The URL can be used to link to this page

Home My WebLink AboutFanning, RussellSUPERVISOR'S OFFICE · 16 South Street C~reenpe~, N. Y. Tel. Greenporf 74)$$0 BUILDING DEPARTMENT TOWN OF $OUTHOLD SUFFOLK COUNTY, N. Y. TOV~N CLERK'S OFFICE Mare Street Southdd, N. Y. Tel. Southold $-3783 BUILDING I'NSPECTOR'S OFFICE Greenporf, N. Y. CERTIFICATE OF OCCUPANCY No. 119 Date July 1~ 19 c~7 THIS CERTIFIES that the building located at N./~ N~t~ M~ffn~ ~r AV~. Street, k4ap No, . Block No. , Lot No. ~'¢~ ~1~r~1 lr; [~.y. in the Town of Sou~old. confo~s substantially fo the ~~~~~d~ meats of the appllcab~ provisions of the law. The occupancy for which this certificate is issued is This certificate is issued fo of the aforesaid building. .............. ~-'(owner, I~ssee or teeanfl (The Certiflcafe of Occupancy will be issued only after the Building Inspector ;s convinced of the completion of the construction in compliance w;fh the Multiple Residence Law and with other laws, ordinances .or regulations affecting the premises, and ~n conformity with the approved Ideas and specifications.} SUPERVISOR'S OFFICE 16 South Street Greenporf~ N. Y. Tel. Greenport BUILDING DEPARTMENT TOWN OF SOUTHOLD SUFFOLK COUNTY, N. Y. TOWt¢ CLERK'S OFFICE Southeld, N. Y. Tel. South~ld 5-3783 BUILDING I'NSPE~:TOR'S OFFICE Southold, N.Y. CERTIFICATE OF OCCUPANCY "~arden oottr~e (c~ '~p)" "cottage '~ barn" No. 120 Date This certificate is issued fo of the aforeseld building. THIS CERTIFIES that the building located a+ ~./fi N~wm~f*~l~ Av~; Street, Map No. 4~** , B~ No. *** , Lot No. in the Town of Soufhold, conforms substantially fo the ~i~+.~: :: ~ :. :. :. ;: :: ::.~ ......... ~~~sde~ require- ments o~ fha applicab~ provisions o~ the law. Tke occupancy ~or which fMs certificate is issued (owner, lessee or tenant) B~Hding Inspector / (The Ce,fificate of Occupancy will be issued only after the Building Inspector is cony;aced of the completion of the construction ~n compliance with the Multiple Residence Law end with other laws, ordinances .or reguJefions affecting the premises, and in conformity wlth the approved l~ans and spec~flcatlons.) SUPERVISOR'S OFFICE 16 Sou~h Street Greenport, N. Y. TeL Greenpor~ 7-O~0 BUILDING DEPARTMENT TOWN OF $OUTHOLD SUFFOLK COUNTY, N. Y. TO~A~N CLERK'S OFFICE Male Street Scmth~d, N.Y. Tel. Soufhold 5-3783 BUILDING I'NSPECTOR'S OFFICE CERTIFICATE OF OCCUPANCY "COTTAGI: tl one) THIS CERTIFIES that the building located at_m.A_~_ ............... ~.,~.~ m.~, e,,t'~',~lT~_____ ~t~ ~,~.~T~et, Map No. ~ , Bilk No. ~ a ed I n ' ' in the Town of Southold, conforms substantially ~~G~~~ fli~b~e~ te ,11 of the require- meets of fha eppllcebM provisions o~ the law. The occupancy for which this ~rfificate is issued This ce~iflcafe is issued ~ ~ .... · ~---a-- ~ fha afore~id bui~ing. JThe Cer~ficefe of Occupancy will be issued only after the Building Inspector is convinced of the completion of the construction in compliance with the Multiple Residence Law and w~th other laws, ordinances.or regulations affecting the premises, and in conformity with the approved ptens and specifications.) BUILDING DEPARTMENT TOWN OF $OUTHOLD SUFFOLK COUNTY, N. Y. TO~A~N CLERK'S OFFICE Main Street Se~lmld, N. Y. Tel. Soctho~d 5.3783 BUILDING I'NSP~CTOR'S OFFICE 307 u t · t CERTIFICATE OF OCCUPANCY "MAIN BOAP. DING HOUSE" .......... .- Street, THIS CERTIFIES that the building located Map No. __ , Block No. ' ~[q]l[ . ...... 4.4,_.~. in +ha To,n o~ So,~old. ~o,~o,m~ ,,~+,,+;,~ o~ce wi~ A~elicafion for Building Permit dated 19_ Building Permit No. dated 19 __, w~and conforms fo all of the require- menfs of the appllcab~ provisions of the law. The occupan~ for ~;ch this ceHificafe ;s issued is This certificate is issued to of the aforesaid building. (The Cer~iflcefe of Occupancy will be issued only~ after the Buildlag Inspector is convinced of the completion of the construction in compliance with the Multiple Residence Law and with other laws, ordlnances.or regulations affecting the premises, and in conformity with the approved plans end specifications.) Original for Municipal Building Department l,,.,k,k,k,V~C*~ STATEMENT OF REGISTRY To be filed in duplicate with the municipal building department or local enforcement agency by every owner of a multiple dwelling, as defined in subdivision 33 of section 4 of the Multiple Residence Law. Within 30 days after the filing of this statement, the municipal building department or en- forcement agency is required by section 300, Multiple Residence Law, to file a duplicate copy hereof with the State Building Code Commission, 1740 Broadway, New York 19, N. Y. 1. Location of multiple dwelling: t x , , / .. (a) Street and number . ..~../~.~.~, ........................ .,.~...~....~ ............................................... (b) Mu~icipa,ty ............. /.?...C f~',~L... ~;.