HomeMy WebLinkAbout173 Fairview DriveD
TO THE B AT)ING INSPECTOR
r 7
of the APPLICATION FOR
PLAN EXAMINATION ANDT' OF WWDSOR,BUILDING PERMIT
IMPORTANT — Applicant to complete all items in sections: 1, 11, III, IV, and IX.
ZONING
O
AT (LOCATION)% J P4_f V'e( / DISTRICT
LOCATION NO.) STREET)
OF BETWEEN AND
BUILDING CROSS STREET) - CROSS STREET)
SUBDIVISION T 11 )Qf C i LOT 53 BLOCK S ZE 3 00
V1
II. TYPE AND COST OF BUILDING — All applicants complete Parts A — D
A. TYP OF IMPROVEMENT D. PROPOSED USE — For"Wrecking" most recent use
1 N w building Res id tial Nonresidential
2 Addition(If residential, enter number 12
Res
family 18 Amusement, recreational
of new housing units added, if any,13 Two or more family — Enter 19 Church, other religiousinPartD, 13)
number of units— — — — -i 20 Industrial
3 Alteration (See 2 above) 14 Transient hotel, motel,21 Parking garage4 Repair, replacement or dormitory — Enter number
5 Wrecking (If multifamily residential, of units ——————— —-- Service station, repair garage
enter number of units in building in 15 Garage 23 Hospital, institutional
Part D, 13)
16 Carport 24 Office, bank, professional
6 Moving (relocation)
17 Other — Specify 25 Public utility
7 Foundation only 26 School, library, other educational
B. OWN RSHIP 27 Stores, mercantile
28 E] Tanks, towers
8 Private(individual, corporation,
nonprofit institution,etc.) 29 Other — Specify
9 Public(Federal, State, or
local government)
C. COST Omit cents) Nonresidential — Describe in detail proposed use of buildings,e.g., food
processing plant, machine shop, laundry building at hospital,elementary
10. Cost of improvement,,,,,,,,,,,,,,,, S Ho school, secondary school, college, parochial school, parking garage for,
department store, rental office building, office building at industrial plant.
To be installed but not included If use of existing building is being changed, enter proposed use.
in the above cost
a. Electrical......................
b. Plumbing ......................
c.Hooting, air conditioning.........
d. Other(elevator, etc.)............
11. TOTAL COST OF IMPROVEMENT $ BY/ Dui
III. SELECTED CHARACTERISTICS OF BUILDING — For new buildings and additions, complete Parts E — L;
for wrecking, complete only Part J, for all others skip to IV.
E. PRINCIPAL TYPE OF FRAME G. TYPE F SEWAGE DISPOSAL J. DIMENSIONS
30 Mas my(wall bearing) 40 Public or private company
Number of stories...............
31 Wood frame 41 Private(septic tank, etc.)
Total square feet floor urea, So
all floors, based on exterior
32 Structural steel dimensions ....................
33 Reinf rced concrete H. TYPE,OF WATER SUPPLY
34 Oth r — Specify 42 - Public or private company
Total land area, sq. ft. ........... 3Q loot
Private(well, cistern) K. NUMBER OF OFF-STREET
PARKING SPACES
Z
F. PRINCIPAL TYPE OF HEATING FUEL I. TYPE OF MECHANICAL
51. Enclosed .......................
35 Gas Will there be central air 52. Outdoors........................
96 Oil conditioning?L. RESIDENTIAL BUILDINGS ONLY
j37E] El ctricity 44 Yes 45 N 53. Number f b dro ms..............
38 C al
39 Other— Specify W1II there be an levator? Full..........2—
54. Number f
46 Y s 47 No bathrooms
Partial........
NOTES and Data — (For department use)
IV. IDENTIFICATION — To b c mpl ted by all applicants
Nam Mailing addr ss — Number, street, city, and State ZIP code Tel. No.
Y c o v eo• P.0 ,ac x 2 7'NCf E7? c%.
owner or
Lessee
2.
Contractor
3.
f -Architect or
Engineer
The owner of this building and the undersigned agree to conform to all applicable laws of this jurisdiction.
