HomeMy WebLinkAbout2051 PALOMAR AIRPORT RD; EXPIRED | MULTI-PERMIT FILE; CB980894; PermitI-A- O
B U I L D I' N G P E R M I T Permit No CB980894
03/26/98 13:49 Pioject No: A9801176
Page 1 6f."1 . .. . Development No:
Job Address: 2051 PALOMAR AIRPORT-RD Suite:'A .
Permit Type: MISCELLANEOUS ,
Parcel No: 213-050-39-00 Lot#:
valuation:' 0 .Construction Type: NEW
Occpancy,Group: Referenbe#: : Status: ISSUED
Description: DEMO CABINETS,FLOORING,NON-' Aplied: 03/26/98
BAERING ROOMS,CEILING TILES-NO NEW CONST Apr/Issue: 03/26/98
Entered By: JM
AppltOwnr : US BUILDING 619 35070710
HWY 101' #19
SOLANA CA 92075 -
*** Fees Required Fees Collected &- Credits
F &e s: 3 qç2 (L/ \ / N / Adjustments: /43'03/26/98 0001 0.0002
Total Fees: f30.dkl Tbt4ynt'\ 30OO
Janc cue: * 30.00
-------------
Miscellaneous Fee /#if / .--0 ..• ' • 30. 00 PERMIT FE]
* MISCELLANEOUS 'T TA • . . 30.00
rTi \It' PFI A. ERNT
.1952
cPE!T HAS.EXPIRED1JCCORDANCE WITH U.B.C.
GINATURE
* • - ,, - A
- • • . •- t •. -
FINAL APPROVAL,
I
. -• .•.
1INSP.- DATE
CLEARANCE_
'CITY OF CARLSBAD • *
• 2075 Las Palmas Dr., Carlsbad, CA 92009 (619) 438-1161
-, PERMIT APPLICATION
CITY OF CARLSBAD BUILDING DEPARTMENT
2075 Las Palmas Dr., Carlsbad CA 92009
(760) 438-1161
1. PROJECT INFORMATION
O6I P/- A17m
Address (include Bid uite#)
A
FOR OFFICE USE ONLY
PLAN CHECK NO.___________
EST. VAL.
Plan Ck. Deposit
Validated By__________________________ Date (-(f
L A
Business Name (at this
Legal Description Lot No. Subdivision Name/Number . Unit No. Phase No. Total # of units
Assessor's Parcel # Existing Use
:ia A&4~; ii
.De tion of Work SQ. FT. Sot S 0 OS S of Bedrooms S of Bathrooms
Cx .17
2 CrTACri
Q
Name Address . City Slate/Zip Telephone S Fax #
3 APPLICANT Qçpntractor 0 Agent for Contractor 0 Owner 0 Agent for bwner -
Name Address City State/Zip Telephone S
:4,'Yi . . .
Name Address City . State/Zip Telephone S
S CONTRACTOR COMPANY NAME " '
(Sec. 7031.5 Business and Professions Code: Any City or County which requires a permit to construct, alter, Improve, demolish or repair any structure, prior to Its
issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
(Chapter 9, commending with Section 7000 of Division 3 of the Business and Professions Code) or that he Is exempt therefrom, and the basis for the alleged
exemption. Any violatikn of Sectipn 7031.5 by any applicant for a permit subjects the applicant toe civil penalty of not more than five hundred dollars I11500I).
Name
State License S License Class Business
'I
me City .,,' State/Zip
State License S
G. WORKERS COMPENSATION -
Workers' Compensation Declaration: I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self-insure for workers' compensation as provided by Section 3700 of the Labor Code, for the performance
of the work for which this permit is issued.
EI have and will maintain workers' compensation, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is
My worker's compensation insurance carrier and policy number are:
Insurance Company C4' I c Policy No. 5-7' 3 00 9' 3 .. Expiration Date 9/A ?/r
(THIS SECTION NEED NOT BEtOMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS 1$1001 OR LESS)
CERTIFICATE OF EXEMPTION: I certify that in the performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as
to become subject to the Workers' Compensation Laws of California.
