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1989-739 CERTIFICATE +C)F CCCCUI'�il'�T�C'�" i TOWN OF QUEENSSURY WARREN COUNTY, NEW YORK 1 s li Date November 27 19 �?� This is to certify that work requested to be done as shown by Permit No. R '� - 7 Q _ 1 :I I has been oovmPleted* i This structure may keoc pd as a Single Ea m i ly n We l 7 i n g Location I Owner Forest Wood Homes i By Order Town Board. TOWrN OF QUEEN SSURY i Director of Bldg. & Code Enforcement li 1 — I BUILDING PERMIT TOWN OF QUEENSBURY No. 99_7aci WARREN COUNTY, NEW YORK - w PERMISSION is hereby granted to Eorest Wood HOMeS OWNER of property located at 1 nt AA A42 n p R Hi drinn Hi ! 7 c 1]ri vn Street, Road or Ave. in the Town of Oueensbury, To Construct or place a Ci gni ca fami l v RWel 1 i ng at the above location in accordance to application together with plot plans and other information hereto filed and approved and in compliance with the Town of Queensbury Building and Zoning Ordinance. T t. OWNER'S Address is HC-02 Box 286P r^ Warrensburg . N . . Y . 12885 -4 2- CONTRACTOR or BUILDER'S Name d Self s 3. CONTRACTOR or BUILDER'S Address Same 4. ARCHITECT'S Name r' Cs co O`• n 5. ARCHITECT'S Address C z tv S_ TYPE of Construction — (Please indicate by X) rb J(A Wood Frame I ) Masonry i ) Steel 1 1 r zi 0 0 7_ PLANS and Specifications No. 32 ' x 46 ' Single family dwelling as per plot plans specifications , and applicationsincluding septicsattached two B. Proposed Use _ C Single family Dwelling i $ 143 . 00 PERMIT FEE PAID — THIS PERMIT EXPIRES Apr 7 019 90 (lt a longer period is required an application for an extension must be made to the Building and Zoning inspector of the town of Queensbury before the expiration date.) Dated at the Town of Queensbury t 19th Da of7 SDetember ig 83 a a SIGNED BY for the Town of Queensbury _ Building and Zoning Inspector `� t: n u: TOWN OF QUEE2ISBURY REVIEWED BY QL4kt C)F 4►FEE PAID $ 3 �~ REC156t(rfiY PERMIT MO. 'fir-' _ '`, ' + sk-P 798.9 BUILDING PERMIT APPLICATION eI pG C©p�C bpi A PERMIT MUST BE OBTAINED BEFORE BEGINNING CONSTRUCTION. NO INSPECTIONS WILL BE MADE UNTIL APPLICANT HAS RECEIVED A VALID BUILDING PERMIT. All applicants spaces on this application MUST be completed and the signature of the applicant MUST appear on the reverse side of this application. The owner of this property is: + ; • r : P.O. Address F l41f f ' ` ` Property Location ?; L� --! C is 1, Tax Map No. rc5 / Has there. been any split of this property since October 1 , 1988 ? / If yes Planning; Board Review is necessary. yes no SUBDIVISION NAME, IF APPLICABLE ,' ��� ,' LOT NO. THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS TO BUILDING CODES IS: NATURE OF PROPOSED WORK : * E'sr:MATED MARKET VALUE OF ✓ Construction of a new building * CONSTRUCTION * $ Addition to a building ' COMPLETE INFORMATION REQUIRED BELOW: *. / t c S . Size of property r €t x ft. Alteration to a building * Existing Buildings() ) Size ft. x ft. (no change to exterior dimensions) �. Proposed building - distance from property line: Other work (Describe) * Front yard ft. Rear yard r fte * Side yards :, fto and ft. GROSS AREA OF PROPOSED STRUCTURE If on corner, setback from