Signature of applicant t
Address Application date
v
DO NOT WRITE BELOW THIS LINE
V. PLAN REVIEW RECORD — For office use
Plans Revi w R uired Check Plan Review Date Plans B Date Plans B Notes4FeeStartedyApprovedy
BUILDING
PLUMBING
MECHANICAL
ELECTRICAL
OTHER
VI. ADDITIONAL PERMITS REQUIRED OR OTHER JURISDICTION APPROVALS
Permit r Approval Check ObDtaired Number By Permit or Approval Check ObtDa ned
ate IJumber By
BOILER PLUMBING
CURB OR SIDEWALK CUT ROOFING
ELEVATOR SEWER
ELECTRICAL SIGN OR BILLBOARD
FURNACE STREET GRADES
GRADING USE OF PUBLIC AREAS
OIL BURNER WRECKING
OTHER OTHER
VII. VALIDATION
Building
Permit number 12865
Bui lding
Permit issued Aug. 18 19 8—
Building
P rmit Fee $ 408.00
prove by•
r5o A
TIT
NOTESVIII. ZONING PLAN EXAMINERS
DISTRICT
FRONT YAR
SIDE - .SIDE YARD
REAR YARD
NOTES
IX. SITE OR • Applicant
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TOWN OF SOUTH WINDSOR
BUILDING PERMIT
Date Aug- 18 1982.
Fee Paid $. .40.8.00 Est. Value $.6 8.,000.00
Permit NQ 128652865
on the We of
Lot #53 Fairview Drive Sued
Street No. 173
Owner H & R Construction Co.
Applicant U & R Con Q true ti on Cc_
CERTIFICATE OF OCCUPANCY ISSUED:
Date
No. 60R 1
Fee Paid $ 3--00
CLASSIFICATION
Dwelling
BUILDING PMdWr
OFFICE OF
N° 12865
THE BUILDING INSPECTOR
of the
I
Town of South Windsor, Conn.
South Windsor, Conn. 'S
94is is to gerfif1j, That
is hereby granted permission to Cwe 11 1109
Moatestimatedvalueo
on the side of I-at—*S5-Fairvi ew Dries = Street on land
owned by .11 A_CQn 2-t Mile i On CO
Said Work to be as described in Application
Nal1"]6 5 and to conform to specifications and plans filed with said Application, and Building By.
Laws of THE TOWN OF SOUTH WIMSOR.
Issued Auge 1A 82•
uildmg nspec or.
Streets and sidewalks, obstructed by excavations or building materials, must be guarded by batrim
during the day and by both barriers and colored lights by night.
SECTION 1343, GENERAL STATUTES OF CONNECTICUT: "When any person shall place
or keep building materials, or any obstacle in any highway (or any sidewalk) either with or without a
in which such waY maylicensethereforfromthestyorboroughY be situated, he shall pay said city,
town or borough all costs and damages which it shall sustain, or be compelled to reason therefor.
i
I
Dwelling - Lot #53 Tim Rid. V 8/18/82
U & R Construction Co.
173 Fairview Drive Permit #12865
Electrician Milton Plouff 7778
H ating Contr. J. Vedovato 5603
Plumbing it J. Vedovato 6016
Oil Burner
C rtificate of Occupancy 6081
Plot plans apprd. per Engr.
Cr-, V 9 .3
leevTNSPECTIOEPORT
Permit # Jo
1 Footing &-17 8 9-
2 Foundation6-le-&A-
3 Framing
4 Wiring
5 Plumbing
6 Heating
7 Lathing
8 C.O. D
I Permit No. .' f TOWN OF SOUTH WINDSOR
SOUTH WINDSOR, CONN.
i
Permit lr
T? 6081
Certificate of Occupancy
THIS TO.2C FY that the,--,
at No CY in the euil n of South Windsor, Connecticut, has
been erected and completed in accordance with the ir, Code and Zoning Regulations of
the Town of South Windsor, and is hereby appr ed f o cupa c .,
Building nspecto
caner, Builder
Fee Paid,Date 19
GARDNER Et PETERSON ASSOCIATES 576 OLD POST ROAD-TOLLAND, CONNECTICUT 06084
LzE.M•h.1 ATiO O PARCEL.. A
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3Bq•8 390.3
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MORTGAGE SURVEY
i
LOT #539 "TIMBER RIDGE", SECTION V
TOWN OF SOUTH WINDSOR, CONNECTICUT
SCALE: 1" = 40'
I hereby certify to Society for Savings, USLIFE Title Insurance
Co. and Thomas M. & Nancy J. Strano that the location of the
building as shown is substantially correct and that there are no
zoning violations of the same.
i
arch 24, 1983
L. S. #10839
LAND SURVEYORSPROFESSIONALENGINEERSJ
BUILDING DEPARTMENT
TOWN OF SOUTH WINDSOR, CONNECTICUT
APPLICATION FOR BUILDING PERMIT
STAFF SIGN-OFF SHEET
Application # Applicant:• Date:G14L--
Location: Zone:
Type of Improvement:
Proposed Use: W- J 3
Kindly review the above building permit application, and if all Commission/Departmental
requirements have been met, sign-off below*.