WARNING: Failure to secure workers' compensation coverage I. unlawful, and shall subject an employer to criminal penalties and civil fines up to one hundred
thousand dollars (S1O0J0p1. Ip1a n the cost of compensation, damages as provided for In Section 3706 of the Labor code, Interest and attorney'. fees.
,SIGNATURE AJ'Ja €' ., DATE
7 OWNER BUILDè1 DECLA ION T'
I hereby affirm that I am exem from the Contractor's License Law for the following reason:
I, as owner of the prop rty or my employees with wages as their sole compensation, will do the work and the structure is not Intended or offered for sale
(Sec. 7044, Business and Professions Coda:' The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does
such work himself or through his own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or Improvement is
sold within one yepr of completion, the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale).
i, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The
Contractor's License Law does not apply to an owner of property Who builds or improves thereon, and contracts for such projects with contractor(s) licensed
pursuant to the Contractor's License Law).
I am exempt under Section Business and Professions Code for this reason:
I personally plan to provide the major labor and materials for construction of the proposed property improvement. 0 YES ONO
I (have'/ have not) signed an appiicstion.for a building permit for the proposed work.
I have contracted with the following person (firm) to provide the proposed construction (Include name I address I phone number / contractors license number):
I plan to provide portions of the work, but I have hired the following person to coordinate, supervise and provide the major work (Include name / address / phone
number / contractors license number):
I will provide some of the work, but I have contracted (hired) the following persons to provide the work Indicated (Include name / address / phone number I type of work):
PROPERTY OWNER SIGNATURE DATE
COMPLETE THIS SECTION FOR NON-RESIDENTIAL BUILDING PERMITS ONL "" '
Is the applicant or future building occupant required to submit a business plan, acutely hazardous materials registration form or risk management and prevention
program under Sections 25505, 25533 or 25534 of the Presley-Tanner HazardoUs Substance Account Act? 0 YES 0 NO
Is the applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district? 0 YES 0 NO
Is the facility to be constructed within 1,000 feet of the outer boundary of a school site? 0 YES 0 NO
IF ANY OF THE ANSWERS ARE YES. A FINAL CERTIFICATE OF OCCUPANCY MAY NOT BE ISSUED UNLESS THE APPLICANT HAS MET OR IS MEETING THE
REQUIREMENTS OF THE OFFICE OF EMERGENCY SERVICES AND THE AIR POLLUTiON CONTROL DISTRICT.
8 CONSTRUCTION LENDING AGEJCY " " ' '"' -
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 30970) Civil Code).
LENDER'S NAME ' LENDER'S ADDRESS___________________________________________________________
9 APPLICANT CERTIFICATION r'' -
I certify that I have read the application and slate that the above information Is correct and that the Information on the plans Is accurate, I agree to comply with all
City ordinances and State laws relating to building construction. I hereby authorize representatives of the Cit%' of Carlsbad to enter upon the above mentioned, property for inspection purposes, I ALSO AGREE TO SAVE, INDEMNIFY AND KEEP HARMLESS THE CITY OF CARLSBAD AGAINST ALL LIABILITIES, JUDGMENTS, COSTS AND EXPENSES WHICH MAY IN ANY WAY ACCRUE AGAINST SAID CITY IN CONSEQUENCE OF THE GRANTING OF THIS PERMIT,
OSHA: An OSHA permit is required for excavations over 5'0 deep and demolition or Construction of structures over 3 stories in height.
EXPIRATION: Every permit issued by the Building Official-under the provisions of this Code shall expire by limitation and become null and void if the building or
work authorized by such permit is not commenced within 365 days from the date of such permit or if the building or work authorized by such permit is suspended
or abandoned at any time after the work s o en edM a p nod of 180 days (Section 108.4,4 Uniform Building Code).
