.,....... 'LA
o
1.0
"""
N_
. ,....;.a,;
-
""l
~
I
01 -"
10
'" CO
o.
.8-co.
-.-1< (0'
,
137.02
-
FD
PIPE
"W
5 39~24'OO .
ORMERLY .
NOW OR F KATRAMADOS
KATHERINE
JOHN &
N
N
tn
o
o
sEA
. "N.ORTH .
ORNE
. JOB No. P3':485
FILE No. 824 F
;5U~ FOR DINA MOLES
.../. .' .
SI1\JATED AT SOUTHOLD
" .
. . .
"TPWN .oF' S.oUTI:l.oLo, SUFFOLI( COUNTY N .Y.'
"
sc;ALE 1" - 30' DATE 9-21-2004
F1LEo MAP No. DATE
TAXMAl' No. (REI' .oNLY') 1000-54-4-3 DISK 2003
, ~\
CERTIFIED ONLY.JO:
.' . . .
DINAMOLE$. '., .... . .
ALisT~TE ~ CORP
FIRST AhtERICAN :mu: INS;' CO: OF NEW YORK
,_. . .',,:
'. '. ~"5~h.NO' 04Sa92
HAROLD f.TRANCHONJR. PENN. lIC.No. 21!i",E
HAROLD F. TRANCHON JR. P.C.
LAND SURV~OR
. P.O. BOX 616
'666 WADING RIVER-MANOR RD. WADING RIVER,
NEW YORK, 11792
631-929-4695
'!
~1 i'r ROVeO AS ;;~OTOJ
'1"'; ,}Ii.J..'lS> J '" Ii -' ~ a ~!.!-e.
F" ~c,,-~,', Y"~'~' ,
1\; " J'- ::.'! ~ 'II' ;'-i:' . ,', c', ",;(C '\; :
.~
....'*..
7 '; ; ;;-.;.>"- t." ,""
~ "< ~ ,>""
OCCUPANCY OR
USE IS UNLAWFUL
WITHOUT CERTIFICATE
OF OCCUPANCY
Fn~_l (ll;",;]i\j(; ii- .
1 FOl:l\\lJ4HON
fl/\.'C:. ;::~:O;J!;::ED
FOR POURED CONCRETE
2, ROUGH FRAMiNG & PLUMBING
3, INSULATION
4 FINAL ' CONSTRUCTION MUST
BE COMPLETE FOR C,O
ALL CONSTRUCTION SHALL MEET
THE REQUIREMENTS OF THE N,Y.
STATE CONSTRUCTION & ENERGY
CODES. Nor RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS
~.-'
,~,
,~'LJ,~[t
//- ~
8
'8~ 0"
I<L- 0"
_o-.~ p~.
y~ Q~~J
r
,..,......
j
,. TOWN OF SOUTHOLD PROPERTY RecORD CARD
""
I
("---/1 r- J Cf
!' ,J '"
...1:..,.<:'./
5")./. Lc,
-.
--
, ..- ,
OWNER STREET VILLAGE DIST. SUB. LOT
IhJ' ~~~J'I~~J wwi. .-t. . -/~_~ / !::.-
FORMER OWNER 1/ NJJ'~ E J). ~Vt- t.(J.!-L- ACR.
. .j-? d
~ W~ A'/) fel TYPE OF BUILDING
G,t?;9U/JS'.NJ ....
I VL. FARM COMM. CB. MICS. Mkt. Value
RES. SEr\S. :<. 0 0
LAND IMP. TOTAL DArE REMARKS -4 a.-t..L-. 1/%-:>/'7/ .J> J;. "" 0""
5 '2- .,.0 ,~(.o() ~/7/ ~ gY .
1</ " (;) .--.
:J-.fOQ /</0 0 ~~e)O 1.///'7/ '7/ /'~+_'JJ -r~~ ~ 3?Ac:. "o/~ /7 '"
IdliPO I</() 0 .9.2 0 0 / -z.,/:1..L/' /7 j . ~j z, v J.1 or. .'-.1/ .... c:.. ",) ./-;>/7 /
JP/)~ Z2..Dl) lID 0(, /tJ/~/7' .
/
.
Tillable FRONTAGE ON WATER / () J. e.. /~o{) ~ 1K't,(;
FRONT AGE ON ROAD ,
Woodland
Meadowland DEPTH ;lJ()'
House Plot BULKHEAD .
Total
~
~,
,,,",
-
OlOR WI/ 1'-/, TRIM .P I-:;~
-
'"
..""----.
ml~i1 .
'.
.". ~ltr;:rn - ' ~l "
-
_:.::1- '-
';"1-'-- ----:.:
~' .3 ;tJ- If
-"''- , ;~:"
, . . .~"'~-...:.,,; . -~-' 1: "-'i :. <I,
~" ,... 'l. 3 I!..