Signature D-
Town Sanitarian:
Comments :
Fire Marshal:
Comments:
Engineering Bureau:
Comments:
Planning Department: i/C,(AA,
Comments: 2 4
Az F&Vy
Kindly review the above improvement, for which a Certificate-of-Occupancy has been requested,
and if all Commission/Departmental requirements have been met, sign-off below*.
Town Sanitarian:
Comments:
Fire Marshal:
Comments:
Engineering Bureau:
Comments:
Planning Department:
Comments:
Pollution Control Superintendent:
Comments:
Additional comments may be attached on a separate sheet.
5/28/82 PRD
7778
ELECTRICAL APPLICATION
Application No. 8889
on the side of
Lot #53 Fairview Drive Stract
Street No. 173
Owner U & R Construction Co.
Electrician Milton P 1 ouf f
FILED IN OFFICE OF
The Building Inspector
Oct. 7 19 82
INSPECTION.
cA'r No Electrical Work shall be started until a Per-
mit is granted by the Building Inspector.
In New Buildings no wiring shall be started
until the plumbing and heating pipes, and the fire
stops (if of wood) are installed, without a special
permit from the office of the Building Inspector.
APPLICATION FOR PERMIT TO DO ELECTRICAL WORK,
No. .....8.8-8.9......................
Permit No. .....7 7.7.8... ..--.......
TO THE BUILDING INSPECTOR
of the
TOWN OF SOUTH WINDSOR9 CONN.
A—_ hereby make application to. perform Electr cal Work according to detailed description below. All
provisions of the Rules for Electrical Installation, Section 48, Building By-Laws, shall be plied th
whether specified herein or not.
South Windsor, Conn., 19 C2-Sign here 1. . ............. .
Address
LocationI-ae.. Side of
Nature of Building How many stories
How many familiesNeworoldBuilding .........orQ.
Kind of Installation 7 . ......... How many Stores ............................................. ................ ..............................
Owner P............ Address .
47710t7"rz CT
Architect ............. ....... Address
AddressBuilder
Electrician Electrician 491 e7l Address
Size of Main Wires Y.L.i/..............913 ..................
No. of Light Loops .. ... .. ...... . ....... No. of Heat Loops . ........No. of Power Loops ...................................
No. of Light Outlets ..3.P .No. of Heat Outlets No. of Power Outlets ................. ............
No) of Light Circuits ...... No. of Heat Circuits No. of Power Circuits
No. of Sockets No. of Heat Receptacles No. of Motors ............
No. of Panels ......... Size of Heat Circuit No. of Power Receptacles
No. of Switches .........14.2........ .Total Wattage ... .................... .. ....... . Size of Power Circuit
Total Horsepower
No. of Straight Electric Fixtures ......... No. of Combination Fixtures
19,No. of Receptacles ........
1-.
Z...4_0'............. ....... ........ No. of Cord Drops ..... ............ . ...... ............... .. ....... ......
3.
Remarks: For other kind of Installation
Estimated Cost
6016 14-
PLUMBING APPLICATION
Appl;d,m No, 6 7 9 4
on the__ side of
Sweet No. _..1 7 3 `S^3
7j, e,Owner ....._
Phumber
Filed in of
The Bo Iaspecmr
Oct. 6 ig 82
a Mary n
No peram shall cross uct, add ID or altar ay
portion of the dwim p qmm of ash bolft
euept to repair leafs) asa a Per it is wed
by the Banding Lmpectw.
Application No.........6....7.9....4................. Permit No. -.60.1.6..................