PPLICANT'S SIGNATURE .'__- DATE
WHITE: File YELLOW: Applicant PINK: Finance
l
B U ± L D I N G P •E R M IT . Permit No: CB980688
03/04/98 15:45 Project No A9800893
Page lof 1".. - Development No:
Job Address: 2051 PALOMAR AIRPORT RD SLiité:
'Permit Type: MISCELLANEOUS • .
. 4670 03/04/98 0001,01
* 02
Parcel No: 213-050-39-00 • . -. ±ot#: ' CPRMT 30.00
Valuation: 0. . .. Construction Type: NEW
Occupancy Group: Reference#: ' ,Status: ISSUED
Description: DEMO NON-BEARING WALL-PINNFUND- Applied: 03/04/98
: .' .. Apr/Issue: 03/04/98
. * . -
.
• Entered By: RMA
Appl/Ownr : U.S. BUILDING & DEVELOPMENT 619 350-0710,
- 243 N HIGHWAY 101,
SOLANA BEACH CA 9207 • .•
, Fees Required *** Feed Collected & Credits
Fees---------------3960
2,Gre
N
Adjustments: *,f- .0.i '%c .T drts: * .00
Total Fees: - . /30.cP)". Tot(Ryf%ni?E: .00
Ba1an D e\ 30.00
.Fee*descriPtionf -Ext. fee Data
.'Mi.scellaneous Fee f#i/. ., 30:00 PERMIT FE
MISCELLANEOUS T@TA / • • 30.00
us '
* \ ;.'' 14' -:.-
- • .-_.-------
CITY OF CARLSBAD
2075 Las Palmas Dr., Carlsbad, CA 92009- (619)438-1161
,
-
PERMIT APPLICATION
CITY OF CARLSBAD BUILDING DEPARTMENT
2075 Las Palmas Dr., Carlsbad CA 92009
(760) 438-1161
FOR OFFICE USE ONJ,Y
PLAN CHECK NO.__________
EST. VAL.
Plan Ck. Deposit
Validated?y 1A-
-- .1/1
1. PROJECT (NERMATlON— /7 -. ç' , .4
Address linclud. ~QglS. ite ) - - -. - - Btdiness Name (at this address)
Legal Description Lot No. Subdivision Name/Number Unit No. Phase No. Total S of units
Assessor's Ce) S Existing Use /
/VOH -, /t 4( p-' ) I
/-4
Proposed Use
Description of Work SQFT.
2.CONTACTPEflSONjIfdltf.rentfrornlppllcaflt)
tot Stories I of Bedrooms S of Bathrooms
Name Address
3 .:AP CA Contracto; 0 Agent for,ontrectgr
'- //'f'
0 Owner
/1,—_./4n,132
City
0 Agent for Owner
. StatofZj,p Telephone S Fax S
-
_1' _pc '3i,'h_,4hii,t-p iôí Name / Address - City State/Zip Telephone S /
4. PROPERTYOWNER .. ••"•..-...•.•.-..-...............
Name Address City State/Zip Telephone I
S CONTRACTOR COMPANY NAME - ' '
(Sec. 7031.5 Business and Professions Code: Any City or County which requires a permit to construct, alter, improve, demolish or repair any structure, prior to Its
issuance, also requires the applicant for such permit to. tile a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
[Chapter 9, commending with Section 7000 of Division 3 of the Business and Professions Code) or that he Is exempt therefrom, and the basis for the alleged
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars 1$5001).
Name Address City State/Zip Telephone I
State License S License Class .
Designer Name Address City State/Zip Telephone
State License S
6 WORKERS COMPENSATION - T
Workers' Compensation Declaration: I hereby affirm under penalty of perjury one of the following declarations:
J. I have and will maintain a certificate of consent to self-Insure for workers' compensation as provided by Section 3700 of the Labor Code, for the performance
of the work for which this permit is issued.