~l ,,-,...": ,"'~ ~ ~"~~i'~' '::C::(:'7'::--':"''. I :; ~:
" b
..J ~
IJ I...
. I - ~
lsry-e <> .. I i P. ~f
M. Bldg. ,tf( 2.~ /'IZ6 /
..2'-/Y3,- ", 7j IIi
Extension
Extension !
~l~fl~lon I
C-VcL6'>:j, py I( J 2-f' /~ /9l!. f'oundation ~;Gs . Bath / Dinette
rJ"': 1-1 ::
Porch Lr/fa ;::./l-f SO /;t/-I easement No Floors F,R K.
-
Porch "D2( .'.. it/ Ext. Walls II4:SR :;;->,' Interior Finish "JA/-t-1?D lR.
., /? X 3 ~ "" <'2 :s- Go 2.S-
Breezeway f'ire Place ND Heat N " . DR.
Garage Type Roof Rooms 1st Floor BR.
Patio , Recreation Room Rooms 2nd Floor FIN. B
0, B. Dormer Dtiveway
Total '2...2. tJe
c
b
tI
"l
.,.:
I
FORM NO.1
BOARD OF HEALTH ............
3 SETS OF PLANS ............
SURVEY .....................
CHECK ......................
SEPTIC FOItH ................
BLDG. DEPT
TOWN OF SOUTHOLQ
EX:lIuined .~...... .1 a., 19~ p.
Approved ~.t':"!~ . J. ?>., 19' (). Pennit No. ).~ ~ ?4 ~.
TOWN OF SOUTHOlD
BUilDING DEPARTMENT
TOWN HALL
SOUTHOlD. N.Y. 11971
TEl.: 765.1802
NOT IFY :
CALL
~
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
Disapproved ale .....................................
TO: J.-I- d ~
. . ..4-U7~~~:G. . .
................ ........................
..............................................()..
. . '{~~.~ .D.. ~ .~-;".. .. .. .
(Builcling Inspector)
APPLICATION FOR BUILDIJ\,G PEflMfT
Date..:.... ... ........, I,...
INSTRUCTIONS
· a. This application must be completely filled in by typewriter or in ink and submitted to the Building Ii!speetor, 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 pan of this appli-
cation.
c. The work covered by this application may not be commenced before issuance of Building Pennit.
d. Upon approval of this application, the Building Inspector will issued a Building Pennit 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 at:ly purpose whatever until a CertifiC:lte 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
Regulations, for the construction of buildings, additions or alterations, or for removal or demolition. as herein described.
The applicant agrees to comply with all applicable laws. ordinances, bUilding code, housin~ code, and regulations, and to
admit authorized inspectors on premises and in bUilding for necessary inspections.
...j
....................... e_........................... .................
(Signature 01 npplicant, or name, if a corporation)
'.
..............................................
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
...................................................................................................
. --.
Name of owner of premises .. '!I.:~. !... ~~.~. . . . . . . . . . . . . . . . . . . . . .. ...... . . . . . . . .
(as on the tax roll or latest deed) .
If applicant is a corporation, signature of duly authorized officer.
................................................
(Name and title of Corporate officer)
B 'Id ' L' N rJ'uNE/0
UJ cr S Jccnse o. .'~~"..... Ie;.. . . . . . . . . . . . . . .
Plumber's License No. ...... ....... . . ....... '"
Electrician's License No. ......................
OlherTrade's License No. ...............:.....
Location of land on which proposed work will be dor.e:. _. _ _. .
..........~P.r!...~1.?.&:........:...........~........... " --
House Number . Street . . Hamlet .......... "
CountyTJ.x~IJpNo.IOOOSQction ...~....~-;....: Block .......t.......... Lot...~...........<..
Subdivision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rilecl Map No. .............. Lot..........,.:..
(Name)
Sl~te existing use and OccupJncy of premises and intended use and OCCupancy of proposed eonstruc'tion: .
:I. Existing use and occupancy f~~..~ ~~ ~
. . . . . . .. . . .. . . . c:..; ...". :~"."~l","",. . . . . . . . . . . . .. . . . . oo. .. . .
t.;M:.. . "~~'W
b. Intended Us . .. .. . . . .. .. .. . . . . . . . .. . . ,. _. :' " , . ",I' "
eandoceupancy ............ "'" .~,,~...,;'.'. .......~.........
,. '. ,
'.'
..'