~.~:~.;~:;~: :~/C .y ........ /~2.~ ................... 2. Description: ~ ,'' (o) Type of construction ............. ~.....~-:Sn.:.[~ ......................... (b) Height of buildin~ includin~ number of stories ........... ~'. ....................... (d) ~umber of oportments .......... ~L..Z7 ..................................................................... (e) Mumber of livino rooms ...~ ............................................................................... (f) Mumber o{ kitchenettes ...... ~ .............................................................................. (~) ~umber of bothrooms .......... Y~ .................................................................. (h) ~umber of woter closets ~ (i) Number of occuponts for which buildin~ wos desioned or intended to be occupied o~ ~od ..................................... L..~ ................................................................ 3. Age of multiple dwelling: (a) Date when constructed ............. ./...~..~.-....'.~.. ......................................................... (b) Dates of substantial additions, alterations or modifications of dwelling, with (c) If now under construction, state when construction commenced and anticipated date of completion ............. /...../...../. .......... ;/. ............................................ 4. Use: Describe the principal use made, or, in the case of buildings under construction, to be made, of the multiple dwelling (such as apartment house, hotel, apartment hotel, lodging house, boarding house, school, convalescent, old age or nursing home, pri- vate dwelling two or more stories in height with five or more boarders, roomers or lodgers, or other classification of multiple dwelling including those specified in sec- tion 33, Multipl~esidence law)y ~ x]~ ;' ....................... l..~.h:.~ ............... /..~ ...... ~: ..................... ~.~ ................ ,~....~ ......... .... .~.~./.. ....... :....,_,.......~. ,~..,,....~ .................................................................................. ......... ....... ....' .. ................................................................(Addre~ o~ Owne~) ,STATEMENT,~ OF FILING ~r~ . .~uilding Department or Other Eu,fo~eme~Ageney) L:'..~...I.:~...".......':.; ...... :~.~....: ............ ....... ;. on the ........... :'>,.~......(.~. .......... ] 95..~ .............. ......... (~t~e ~d ~l~a~lon ~ Official ~th whom S~en~ of ~t~ was ~) F Original for Municipal Building Department STATEMENT OF REGISTRY To be filed in duplicate with the municipal building department or local enforcement agency by every owner of a multiple dwelling, as defined in subdivision 33 of section 4 of the Multiple Residence Law. Within 30 days after the filing of this statement, the municipal building department or en- forcement agency is required by section 300, Multiple Residence Law, to file a duplicate copy hereof with the State Building Code Commission, 1740 Broadway, New York !9, N. Y. 1. Location of mu tip e dwe 'rig'. ~//~' ---~'/ ,- r-, · · ~/ ' (a) Street and number ..'.~.L...[..~-:t~.....~_~./~:.~ ~. ; 1~,, ~ ZJ . , ' ...................... ....... .............................. (b) Mumclpahty 2. Description: .............ff~.....}..~2::.~...~ ............................................ (o) Type of construction (b) Height of building, includin~ number of stories (c) Type of heotin~ focilities .... ~¢ [~ ......................... (d) Number o{ op~rtments ........................................................................................ (e) Number of living rooms (f) Number of kitchenettes ............ ...;.._..:..,...;.,? ................................................... (g) Number of bathrooms .......................... ~ .~,~((~ ;;:....: .................................................... (h) Number of water closets (i) Number of occuponts for which building was designed or intended to be occupied or used ............................. ~ ....................................................................... 3. Age of multiple dwelling: (a) Date when constructed ............ .~......../...~...~ii~ ...................................... (b) Dates of substantial additions, alt~ations or modifications of dwelling, with brief description thereof .............. .~ ...........~ ...... ./ ...................................... ................................................................................ ~:~ ........ ~ ....................................... (c) If now under construction, state when construction commenced and anticipated date of completion ................... ~, ........... ., ...... :t ................................................... 