TO THE BUILDING INSPECTOR
of the
TOWN OF SOUTH WINDSOR, CONN.
hereby make application to perform plumbing according to detailed description below. All
provisions of the Rules for Sanitation, By-Laws, Sections 33 to 47"1 ive, shall be complied with whether
specified herein or not.
South Windsor, 114---- Sign here ....... v ... ........................... .............
Address
qV......................... ..... Street5 ........................... side of ...- ... - .5Location .......................
47,,'
Nature of Building How many stories --t........./................. ..................................
Owner .......... Address ....... .....;!.
Architect ................ Address ..... .. .... ........ .. ..... ................................................. ..................
Builder Address I....................
Address 4.Plumber .............
DRAINAGE
CESSPOOLS, How many Where locatedI
hev iAretheywatertightOfwhatmateriaaretheybuilt .. ....
poolSizeofpipefromhousetocpooll Kind of pipe I......
MAIN DRAIN IN CELLAR, Maten, I Diameter .......5.............................................................I...... ........... ............
Above or below cellar bottom
SOIL PIPES, Material Diameter . ..V................................................................................................
WASTE PIPES, Material Diameter
TRAPS,Type proposed to use is
RAIN WATER LEADERS, where do they run to . . .... .... ....I.............................................................................................................
REFRIGERATOR WASTES, where do they run to . ... .. .......... .................................................................................... ...............................
TANK OVERFLOWS, where do they run to I.....................................................................................
FIXTURES
WATER CLOSETS, How many Where located ....
Distance from trap to vertical soil pipe ..................................... Pattern
WASH TRAYS, How many . .. ... ................................... .. Where located . . ..... .... ..................................................................
SINKS, How many .............. ...../..................................................... Where located ......k............ . ...................................................
BUTLER'S SINKS, How many ........................................................ Where located... ...... .......................................................................................
REFRIGERATOR SINKS, How many . .................................... Where located ................................................................................................
LAVATORIES,How many ....................................................... Where located ......./44_ .........................................................................
BATHTUBS, How many.................../.............................................. Where located ........
URINALS, How many . ................... ........................................... Where located .................................................................................................
Are water closets and urinals to be local vented If not, is there a window in outer wall
of room where same are to be located .......
Estimated Cost
PERMIT #
Application For 6704 5603DEPARTMENTDECISION
N Heating PermitO
3 rz APPLICATION IS HEREBY:
DEPARTMENT OF LICENSES AND INSPECTIONS
N ov APPROVED DISAPPROV D
TOWN OF SOUTH WINDSOR
o a 3/25/82
00 O DATE
r
IEF INSPECTOR APPLICATIONS MUST BE PRINTED OR TYPED. BEGIN WITH NUMBER ONE BELOWO
p y 1. LOCATION OF JOB
0
O
173ONO. BTREET
v f
r S
LOT NO. FLOOR APB. NO.
O
lV
O
V;C E 2. OWNER
ti +
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0 3 S. ADDRESS
4.PHONE efe
S. APPUCANT
ari ad
B. ADDRESS
a
7.PHONE6
G. LICENSE NO. p
a
p w B. EXPIRATION DATE OF LICENSE
10. ESTIMATED COST S ttz zw
en
I1. IS THIS A CONTRACT COSTT YES Np
12. FEE ENCLOSED :_ Permit 12865
O IS. TYPE OF BUILDING:m
RESIDENTIAL COMMERCIAL
Ocis14. TYPE OF JOB: INDUSTRIAL3
r'i IGINAL ALTERATION13INSTALLATIIfADDITION
REPAIR
APPLICATION FO HEATING PERMIT (Continued it m Reverse side)
11. LOCATION OF JOB s_3 Z 7 Ll)
NO. STREET FLOOR APT.NO.
12. TYPE OF INSTALLATION: 19-OIL BURNER Cl ELECTRIC VENTILATIO SPRINKLER
GAS BURNER STACK INCINERATOR MISCELLANEOUS -
I ENTIFY
SIZE 7J OFCTANKN OF FILL c OF VENT
SIZE SIZE
13. OF TANK
14. B.T.U. EQUIP. AT REGISTER RNACE MAKE AND NO. AT BONNET FIRING RATE
BOILER OR FURNACE MAKE AND NO. B.T.U. OR SQ. FT. NETZIQ4 B.T.U. OR SQ. FT. GROSS FIRING RATE,
FLOORS TO BE HEATED NEW OR OLD BUILDING g/ INSULATED — YES OR NO
TYPE OF WALL INSULATION ROOF OR CEILING INSULATION
XAVG. SYSTEM WATER TEMP. 4 G B.T.U./SQ. FT./HR. EMISSION
INDOOR-OUTDOOR TEMPERATURE DIFFERENCE FAHRENHEIT
MAKE OF RADIATION: BA OARD. PPER CONVECTORS. OR C.I. RADIATIO OUTPUT PER SECTION OR LINEAL OF RADIATION. SQ.