side street J- ft. 1st Floor sq. ft. / 00c W OCCUPANCY INFORMATION 2nd Floor__ ' sqw ft. * - Primary Building - Other Floors sq. ft. * One Family Dwelling (not cellar or ment) 'I' 3 ,► Two Family Dwelling TOTAL FLOOR AREA ] � l" sq, ft.. Multiple Dwelling/Number of units � Size of new structure aft x 'I, , ft, . * Business Foundation-pier/slab/crawl/partial/iuli * Industrial (circle one) " Other * No* of stories (habitable space) Height (,grade to ridge) fte ,. If addition, what will use be? If residential, no, of families r No. of rooms(excluding baths) • Accessory Building No. of bedrooms " Detached Garage ONE/TWO Car No. of bathrooms Primary heating system + ' A ,ttached Garage ONE � car_ .. . Type of fuel * Private storage building No. of fireplaces to be installed * Other W iU a wood stove be installed " Central Air conditioning # OV* ER BUILDING PERMIT APPLICATION CONTINUED - BUILDING SPECIFICATIONS: Type of construction, wood frame, fire safe, etc. Will any second-hand or upgraded lumber be used? If so, for what ? Foundation wall material Thickness Depth of foundation below grade (to bottom of footing) Will there be a cellar? Heated or unheated ? Floor sq, footage sq ft . Will there be a basement ? Will any portion be used as living space? (If so, what portion? sq ft. Type of use? Type of roof - sloped/fiat Ished/other Material of roof Size, wood studs ""x spacing." o. c. length ft. Joists (floor beams) 1st floor 'rx " spacing "o. c. span _ft" Joist (floor beams) 2nd floor 'rx " spacing "o. c. span `t f#. Overlays (ceiling beams) "x '" spacing." o. c. span ft, Roof rafters '"x " spacing o. c. span ft. Roof trusses (pre-engineered) spacing." o.c. span '; ft . Exterior wall finish i _ of what material ? Interior wall finish f If a garage is to be attached, describe materials to be used for FIRE SEPARATION: Is there to be an opening between garage and dwelling? If so will a Fire-rated door, enclosure, self-closing device be provided? Will a flue-lined chimney be installed? Height above roof ft. Depth of chimney foundation below grade ft. Depth of fireplace hearth ft. in. Water supply - '.Municipal or% private well SEPTIC SYSTEM Distance from ANY private well (including adjoining properties ft . (A separation application is necessary for any repair or new installation of septic system ) NAME OF BUILDER_+ %ADDRESS j,,. ..'-. CI t' TEL. N . NAME OF PLUMBER ; , -1 t ADDRESS TEL, NO. NAME OF MASON ; ADDRESS TEL. NO. NAME OF ELECTRICIAN ADDRESS TEL. NO. DECLARATION To the best of my knowledge and 'belief the statements contained in this application, together with the plans and specifications submitted, are a true and complete statement of ail proposed work to be done on the described premises and that all provisions of the BUILDING CODE, THE ZONING ORDINANCE, and all other laws pertaining to the proposed work shall be complied with, whether specified or not, and that such work is authorized by the owner. Signature Owner, owner's agent, architect, contractor SPECIAL CONDITIONS OF THE PERMIT: BY TOWN OF QUEENSBURY WARREN COUNTY , NEW YORK Application for : BUILDING PERMIT IN COMPLIANCE WITH THE NEW YORK STATE ENERGY CONSERVATION CODE A permit must be obtained before beginning work . ANSWER ALL of the following : 1 , Gross Floor area 2 . Type of heat 31 Is the building mechanically cooled ? 