I have and will maintain workers' compensation, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit Is
issued. My worker's compensation insurance carrier end policy number are:
Insurance Company (,4j 'q ,i,',- _4_)cL,','f1'~ Policy No. 513 cDo cL 3c- Expiration Data 91.7
(THIS SECTION NEED NOT BE CI5M'LETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS ($1001 OR LESS)
CERTIFICATE OF EXEMPTION: I certify that in the performance of the work for which this permit is issued, I shall not employ any person In any manner so as
to become subject to the Workers' Compensation Laws of California.
WARNING: Failure to a a workers' comgenastlon coverage I. unlawful, and shall subject an employer to atminal penalties and civil fines up to one hundred
thousand dollars 1$ 100 0) to jhe cost of compensation, damages as provided for In Section 3706 of the Labor code, interest and attorney'. fees.
IGNATURE
7 . OWNERBUILDERDECLA A. RATI . •:.. 7I77
I hereby affirm that I em exempt f the Contractor's License Law for the following reason:
I, as owner of the property or my employees with wages as their sole compensation, will do the work and the structure Is not Intended or offered for sale
(Sec. 7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or through his awn employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner-builder will have the burden of proving that he did not build or Improve for the purpose of sale).
I, as owner of the property, em exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and contracts for such projects with contractor(s) licensed pursuant to the Contractor's License Law).
I em exempt under Section Business and Professions Code for this reason:
I personally plan to provide the major labor and materials for construction of the proposed property Improvement. 0 YES ONO
I (have / have not) signed an application for a building permit for the proposed work.
3; I have contracted with the following person (firm) to provide the proposed construction (include name I address / phone number / contractors license number):
I plan.to provide portions of the work, but I have hired the following person to coordinate, supervise and provide the major work (Include name / address / phone number / contractors license number):
I will provide some of the work, but I have contracted (hired) the following persona to provide the work Indicated (Include name / address / phone number I type of work):
PROPERTY OWNER SIGNATURE - DATE
COMPLETE THIS SECTION FOR NON-RESfDENTML BUIlDING PERMITS ONLf'"
Is the applicant or future building occupant required to submit a business plan, acutely hazardous materials registration form or risk management and prevention
program under Sections 25505, 25533 or 25534 of the Presley-Tanner Hazardous Substance Account Act? 0 YES 0 NO
Is the applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district? 0 YES 0 NO
Is the facility to be constructed within 1,000 feet of the outer boundary of a school site? 0 YES 0 NO
IF ANY OF THE ANSWERS ARE YES. A FINAL CERTIFICATE OF OCCUPANCY MAY- NOT BE ISSUED UNLESS THE APPLICANT HAS MET OR IS MEETING THE REQUIREMENTS OF THE OFFICE OF EMERGENCY SERVICES AND THE AIR POLLUTION CONTROL DISTRICT.
-
[8 CONSTRUCTION LENDING AGEI1IICY - -
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 30970) Civil Code)..
-
LENDER'S NAME LENDER'S ADDRESS .
[9. "'APPLICANT CERTIFICATION ........
- :...............
I certify that I have read the application and state that the above information Is correct and that the information on the plans Is accurate. I agree to comply with all
City ordinances and State laws relating to building construction. I hereby authorize representatives of the Clip of Carlsbad to enter upon the above mentioned
property for inspection purposes. I ALSO AGREE TO SAVE, INDEMNIFY AND KEEP HARMLESS THE CITY OF CARLSBAD AGAINST ALL LIABILITIES.
JUDGMENTS, COSTS AND EXPENSES WHICH MAY IN ANY WAY ACCRUE AGAINST SAID CITY IN CONSEQUENCE OF THE GRANTING OF THIS PERMIT.
OSHA: An OSHA permit is required for excavations over 5'0 deep and demolition or construction of structures over 3 stories in height.