FT. OR B.T.U.
DESCRIPTION OF WORK G[15. TO BE DONE:
18. HEAT LOSS SCHEDULE. (TO BE INCLUDED FOR ALL JOBS):
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i
t
F,,a 7'_, r. :F A[c,rb..'- ' .. _.'+.Y gy..y , c._ . ,,.•aan .rt.
B. DOMESTIC HOT WATER DEMAND B.T.U./HR.
C. PIPING, OTHER THAN NORMAL B.T.U./HR.
ALLOWANCE FOR HEAT VALVE OF FUEL (A B C) FACTOR
17. ELECTRICAL WORK BY:
NAME ADDRESS
SUBCONTRACTORS AND
te. THEIR TRADES
ALL WORK COVERED BY THIS APPLICATION HAS BEEN AUTHORIZED BY THE (OWNER) OR (AGENT) OF THIS PROPERTY AND WILL
BE DONE IN STRICT ACCORDANCE WITH TH BUILDING CODE.
APPLICATION TO BE COMPLETELY FILLED IN.
DATE SIGNATURE OF APPLICANT
FINAL gsP
z Z s APPLICATION FOR BUILDING PERMIT
Plumbi
HVAC Date:
Sprinkler 173 FAIRVIEW DRIVE
Electric L S Estimated Costs CPO
Zonin Permit Fee$ JA 0
Affidavit NO. 19792 Occupancy Fee $ 3
Eng. Dept. COMPLETE RED BOXED AREAS.Fire Dept. TYPE OR PRINT ONLY Total Fee $ /1-3
Health Dept.
Approved for CO: 2 L t SIGN ON REVERSE SIDE.
Additional Cost) $
TO BUILDING DEPARTMENT, TOWN OF SOUTH WINDSOR, CT
The and rsigned, hereby applies to do work according to the following specifications:
Job Location Lot No. Side of Street Zone
A 6,FLZ . Ail,&Atop byy 3SApplicant , fSW .r Tel. #
Addresses SRm Zip_ Lic.# 303 4,g$L'STRE T CITY STATE
Own ddress ?-! <<-+ LYw-
ATe ritftt ddress
Sire New Area: Ft. Front Overall Ft. Deep Overall Total Area A Garages
Size of Lot - Lam' S4 ye? Lavatories' Dist. from Street Line Bathrooms Rooms 1st 2nd 3rd
Purpose of this Permit - Z AU640 uAl-13
City Water Well Septic Sewer
Use Group U Construction Type Q_
Approved by Date BD1A 11/88
I h reby agree to conform to all the requirements of the Laws of the State of Connecticut and the Ordinanc s of the Town of South Windsor
and to notify the Building Inspector of any alteration in the plans or specifications of the Building for which this permit is asked,and agree
that this building is to be located the proper distance from all street lines,side yard lines and required distances from all other zones and is
located in a zone in which this building and its use is allowed.
Signed Al
I hereby apply for a Certificate of Occupancy for the work described in this application for permit.