4 . Percentage of area of windows and doors # A . Over 16 % Only 19 Uo value of gross area of walls , roof / ceiling aqA floors exposed to ambient conditions 2 , Floor over heated spaces NO a . Are foundation walls sulated ? YES O 1 . If 'YES , what the R value ? 3 . slab on grade S NO a , if YES , at is the R val of insulation and Perim r of floor ? 4 , Is b ement treated ? ES NO a R value of in ation Type of insulation B , Under 16 % Only 1 . R value of roof and floors exposed to ambient conditions. 2 , R value of exterior walls 3 , R value of glazed area 7 4 , R value of doors 5 . R value of floors over unheated spaces 6 . R value of slab edge insulation - unheated slab 7 , R value of slab insulation - heated slab S . R value of heated basement/ cellar walls ( above grade ) 9 . R value of heated basement / cellar walls { below grade ) 10 , Type of insulation c , Controls 1 . Thermostat maximum heat setting D , Duct Systems i . Is duct system installed in unheated spaces ? YES NO a . If YES . R value of duct installation b . R value of duct in other areas E , Piping Insulation 10 Size of hot water or cooling carrying agent pipe 20 R value of pipe insulation F , service Water Heating 1 . Performance efficiency 2 . Temperature control setting maximum G , For Swimming Pool Only 1 . Maximum heating Telephone No . ( applicant ' s signature ) OWN OF QUEENSBURY APPLICATION FOR � 1 v SEPTIC DISPOSAL PERMIT DATE LOCATION OF PROPERTY FOR INSTALLATION ;• . 0,4 . ; r ' t i y 3c- Owner's Name: :- Telephone: Address: Installer's Name: 6PA : ;: #'7 r - r Cl Telephone: ] 1 y Number of bedrooms (residential only) - ' Total daily flow (compute (d 150 gal per bedroom ) Topography: Circle one: i Flat ,>Rolling Steep Slope % of Slope Soil Nature: Circle one: S nd. - Loam Clay Other /Depth: Feet Ground Water: At what depth? Feet � ., Bedrock or Impervious Material: At what depth? Feet Percolation test: Circle one: not require -required rate min. inch. Domestic water supply: circle one: Munici Well Other If domestic water supply is a we6v Separation: Water supply from septic absorption feet PROPOSED SYSTEM : Septic Tank . 0 gal. ( minimum size: 1 .000 gal.) TILE FIELD: Each Trench feet/Total system length feet SEEPAGE PIT{S}: Number of m / Size each ? feet by _ feet Size of stone to be used # "3L./Depth or Thickness feet I have read the regulation on the reverse side of this sheet and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance. } SIGNATURE OF RESPONSIBLE PERSON: ' DATE: I 1 OVER Septic System Inspections : A . All applications for septic system installation , alteration or repair , as required by the Town of Queensbury Sanitary Sewage Ordinance , shall be submitted to the Building Department at least 24 hours before start Of construction and shall include a plot plan showing : l . ) the proposed location of the system 2 . ) location and distance to lot lines 3 , ) location and distance to structures 4 . ) location and distance to any water supply 5 . ) size and dimensions of all tanks , distribution boxes , mile fields and /or drywalls B . No system shall be covered before inspection and approval by the Luilding Inspector . Failure to comply with this requirement may r* sult in the uncoverinb of the system by the installer and a fine of up to $ 250 . 