4. Use: Describe the principal use made, or, in the case of buildings under construction, to be made, of the multiple dwelling (such as opartment house, hotel, apartment hotel, lodging house, boarding house, school, convalescent, old age or nursing home, pri- vate dwelling two or more stories in height with five or more boarders, roomers or lodgers, or other classification of multiple dwelling including those specified in sec- tion 33, Multiple ~,esidence Law)./~ .,.: .......... ......... .......... ....... ri,ea with the ......... ~'....~..:....:.:::.::.:...~ ......... :~.~.:.....::-1'....~.~ .................of the ~ ~ (Bui~ing De~a~men~ or ~her ~orc~nt ~e~) ~ (Name of M~icipality) / te of ~1~) Original for Municipal Building Department STATEMENT OF REGISTRY To be filed in duplicate with the municipal building department or local enforcement agency by every owner of a multiple dwelling, as defined in subdivision 33 of section 4 of the Multiple Residence Law. Within 30 days after the filing of this statement, the municipal building department or en- forcement agency is required by section 300, Multiple Residence Law, to file a duplicate copy hereof with the State Building Code Commission, 1740 Broadway, New York 19, N. Y. 1. Location of multiple dwelling: // 1£ ~- ~ ~ * ~) ~/ ~ (a) Street and number.,~..~.,..~......~..,,...;_)....,..?_; '7'"'"';7':'"',"'~-'-'"' "'"'"'"'"":~"Z'~'~"~'~'~'~'"~ ~ b ~ '~ ~' (b) Municipality ...... ~.'~.....~.~......~.~:y~j:?..~.~...[~.~./..~..~.~...~:~.~.~.'''''''''''''''' 2. Description: ~ (a) Type of construction ................ ~ ............................................ (b) Height of building, including numbe~ of stories ....... ./. ...................................... (c) Type of heat ng facil t es ........... ~....~...;~ ................ (d) Number of apartments . (e) Number of living rooms ~~~~'.~ (f) Number of kitchenettes .......... ~.'. .............................................................. (g) Number of bathrooms ~ (h) Number of water closets ...................................................................................... (i) Number of occupants for which building was designed or intended to be occupied or used ................................ ~ ...................................................................... 3. Age of multiple dwelling: (a) Date when constructed ~ ./ c~ ~t~-0 (b) Dates of substantial additions, altera~ons or modifications of dwelling, with brief description thereof ............. ./ ..........·7' ........ ,] ......................................... (c) If now under construction, state whTn construction commenced and anticipated date of completion 7" .... /' / ..................................... 4. Use: Describe the principal use made, or, in. the case of buildings under construction, to be made, of the multiple dwelling (such as apartment house, hotel, apartment hotel, lodging house, boarding house, school, convalescent, old age or nursing home, pri- vate dwelling two or more stories in height with five or more boarders, roomers or lodgers, or other classification of multiple dwelling including those specified in sec- tion 33, Multipl~sidence Law)./ . ('"~ )~ , ...... .T .......................................................................................... '.~ C'' ~.~ ~ e ork Dated.gt ..~/..~. .......... .~....L/.~.! ......... N w Y ........ ....... ............. .,,z... /m , / .................... ................. ,.m ~ /;~TATEMENT~OF FILING F,led w,th the ...... ~.~.i ............... '~ ...... ~...~: ............................................ of the '~' 7 ~ ~ (BulldJJag Dep~tme~t or ~her ~e~t ~y) /-~ ....... {......~:;.% :t: x..:., .......~ .......on the ......... :...~. ....... ~ ........ ,)Name of MunicipaliBy) ' (// (~te/of ~1~) ........... (B~at~e and ~i~a~on whom S~ment of Original for Municipal Building Deportment STATEMENT OF REGISTRY To be filed in duplicate with the municipal building department or local enforcement agency by every owner of a multiple dwelling, as defined in subdivision 33 of section 4 of the Multiple Residence Law. Within 30 days after the filing of this statement, the municipal building department or en- forcement agency is required by section 300, Multiple Residence Law, to file a duplicate copy hereof with the State Building Code Commission, 1740 Broadway, New York !9, N. Y. 1. Location of multiple dwelling~ / , ,/ (,) Street and number~x ~ ,,,"~"'""~'L'"'7'7'"u'"'{~*-- ,, .............................. ~ ............... .......... ............................................. 2. Description: (a) Type of construction .............. k: ...................................................................... (b) Height of building, includinfl nu~ o~ stories .......... (c) Type of heating facilities ~ ~ ............... ......... (d) Number of apartments (e) Number of living rooms ......... ~ ......................................................................... (f) Number of kitchenettes (g) Number of bathrooms ................ ~ ............................................................. (h) Number of water closets (i) Number of occupants for which building was designed or intended to be occupied or used ..................................... ~ 3. Age of multiple dwelling: "~" "~'Z~'"'/~'"%'A (a) Date when constructed ................. :....../...~.~..~i..O. ................................ (b) Dates of substantial additions, alteraticjl~s or modifications of dwelling, with brief description thereof ... ~..~ ~. ...................................... (c) If now under construction, state when construction commenced and anticipated date of completion .................. '/"/'t 4. Use: Describe the principal use made, or, in the case of buildings under construction, to be made, of the multiple dwelling (such as apartment house, hotel, apartment hotel, lodging house, boarding house, school, convalescent, old age or nursing home, pri- vate dwelling two or more stories in height with five or more boarders, roomers or lodgers, or other classification of multiple dwelling including those specified in sec- tion 33, Multiple Re~ence Law). / (.~ ~ · .... ....... ....................................................................................... Dated at ..¥...~...~Lf~?:.:.. New York '~ ~ ~ t , (Name of . ~TATEMENT OF FILING Fded with the ..... ~.~ ............. .{ ......... ~.....'.~/.....~.......~.~ .......................... of the ...~.~:....~.....~~/:~ the .......... }..~.....~.~. ....... 195.~.. ~hom Sta~ment of ~gist~ w~ ~I~) Original for Municipal Building Department STATEMENT OF REGISTRY To be filed in duplicate with the municipal building department or local enforcement agency by every owner of a multiple dwelling, as d~fined in subdivision 33 of section 4 of the Multiple Residence Law. Within 30 days after the filing of this statement, the municipal building department or en- forcement agency is required by section 300, Multiple Residence Law, to file a duplicate copy hereof with the State Building Code Commission, 1740 Broadway, New York 19, N. Y. 1. Location of multiple dwelling: , Street and number--...~.Z.~...../..~..."~....i..~..r.~f.,~..~!.<.~'~..~?.~....~t~l..~....~' (a) .... ........ ,, ............................... (b) Municipality 2. Description: (a) Type of construction ............. ..J~..~7..~....~ .................................................. (b) Height of building, including number of stories ..... ..~'...~ .............................. (c) Type of heating facilities ...... ff..~ ...................................................... (d) Number of apartments ............................. ~..~p..~ ................ (e) Number of living rooms ....... ./...~../...... ..................................................... (g) Number of bathrooms ............... C'~. ................................................................... (h) Number of water closets .............. i~,~. ................................................................. (i) Number of occupants for which building was designed or intended to be occupied or used ......................... .~.....~ ................................................................... 3. Age of multiple dwelling: (a) Date when constructed ............ ...'~....~.....~?..~..../...Z.~...~.. ....................................... (b) Dates of substantial additions, alterations or modifications of dwelling, with brief description thereof "'"'"~'"/'"-':Z~'~"'~ ................................................ (c) If now under construction, state when construction commenced and anticipated date of completion ........ y.....;.j;::~,~;;;.;;.~e...C.* ....................................... 4. Use: Describe the principal use made, or, in the case of buildings under construction, to be made, of the multiple dwelling (such as apartment house, hotel, apartment hotel, lodging house, boarding house, school, convalescent, old age or nursing home, pri- vate dwelling two or more stories in height with five or more boarders, roomers or lodgers, or other classificatioq of multiple dwelling including those specified in sec- tion 33, Multiple Residence Law). ~ ~ ~ ~__ .......................... ........ t ....... ......... (Address of Owner) Filed with the ........................................ ] ....................... .,J.......;'...Z ............................ o ~ (BuQdtng ~e~ar~n~ or ~her ~orc~en~ ~e~y) (~me or ~io'~ ' ~) ~ [~ (~ ~f ~'~) ., .............................. whom S~ment of Original for Municipal Building Department STATEMENT OF REGISTRY To be filed in duplicate with the municipal building department or local enforcement agency by every owner of a multiple dwelling, as defined in subdivision 33 of section 4 of .the Multiple Residence Law. Within 30 days after the filing of this statement, the municipal building department or en- forcement agency is required by section 300, Multiple Residence Law, to file a duplicate copy hereof with the State Building Code Commission, 1740 Broadway, New York !9, N. Y. 1. Location of multiple dwelling: (a) Street and number .... z~/.~.....Jk~.~...3.1).~'.~'.o]..,]~..~..'c.e.~.~...~:...~..~q.~;.~.fl~.~... (b) Municipality .............. ~ ~... ~.~ ;~.~ ]~ ~...t'..¢.~...~t~ ~. ...................................... 2. Description: (a) Type of construction ..... ]~ft~,fl ........................................................................... (b) Height of building, including numb'er of stories ....]. .......................................... (c) Type of heating facilities ...... 2,.~ ................................................................... (d) Number of apartments ...............-. ........................................................................ (e) Number of living rooms ........... .~. ......................................................................... (f) Number of kitchenettes .............- ........................................................................... (g) Number of bathrooms ......... '1 ............................................................................. (h) Number of water closets ....... ~, ............................................................................. (i) Number of occupants for which building was designed or intended to be occupied or used ............................... 5 .............................................................................. 3. Age of multiple dwelling: (a) Date when constructed ......... .~.e..~.~'..e....~....0..0. ..................................................... (b) Dates of substantial additions, alterations or modifications of dwelling, with brief description thereof .......tY.C~ .................................................................... (c) If now under construction, state when construction commenced and anticipated date of completion ............................................................................................ 4. Use: Describe the principal use made, or, in the case of buildings under construction, to be made, of the multiple dwelling (such as apartment house, hotel, apartment hotel, lodging house, boarding house, school, convalescent, old age or nursing hame, pri- vate dwelling two or more stories in height with five or more boarders, roomers or lodgers, or other classification of multiple dwelling including those specified in sec- tion 33, Multiple Residence Law). ..................................... ~.o.~m~../.~...~.~..e.~...~.o.~ ~.~t.~ ~.~ ................................... Dated at ..... ~.~..e..~....~.~?...o.~.].~ ........ , New York ..... ............... ....... ..... .................... Filed with the .............................. .q/.....~ ...............,,,,~'~'/"~"7 ......................... of the . ..~....~..~..~.~. on the ~.. ~ 19~....~ ';/'7 / Original for Municipal Building Department STATEMENT OF REGISTRY To be filed in duplicate with the municipal building department or local enforcement agency by every owner of a multiple dwelling, as defined in subdivision 33 of section 4 of the Multiple Residence Law. Within 30 days after the filing of this statement, the municipal building department or en- forcement agency is required by section 300, Multiple Residence Law, to file a duplicate copy hereof with the State Building Code Commission, 1740 Broadway, New York 19, N. Y. 1. Location of multiple dwelling:t~ s ~ (a) Street and number .L~.e~...~lC~'.~.Q].~..~,.',,r.~e...~c....,~..~.'~.e. fl.t ................... (b) Municipality .......... .~ ~ .~.,. ~.~.'. ~.~ .o..]_...~. ~....~.e. ,~..., .~ g..~..~. ........................................... 2. Description: (a) Type of construction ...~P.:?,.~ ............................................................................. (b) Height of building, including number of stories ..2~ ......................................... (c) Type of heating facilities ...t. Lg..t)..e. ........................................................................ (d) Number of apartments ................ D..~.~..~.~.~;..~.o..o.z~. ............................................. (e) Number of living rooms ............. ~.~ .......................................................... ~ ~z' ~ (f) Number of kitchenettes .................... .~.~.g.h.,,.