--r
3. Nature of work (check which applicable): New Uuiluing .......... Auuitic,n .......... Alteration ......... . .
Rep:1i~ .............. R~moval . ............. Demolition ............. .Swi:nr.ling pool. ~;,; 'r; ','J"
TenniS Court j......~ Accessory Building. . . . . . . . . . Fence ....... Other \.Jor"-::,~~
I. Estimated Cost. . . .1 J!C? . . . . . . . . . . . . . . . . . . . . . . . . . . . ., Fee . . . . . . . . . . . . . . . . . . . . . . . . ..... . . . . . . . . . .
(to be paid on filing this applic:ltJon),
l. If dwelling, number of dwelling units. . . . . . . . . . . . . .. Number of dwelling units on each floor, . ..... .~:. . . . . . .
Ifgara;:e.numberofcars ........................................................ ................ ,
l. If business. commercial Or mixed occupancy, specify nature and extent of each type of use, . . . . . . ....... . . . . . .
7. Dimensions of existing structures, if any: Front. . , . . . . . . . . .'. " Rear . .... . . . . . . . . . .. Depth.............. . .
Height ............... Number of Stories. . . . . . . . . . . . . . . . . . . . . . . . .. . . . , . . . .. . . .. . .. ...... .. . .. . .
Dimensions of same structure with alterations or additions: Front ................. Rear................; ..
Depth. . .. . . . . . . . . . . . . . . . . . . Height. . . . . . . . . . . . . . . . . . . . .'. Number of Stories. . . . . . . ........ . . . . .. . :
3. Dimensions of entire new construction: Front. . . . . . . . . . . . . .. Rear............... Depth ..............
Height ............... Number of Stories. . . . . . . . . . , . . . ; . . , . . . . . . . . . . . . ' . , . . . . . . , . ,..... . . . . . . . .
Si.,c of lot: Front Rc" ,",,"'[h.
'j,. 0' Purc'l:lS~ 'n~', ~':i-:..: 'iil''j-i'" ~- .,.,.,.. ~.;.,...""..~. ',j"tii.'Ci-' a:U'/?/:.(;
J. L-,. .", '" I....... -tf... ... . e......... . . .... .. '" ........... Na-nc 01 l'onnci ()\V!h~r ....... .j.;.... _. ... -: "'_:. . ... ...
J.' 7.0"''' or use ,lIst".t in which premises Jrc ,itu:J.ted . . . . . . . . , . , . . . _ . . . . . , , . . , , , . . . . , . , , , . , , . , . . . ' , . . . '. . ,
.) D~cs p~'ofJoscd construction 'dolatc .3ny zoning b\.~. ordin:J.~cc or rcgul:Jtion: ........ '.' .. . . .. . ....... .. . .. ....... ~-" .. .. .. .. .cN~ ..
3. Will lot be regraded .. ~.... '1.;.(." ..... _..., win excess fill be removed Irom premlscs: , Yes.. ...~. .
4. Nanl'~ of Own,:r of premises 'J!o~ -:E'.C"';"~~ddrcss ~~'f.~~~ . ,Phone No, $Z~:. ~,;,."l.'I-.. .,
NJrne of ArchItect ........................... Address ..... ....... /. . '1:. Phone No, ......... . . . .. .. .
N::une of Contractor ... . . . . . . . . . . . . . .: . . . . . . . . Address ................... Phone No, .... ~. . . ; . . ..
IS.Is this property located within 100 feet of a tidal wetland?*YES.-.~...
*If yes, Southold Town Trustees Permit may be required.
PLOT DIAGRAM
,
.
Locate clearly and distinctly :Ill buildings. whether existing or proposed, and. indicate all set"back dimensions from
lroperty lines. Give street and block number or description according to deed, and show street n:unes and indicate whether
nterior or comer lot.' - ..
..,
~ -.,,'
~
"
..
STATE OF };EW YORK,
COUNTY OF . . . . . . . . . . . . . . . .. S.S
..................... ............................
being duly sworn, deposes and says that he is the applicant
, (Name of individual signing contract)
above namcd.
u.. I'S tIle
nl; .... . . ......... .. . ............. . ,...... ... .... ..... ............ ................... .' .
(Contractor, allcnt. corporate officer, etc.) . . . . . . . .
of said owncr or owners. and is duly authorizcd to peFform or have performcd the said work and to m:tke and file this
application; that all statemcnts contained in this appliqtion arc true to the best of his knowledge and belief; and that the
work will bc perfonned in the manner set forth in the application tiled therewith. '
Sworn to bdore me this .
!
. " . . . . . . . . . . .1. . . . . . . .day of . .~. . . . . . . . . . . .. 191(/.
Notary Public. ........;{.{... ~'!-:.11: ,0 1-. ?!~. County
,,'
i
, '
IIlIMY IIU/l r. I( war
...=~,
.. EIfl/qIIIiIcli 3O.1L.:Zf
. .(lJQ,. 2~. . . . . . . . . . . . . . . . . .
(Signature of appliC:lDt)