00 . C . An approved copy of the plot plan shall be available on the construction site , Failure to produce said plot plan at time of inspection may rusult in an immediate work stoppage , D . Should unforeseen problems during construction prevent proper installa— tion , alteration or repair of an approved system , a new ,proposal must be submitted to the Queensbury Building Department before further construction , Town of Queensbury BUILDTNC and CODES DEPARTMENT Bay and Haviland Roads Queensbury , New York 12804 k4Ina r ka i TOWN OF Q'UEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS QUEENSBURYr NEW PORK 2280& TELEPHONE (518) 792-5832 BUILDING INSPECTOR' S REPORT REQUEST FOR INSPECTION/ RECEIVED �,/ NAME LOCATION J" cr ,ryr DATE Ze� a:/ PERMIT # APPROVED YES NO FOOTING/PIERS �+ MONOLITHIC POUR FORMS FOUNDATIONfDAMP-PROOFING BACKFILL APPROVAL- ROUGH PLUMBING FRAMING ELECTRICAL ROUGH-I INSULATION: FOUNDATION FLOORS WALLS ILING 94� NAL INSPECTION: _ CHIMNEY HEIGHT l L ell I r ROOFING SIDING EXTERNAL PORCHE (STEPS �r STAIRS-CLEARAN & RAILS_ — PLUMBING FIX ES/RELIEF EVE INTERIOR TRI PRIVACY DOO FINISHED F RS GARAGE FIRE OOFING DOOR CLOSE S) _.., SMOKL� DE T TORS 1 -- FINAL ELECTR CAL INSPECTION FINAL APPRO L OF CONSTRUCTION i A SIGNED CE IFICATE OF OCCUPANCY' MUST BE OBTAINED PR THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED!' REMARKS: � �} jt I NSIPECTOR MIDDLE DE'PARTM N1r INBIRMCTION AGENCY, INC. ow T 2 -T INSPE^ oate, November 21 , 1989 Ce rrlf 1p$ that le i uiprnent listed has been exa"Oha&q approved as being in accord with the National Elect e e pplicabte governmental, utility acid Ag§Vi .; S. Owner: Forest Wood s„ P ing Occupant: Single Farm , 1 1 1i.� L4G.3t1[}fi: Lot 66 Cor p} ea& �Ti n lam' cal WAR, * laarQC uiPmarH aed irlatallspon is petted tnla L 1 daze- If additional e4�ni;�h da iMrf]{IUC+BC Or eliBr app made to 4l \ existing sv Stem ttiili Ica" be null end void, and application tOr ,Equipment: 115 Outlet 500 ecAPp tacle s ; 35 Fixtures ' e�ins�ection eho Wtl be submitted p thy to this Aygncy. u, P� $ �' ! B48d r 01 it)is ca�'t, itiCate lhould nt 'Jame to hla prdpeny in;UMMCe carrier 200 Am $ery , 6 Appliance . agen, or comoyny�aaevi4fpnc ertiticallonotelectricalequipmentappraued 'y as specified_,r Herd es Elect �``' � ~---• -- r APpl�cant: 'Tent'tt Avenue _ tJ . 15 -03C7463 � � � Hudson Falls , NY 1 renw Fla. 7W El. t aL.t gown a/ Queen31ury BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R . D. i Sox 98 Queensbury, New 'York 12801 SEPTCIICC DISPOSAL SYSTEM INSPECTION111, / NME _ N '? r i / LOCATION DATE ! PERMIT NO . Sollo TYPE San - Loam - Clad* - Percolation Test � Requ1red7 YES Percolation rate `- Min/Inch j TYPE of SYSTEM : Absorption field , t taall Lerlfgth Length of eac 'Depth enches S of ~;ravel SEEPAGE i} ITS-(Number of) Size- '00 . X ft. Gravel size VE PIPING : Size ,T Type Bldgo to tank Tank to clisto box Disto boa to field/pit 4 +� Openings sealed? ;tI NII Partial LOCATION/SEPARATIONS : Foundation to tank CpUkX ��- t' 41 ,..D f Foundation to absc rPt,>�i.onS 17� Absorption to lot li}ke Separation of pits f t LOCATION OF SYSTEM bN PROPERTY (ci cle one) Front - �" - Lef side - Right de - L COMMENTS : ti + GAoLA C& tt { i L O�v 9. 