EXPIRATION: Every permit issued by the Building Official under the provisions of this Code shall expire by limitation and become null and void if the building or
work authorized by such permit is not commenced v4hin 365 days from the date of such permit or If the building or work authorized by such permit is suspended
or abandoned at any time after the work is com7Ød f a pri f 18 days (Section 106.4.4 Uniform Building Code).
ALICANT1S URE i .
.
3
WHIT File YELLOW: Applicant PINK: Finance
ON of Carlsbad
MISCELLANEOUS Permit No: CB951888
Job Address: 2051 PALOMAR AIRPORT RD Status: EXPIRED
Permit Type: MISC Applied: 12/26/1995
Parcel No: 2130503900 Lot #: Approved:
Reference No: Issued:
PC #: Inspect Area:
Project Title: INSTALL MAGLOCKS
Applicant: Owner:,
FALCON, AL HUGHES AIRCRAFT CO
2051 PALOMAR AIRPORT RD
CARLSBAD,CA.
619 931-3539 :
Fees: $0.00 J Additional Fees: $0.00 Total Fees: / $0.00 Balance: $0.00
-J
PERIvUT APPLICATION
City of CarLsbad Building ,Department
2075 Las PaLmes Dr., CarLsbad, CA92009 (619) 438-1161 .- 4
PERMJT1YPE
From List I (see back) give code of Permit-Type: 4 - -:
---------------------------------------------------------
For Residential Projects Only: From List 2 (see back) give
PLAN CHECK NO. 6 18
EST. VAL
PLAN CK DEPOSIT -
IVAI In. BY .- -
CodeofScwre-Te:
Net Loss/Gain of Dwelling Units
PROJECT INFORMATION FOR OFFICE USE ONLY
Address2051 Palomar Airport Rd. Building or Suite No. *
Nearest Cross Street Yarrow .& Camino Vida Roblé- l
- LEGAL DESCRIPTION - Lot No. Subdivision Name/Number Unit No. Phase No.
- 'Parcel A of Ma5 No.' 9959 'CoiTmty RcorderFiie 8O-13966O CHECK BELOW IFSUBMITfED:
02 Energy Calcs 02 Structural Calcs 02 Soils Report .01 Addressed Envelope ,
'ASSESSOR'S PARCEL EXISTING USE - PROPOSED USE DESCRIPTION OF WORK One Wing Basement +2 Stories- - B-2 Occupancy
SQ. FT. 1951000 ' # OF STORIES . # OF BEDROOMS # OF BATHROOMS A. (uN IASJI 1'LKiN (it different from apolicant)
NAME (last name first) Falcon, Al - ADDRESS 2051 Palomar Airport Rd. - -,
CITY Carlsbad STATE CA ZIPCODE92009 DAY TELEPHONE .. (619) 931-3539 . 4. APPLICANT LI CONTHACIUR U AGENT FOR CONIHACIOR U OWNER U AGENT FOR OWNER -- -
NAME (last name first) ADDRESS .' , . A. . .- -. . -
SDA SECURITY SYSTEMS INC. 2054 STATE ST. SAN DIEGO, CA "92101- 619-2393473 CI1Y ,. ..' . STATI . •, ' ZIP CODE - DA't TELEPHONE • -
NAME (last name first) Palomar Products, Inc. -
ADDRESS 2051.. Palomar Airport Rd..
CITY Carlsbad . STATE CA 'ZIP CODE 92009 . DAY TELEPHONE (619) 931-3539
NAME (last name first)
- . . . ADDRESS . . . . .. -
CITY STATE 1 ZIP CODE. . DAY TELEPHONE
STATE LIC. # 2 4566 8 LICENSE CLASS C —7 & C(;10 CITY BUSINESS LIC. # 2 41500
DESIGNER NAME (last name first) - --- ADDRESS-
CITY . STATE ZIP CODE DAY TELEPHONE - STATE LIC. # WORKERS WMPENSATION
Workers' Compensation Declaration: I hereby affirm that I have a certificate of consent to self-insure issued by the Director of Industrial
Relations, or a certificate of Workers' Compensation Insurance by an admitted insurer, or an exact copy or duplicate thereof certified
by the Director of the insurer thereof filed with the Building Inspection Department (Section 3800, Lab. Q.