Signed
DO NOT WRITE BELOW THIS LINE—
INSPECTION RECORD 3+
Footing Framing jua I s'f'e-e 1 ID-S
Foundation Fireplace/Chimney Insulation
Plumbing Permit# Inspections:
HVAC Permit# Inspections:
Electrical Permit# Inspections: - C-e
Sprinkler Permit# Inspections:
Inspection / Approval Date By Appl
Code Description Due Whom Code Comment
92-19792-B 18,000
B09 OTHER 05/04/92 003 A STRUCTURAL STEEL OK
E03 ROUGH 05/28/92 003 D NOT COMPLETE
E10 FINAL 06/02/92 003 A
B10 FINAL 02/22/93 JFH A
92-12192-E 500
Total Est Value 18,500
GARDNER Fs PETERSON ASSOCIATES—`rra MMrrM nub ro&LANp, cONNecricur osm
SEcT1aN III. - ,
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7A,% RV1EW R1VE•
POOL - PERMIT PLAN
LOT #53 - TIMBER RIDGE - SECTION V NOTICE
173 FAIRVIEW DRIVE Reproductio:ls of this ;—Acm are invalid if they doPREPAREDFORANGELOALLEANO
not bear the impression' seal of the undersignee.TO F SOUTH WOINDSOR, CONNECTICUT
Land Surveyor-and* Professional En r eer,SCALE:
I hereby declare that this map and survey were prepared. in ; cCordance with the
standards_ of a Class A-2, survey as defined in the-Cdde"of,.Practice For Standards
of Accuracy of Surveys and Maps, adopted December 10, 1975 as amended by the
Connect4tAss- fci.ation and Surveyors, Inc.
DATE: March 17, 1992 L.S. #10839 '
REFERENCE: Resubdivision Plan Portion of Parcel "A" Timber Ridge Section V
South Windsor, Connecticut Subdivider: U & R Housing Corporation Gardner &
Peterson ASsociates Tolland, Connecticut Scale 1" = 40' Date 8-27-80 j,
PROFESSIONA4 ENGINEERS LA-1YP S(JRVEY0RS Z- -Ar-5 3 P
VY
MAR 2
rertitWd that t,-, pi-,m
i,s of the proposed buflj.--.
cted at
her with
fj by the Uml,li'lg
I. oppimation ant lio-!
11
e 0
0,d r, I-Id c ndit,
ijinancez rkguj4jmg Uuildl"i m.
L1 With
Approved ThWe WWO
14JI"g Inspeaw
jq -7
i-
ZONINGATIONOF
apnedjo
tru ALIW
00sed buildirg(S), use(S)
Arts) tO
on this plan ap
as chow cUrr2"nu
O
With
aTidVa
as nay apply.
Wt Zq Rot
ate
PERMIT #
DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
Application is hereby :
TOWN OF SOUTH WINDSOR
DISAPPROVED BUILDING INSPECTION DEPT.
644-2511 Ext . 230
Application must be printed or typed .
Date Building Inspector
1 . LOCATION OF JOB
FEE SCHEDULE No . Street
0 - $19000 -10. 00 Floor Apt . No .
Over $1 ,000 -10.00
2 . OWNER 7per $1 ,000 or st
fraction thereof
3 . ADDRESS 1:2 3
4 . APPLICANT
5 . ADDRESSte_?
ae.e zw
6 . ESTIMATED COST
7 . IS THIS A CONTRACT COST
Yes NoOn
8 . FEE ENCLOSED $ lQ, DQ
1 j-7
9. TYPE OF BUILDING :
c-- RESIDENTIAL COMMERCIAL
10 . TYPE OF JOB :
Original Installation
Alteration/ Ei til /Repair
BD 3A 11/88
APPLICATION FOR ELECTRICAL PERMIT (Continued from Reverse Side)
11 . LOCATION OF JOB_Z23
NO . STREET APT. NO
12 . TYPE OF INSTALLATION
13 . SIZE OF MAIN FEEDER
c
14 . NO . OF LIGHT LOOPS 15 . NO. OF HEAT LOOPS
16. NO . OF POWER LOOPS 17 . NO. OF LIGHT OUTLETS
18 . NO . OF HEAT CIRCUITS 19 . NO. OF POWER OUTLETS
20 . NO. OF CONVENIENCE OUTLETS 21. NO. OF HEAT CIRCUITS
22 . NO. OF POWER CIRCUITS 23. NO. OF LIGHT CIRCUITS
24. SIZE OF HEAT CIRCUITS 25 . NO. OF MOTORS
26 . NO. OF PANELS 27 . TOTAL WATTAGE
28 . NO. OF POWER FEEDERS 29 . NO. OF SWITCHES
30. A/C LOAD 31 . SIZE OF POWER FEEDERS
32 . NO . OF FIXTURES 33 . TOTAL HORSEPOWER
34 . NAME OF SUBCONTRACTORS AND THEIR TRADES
35 . REMARKS AND FURTHER DETAILS :
LV ppo /
LICENSE NO .SIGNATURE OF APPLICANT DATE
PHONE NUMBER: 44 Y 7 r 3 S-zK5—