~ ................................................. (g) Number of bathrooms '3 (h) Number of water closets ............... ~ ..................................................................... (i) Number of occupants for which building was designed or intended to be occupied or used ....................................... .2...2. ................................................................... 3. Age of (a) (b) multiple dwelling: Date when constructed .......... .~..e.~.o..~ff...~..g..0..0.. .................................................... Dates of substantial additions, alterations or modifications of dwelling, with brief description thereof .......... ~'~o~e ................................................................. (c) If now under construction, state when construction commenced and anticipated date of completion ............................................................................................ 4. Use: Describe the principal use made, or, in. the case of buildings under construction, to be made, of the multiple dwelling (such as apartment house, hotel, apartment hotel, lodging house, boarding house, school, convalescent, old age or nursing home, pri- vate dwelling two or more stories in height with five or more boarders, roomers or lodgers, or other classification of multiple dwelling including those specified in sec- tion 33, Multiple Residence Law). ................................ 3.~ ~:.m.e z... b.(~.c~J. ~.. ~ ozzs e .................................................. Dated at ....... J'.~..e.?....~.?:~..~..o..]=.?.~: ...... , New York ................ i×;~;.;;;..;~..~;~....~. ..... ..~ STATr~MENT OF FILING ....... .............. ....... (~me of u '*'pa'~y) .~.(Da~ of ~) (8~e and ~i~on,,~ ~ielal wl~h whom ~meng of Original. for Municipal Building Department STATEMENT OF REGISTRY To be filed in duplicate with the municipal building department or local enforcement agency by every owner of a multiple dwelling, as defined in subdivision 33 of section 4 of the Multiple Residence Law. Within 30 days after the filing of this statement, the municipal building department or en- forcement agency is required by section 300, Multiple Residence Law, to file a duplicate copy hereof with the State Building Code Commission, 1740 Broadway, New York 19, N. V. 1. Location of multiple dwelling: (a) Street and number ...J~i/.~...~k`e.~.~..~.~.~.A...Y.e...~..g..e...~.-5.~....~..~.~.e..e.~. ...... (b) Municipality ............. ,L\ .e~.. ~.1¢~'.~.Q ] ~.~ ..... Z~ f~ .. ~C~2~ ..................................... 2. Description: (a) Type of construction ....... ~?...~.~.e. ......................................................................... (b) Height of building, including number of stories ...;~. .......................................... (c) Type of heating facilities (d) Number of apartments - (e) Number of living rooms .................. /~-. ................................................................... (f) Number of kitchenettes ................. ..- .................................................................... (g) Number of bathrooms .................. 2 .................................................................... (h) Number of water closets ................ ~ .................................................................... (i) Number of occupants for which building was designed or intended to be occupied or used ...................................... ..~ ..................................................................... 3. Age of multiple dwelling: (a) Date when constructed . ..~.¢~..g.~:.e... ~,~..0..0. ........................................ (b) Dates of substantial additions, alterations or modifications of dwelling, with brief description thereof .................................................................................... (c) If now under construction, state when construction commenced and anticipated date of completion ............................................................................................ 4. Use: Describe the principal use made, or, in the case of buildings under construction, to be made, of the multiple dwelling (such as apartment house, hotel, apartment hotel, lodging house, boarding house, school, convalescent, old age or nursing home, pri- vate dwelling two or more stories in height with five or more boarders, roomers or lodgers, or other classification of multiple dwelling including those specified in sec- tion 33, Multiple Residence Law). ......................................... ~.o. ~.~ ...~. f~ ~...~.g~,~.e.~...~.o.~. Z'.ci.,.e. ~.~ ............................... Dated at ..}!~..~tz~'.~'o'L~c ............ New York STATEMENT OF FILING Filed with the ...~~.?j...~..~...~...~........~.....~ .............. of the (Building gep~rtment or O~her Er~orcemJ~tJAgency) ...... ~..~....~ ....... on the ..................... .~.........~...~... ..... ,9~...~.. ....... ........ (~at~e a~d ~i~a~on w~om S~ment of ~t~ w~ ~)