INSURANCE COMPANY REPUPLIC INDEMNITYPOLICYNO. 3505024 EXPIRATION DATE. 1/1/96,
- Certificate of Exemption: I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner
so as to becom su ecttot or rs' mpensation Lws of Califo
/ SIGN /
, . .
Owner-Builder Ueclarationl hereby atlirm.that I am exempt from the Contractor's License Law for the following reason:
I, as owner of the property or my employees with wages as their sole compensation, will do the work and the structure is not intended or
offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds
or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended • - or offered for sale. If, however,'the building or improvement is sold within one yea? of completion, the owner-builder will have the burden
of proving that he did not build or improve for the purpose of sale.). - '''•• . .
I, as owner of the property, am exclusively contracting 'ith licensed contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon;and contracts for such projects
with contractor(s) licensed pursuant to the Contractor's License Law).
I am exempt under Section Business and Professions Code for this reason: -
- (Sec. 7031.5 Business and Professions Code: Any City or County which requires a permit to construct, alter, improve, demolish, or repair
any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the
provisions of the Contractor's License Law (Chapter 9, commencing with Section 7000 of Division 3 of the Business and Professions Code)
or that he is exempt therefrom, and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars [$5001). f SIGNATURE - -. . - ' DATE
COMPLETE THIS SECTION FOR NON-RESIDENTIAL BUILDING PERMITS ONLY: . .
Is the applicant or future building occupant required to submit tusiness plan, acutely hazardous materials registration form or' risk management and prevention program under Sections 25505, 25533 or 25534 of the Presley-Tanner Hazardous Substance Account Act? - -. . DYES - NO -. . . .• - . - ..
Is the applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district? . DYES NO
Is the facility to be constructed within 1,000 feet of the outer boundary of a school site?
DYES NO
IF ANY OF THE ANSWERS ARE YES A FINAL CERTIFICATE OF CXUPANCY MAY NOT BE ISSUED AFfER JULY 1, 1989 UNLESS THE APPLICANT
HAS MET OR IS MEETING THE REQUIREMENTS OF THE OFFICE OF EMERGENCY SERVICES AND THE AIR POLLUTION CONTROL DISTRICT.
9. WNS717IUCI1ON LENDING AGENCY
-, I hereby affirm that there, is a construction lending agency for the rtormance of the work for which this permit is issued (Sec 3097(i) Civil Code).
LEbER'S NAME - LE- NDER'ADDRES - -. - - - -10. AI'PUCANI, WI.ICA liON . - . - - - -
I certify that I have read the application and state that the above information is correct. I agree to comply with all City ordinances and State laws relating to building construction. I hereby authorize representatives of the City of Carlsbad toenter upon the above mentioned property for inspection
purposes. I ALSO AGREE TO SAVE INDEMNIFY AND KEEP HARMLESS THE CITY OF CARLSBAD AGAINST ALL LIABILITIES, JUDGMENTS, (lISTS
AND EXPENSES WHICH MAY IN ANY WAY ACCRUE AGAINST SAID CITY IN CX)NSEQUENCE OF THE GRANTING OF THIS PERMIT.--
OSHA. An OSHA permit is required for excavations over 50 deep and demolition or construction of structures over 3 stones in height
Expiration. Every permit issued by the Building Official under the provisions of this Code shall expire by limitation and become null and void if the
- building or work authorized by such permit isot commenced within 365 4ays from the date of such permit or if the building or work authorized by,
such permit is suspended or abandon at ar)9time after ~7;V a dod of 180 days (Section 303(d) Uniform Building e)
-
APPLICANTS SIGNATURE
- - - - - ,
-
'i-, DATE:
-