1� �Crc�.f L� 4. pk: 0IL SYSTEM USE APPROVED ES NO Bui ,ding Inspec or 01/86 and vl TOWN OF i.QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVILAArD ROADS QUEENSBURY, NEW YORK I280& TELEPHONE (518) 792-5932 BUILDING INSPECTOR ' S REPORT REQUEST FOR XNSPECTION REC XVED NAME LoCCATXON DATE PERM.TT it APPROVED Y S NO FQOTXNGIPXERS MONOLXTHXC POUR FORMS FOUNDATIQNf DAMP—PROOFXNG B1CKF2T L APPROVAL QUGH PLUMBING FRAMXNG ELECTRICAL ROUGH-XW t2'NSULATXON: l\ FOUNDATION FLOORS WALLS CEXLXNG FINAL INSPECTXON - CHXMNEY HEXGHT ROOFING SXDXNG EXTERNAL PORCHES/STE S STAXRS—CLEARANCE & TLS PLUMBING FIXTURES/R LIEF VA VE INTERXOR TRXM/PRIV CY DOORS FTNXSHED FLOORS GARAGE FIREPROOFX G DOOR CLOSERS) — SMOKE DETECTORS FXNAL ELA NSPECTION FXNAL APCONSTRUCTION A ,STONEDTE OF OCCUPANCY MUST BE OBTAINEDBUILDING DEPARTMENTBEFORE THESE PROCCUPIED! REMARKS: XNSPECTOR TOWN OF QUEENSBIIRY BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS QUEENSBURY0 NEW YORK 1280& TELEPHONE (518) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR INSPECTIONS RECEIVED _ NAME l� tooyyGyGf � LOCATION DATEPERMIT # (✓� ,n, - APPROVED — YES NO FOOTING/PIERS MONOLITHIC POUR FORMS F0UNDATXNY1DAMP-PROOFSNG BAYCKFIL .e'L RPROVAL L r H PLUMBING < ING ELECTRICAL ROUGH-IN INSULATION: FOUNDATION FLOORS J WALLS CEILING FINAL INSPECTION: < CHIMNEY HEIGHT ROOFING .SIDING EXTERNAL PORCHESf EPS. STAIRS-CLEARANCE A RAILS PLUMBING FIXTUR /RELIEF, VALVE INTERIOR TRIMI IVACY DOORS FINISHED FLOG GARAGE FIRE FIND DOOR CLOSER (( ) SMOKE DETEC ORS FINAL', ELECTR AL INSPECTION FINAL APPROV L OF CONSTRUCTION A SXGNED CE TIFICATE OF OCCUPANCY MUST BE OBTAINED F M THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED! REMARKS: 1 £N.9PECTOR y T' TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT .SAY & HAVILAND ROADS QUEENSBURY, NEW YORK 1280k TELEPHONE (5I8) 792-58.32 BUILDING INSPECTOR' S REPORT REQUEST FOR INSPECTION RECEIVED NAME / LOCATION ry e DATE PERMIT #_ 3l f APPROVED YES NO OOTING,lP.I`ERs MONOLITmTc POUR FORMS FOUNDA'T"I DAMP-PROOFING BACKFILL A PROVAL ROUGH PLUMBY#G FRAMING ELECTRICAL R H-IN INSULATION: FOUNDATION r FLOORS WALLS CEILING FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SIDING EXTERNAL. PORCH S/.STEPS STAIRS-CT EARA CE & RAILS PLUMBING FIX 14Es/RELIEF V ..VE INTERIOR TRI /PRIVACY Z7C7ORS FI NI.S!!ED F RS GARAGE FIRE ROOFING DOOR CLOSE (S) SMOKE DET TORS FINAL ELECTRICAL INSPECTION _ FINAL APPROVAL OF CONSTRUCTION A SIGNED CERTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED! REMARKS: r � 4 TNSPEfTOR bWN OF QUEENSBURY JILDING AND CODES DEPARTMENT �Y & HAVTLAND ROADS C}C9 lEENSBURYr NEW YORK 12801. LEPHONE (518) 792-5832 BUILDING INSPECTOR ' S REPORT EQUEST FOR rNSPECTION RECErVED__ :NAME 'LOCAT ION d --A` DATE 'C PERMIT # `� APPROVED -- YES NO FOOTrNG/PT S C j MONOLITHr UR FORMS r' OUNi7AT Z"ON/D P-PROOFING 706 �CKFILL APP AL ROUGH PLUMBING FRAM.ZNG E'LECTRrCAL ROUGHr INSULATXON: FOUNDATION FZX)ORS WALLS CEILING FINAL INSPECTIO CHIMNEY HEIG ROOFING SrDTNG EXTERNAL RCHES/STEPS _. AIRS-C ARANCE 1S RAILS PLi XNG FIXTURES/RELIEF LVE rNTERTD TRIM/PRIVACY DOORS FTNTSH FLOORS GARAG FIREPROOFING DOOR LOSERS) SMOK DETECTORS FrNAL LECTRICAL INSPECTXON FTNAL APPROVAL OF CONSTRUCTION A STONED CERTIFICATE OF OCCUPANCY MUST BE OBTAXNED FROM THE BUILDING DEPARTMENT .BEFORE THESE PREMISES ARE OCCUPXED! REMARKS: fj fiLoo &Y 41 TNSPE4CTOR TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT J ieol z 3 BAY & fiAVXLAND ROADS QUEENSB'URY, NEW YORK I28OgZ. TELEPHONE (518) 792-5832 BUILDING INSPECTOR ' S REPORT RWUEST FOR INSPECTION RECEIVED NAME — `" a- [ )111 ZOCAT'XON Ire.=*[ c to JQ 11► s t _` DATE PERMIT # ' C/ ^ 73 APPROVED Y S ko► FOOTXNG/PXER5 NO M04N0LXTffIC POUR FORMS FOUNDATION/ p pROOFZNG .BACKFXLL APP VAL ROUGH PLUMBX FRAMING ELECTRICAL ROU #�1^XN INSULATION. FOUNDATrom 1 FLOORS WALLS , ' CEILING FINAL INSPECTION. CHXNN,XY HEIGHT ROOFING SIDING RXTERNAL PORCHE /STEPS STAIRS—CLEARAN E & RAILS PLUMBING FXX RES/RELIEF LVg INTERIOR TRI /PRIVACY DOORS FINISHED F RMr. GARAGE FXRE ROOFING DOOR CLO E (S) SMOKE DE T TORS FINAL ELEC ICAL INSPECTION FINAL APPR AL OF CONSTRUCTION A SIGNED CERTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED! REMARKS: XNSPECTO,R NMMWAW y•� .. .Natronol 'Headquarters � �' .'{ llFrigswood .l: as IDS . . t Bate' City. Town or T6wnship allCountyr Iri!' rs State Liocation/Address = (If Located in Rur Area - Please Arta erections) Pole #Owner1111 _ Id Occupied AS ParMnit �h , Occupant r {. f ';,; ;' Bulliding: IVevii {]rdQ is ' A"a in BuildingFlq$►r :*, etc.}; ` far: Whin Serwce or: Readyfor. lns ectlan: Fee Rerxiitted � Cash Check • ; +. :a , �F b: , IrI]aka Pa able .•her M-L]i..I:+A. . . Number of Rough WrrIng Outlets Elect. .H eat " ?so sgea mq s xvea o zseo ssaa wS x Switches t Lights Amp. .$erylt�e .t . '` Swrifsos Unit Dishwillsbor, " flanr h Recap leg Water Heater ter :Air Conditioner ---�bryer c. . PurH ml r lei 43verxGiairbage Dispersal . W!w ri Ind .Controls for �: li�l.;fiecepl�tacles � ' Other =^--Fractional H:� t' Fans Equipment^ n Mtrk Nu ber 1 JE E/le 1/e IJ�. E/4 Ef3 EPEE 3/4 I ' 2% .L 3 9, 7�Is 10. E5 2Q ' as .i0 O rk Number F e fir, p . o ach Sire :.x i Applicant's. ._ Signature * . T1A ,: 1 lthae 4 #OL fllly: Irt. ##oant`s dress:: r Ptwne # t(Stg1 L, x _,' rvice .Request # �"r +� ' f,• 'f " BFkECEIVED. s ;"p�` bATEIhISPFAf s ' a: .e . Correct Location : Same as AboveQ or: c .. LLL Red Notice Label s# . . : Rough Wiring Outlets Surface Unit riven G]Swit es R F." S ..}Nafer H IXt1E ` teaar�ari- ° - - , .' •s. �. Arrlp. .Senreoe Equipment Burr`er: n9 '�eGorltra#i< for + i > Amp', Service ndubtors ►. Pump Vent Pans : '... MOTORS i'f,P, 1/L4. I/i0 I/8 I/5 3/4 E/ -E $/ - • .e '- .7+h 30 35 80 29 p+. ; Mark Number of Each Size �� / Elect. Heat ana Asa x000 Iss6 150o xasa soap zsso s ae epos f�,; Q RW Progress: Inc. ZOO' i lCC1 Q Contractat �•- ' Q CFT Vidlation : Work. Comp. Q Ind,, Q Q L/A ^ '-owner CASH L/A CHIC# Q IPA . , Muni l IfA�D Da}t6 Gut err cdrd Q '1 emp -. -: ate' .J_ •f 1 ,. �, 1 wC �.F; .y: "s,.p f .1 Date i Y K :_ +Ri*PLICATIt}iVFOR1N IVK7. 250. > +kre9 eat 37 ZL V vy