17A-001 220 SPRING GROVE AVE BP-2017-0649
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man:Block: 17A-001 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2017-0649
Project# JS-2017-001060
Est.Cost: $18000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VISTA HOME IMPROVEMENT 110285
Lot Size(sa. ft.): 13503.60 Owner: FRITZ NICOLE
Zoninr: R1(1001/URA(100)/WSP(100)/ Applicant: VISTA HOME IMPROVEMENT
AT: 220 SPRING GROVE AVE
Applicant Address: Phone: Insurance:
2003 RIVERDALE ST (413) 382-0249 WC
WEST SPRINGFIELDMA01089 ISSUED ON:II/8/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House/I Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: O1: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeTvpe: Date Paid: Amount:
Building 11/8/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
\ Department use only
City of Northampton Status of Permit:
\
Building Department Curb Cut/Driveway Permit
�.� 212 Main Street Sewer/Septic Availability
Room 100 Water/Well/7 Cbs
Availab%ity
Northampton, MA 01060 Two Sets of Structural Plans
one 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
TION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION -SITE INFORMATION
1.1 Property Address' This section to be completed by office
2 20 (32‘nrQ Qra �-tf� Map Lot Unit
c t oy e- C9- 1 N Pc IO \O CQ Z Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
NZv
(Print)
i NZ •4c)- 1. • •
Name(Print) ^ oMI ' ` egHt-I`—I
��s '"U�,Y w lephone
Signature
2.2 Aut orized A nt:
9Lvyv_, 21M3ivexdC1Xe-1,- WAQS nr �Sd
Name( ) Current Mailing Address k)Pr 0 t(. s"9
ior1 ` (4Q — ( O> Who— I4 el 2N lephonene
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1, Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection 1 .-� f
6. Total=(1 +2+3+4+5) 1 51000 Check Number 4/J ,m
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: a 44 A Lt's
Builds g Corn esioner/Inspector of Buildings
Nov 8
i
Derr or^wino-^= ca-!Ois
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) `�
New House n Addition 1E1l Replacement Windows Alteration(s) l Roofing y1
Or Doors D ,W 1`
Accessory Bldg. ❑ Demolition ❑ New Signs (C] Decks [q Siding[C] Other[CO
Brief
Work' P,.c<YQ\14e- lCl clh\cJ\4R `- eiu-t€ -c �1\CxCP . kA) YU-w '
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ga.If New house and or addition to existing housing, complete the following:
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
It Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply _
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
V
I, ILl OU \‘r\T? ,as Owner of the subject
property
hereby authorize \w \Q \ 1�1\Iv ej\ &1f U.._
to act on my behalf, in all matters relative to work authorized by this wilding permit application.
QQ - aK\ e - --
SignatureofOwner \ ,^ �(J \(n Date
\d'l_�V ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
ilk .��
1
Sign,ture•--• erlAgent / Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:: \ n_�/�\ Not Applicable ❑
Name of License Holder: 1 't'C � '1 ) V 1 V (Th..� l I 0 1
License Number /�
_2033 ki- a �� k ) t ;ad eActeiExpirationDai�Onab
Line %to- 114x1
lepho
9.Registered Home Improvement Contractor: Not Applicable 0
19-2058'
Co - •any Name Registration Number
2 s-� 'PIN ala/1-2S� \,J f\tad 1 u ( z c ZOCI
Address Expirati n Date
L /'�Q"e- O' °gel Telephone,q S -
_ oz
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of thebuilding permit.
`
Signed Affidavit Attached Yes )41^\ No C
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such`homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning LawsLand
�State of Massachusetts General Laws Annotated.
Homeowner Signature Vim'o ., C^IX 1 LPV_X'-
VMafachuntts Department of Public Sand. COOStrildiOn {
Board Of Building RqulMgns and stMWard. RMrBMO�BUPMMaa
lsense'Cs-1102116 4hraabimed-BuitI�tg of any group wlucll cpmein
rwmuniconaUumion Supervisor 11 Mary/bi ed-BukWpc MMlWieudcmpMralm
O.00
KEITH Ye ocwx
2114 MODUN.IRy10
MIST IIMFOD CT MS
r1 CA_— f aortae dm: Priam npans*aat tNllo Of.*MMamauaW
Cw4,mnewnr 01+0.2020 sW�AWMC dt Num* mwMwnr.
P14Imar4Itt WarmR:VattMa4$fl X!
Cele ` oinino,uttealtA of04(asoadezlelto
: a Office of Consumer Affairs and Business Regulation
_ - ry_;
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration'. 162058
Type: LLC
Expiration 1/12/2017 Tra 282537
SAMBRICO LLC dba VISTA HOME IMPROV
BRIAN RUDD
2003 RIVERDALE ST - - - -
WEST SPRINGFIELD, MA 01089 - - - -
Update Address and return card.Mark reason for change.
SCA 0 mum Address Renewal Employment Lost Card
.-11,.1%., ,..n,,..,tf1 rr!/,.:.,.d.,..]i.
3 . Office of Consumer Affairs&Business Regetrtion License or registration valid for individul ase only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
bn:on: 162058 Type: Office of Consumer Affairs and Easiness Regulation
pUatio11121201] LLG IO Park Plaza-Suite 5170
Boston,MA 02116
SAMBRICO LLC dba VISTA HOME IMPROVEMENT ,
BRIAN RUDD j'Aili / '
2003 RIVERDALE ST .2.1---,42.6.— �/
WEST SPRINGFIELD,MA 01089 Undersecretary ' d without signature
a a ., ia_ 1.a. ia' ,A a a_ 1 a LL• i r a_* a s iw 1_ a s p is _`.A
� • • ar ae ♦ ✓ a •
STATE OF CONNECTICUT f DEPARTMENT OF CONSUMER PROTECTION e
'
*J!
Bc it known that
1 SAMBRICO LLC ;
2003 RIVERDALE ST , 1
W SPRINGFIELD,MA 01089-1060
is unified by the Department of Consumer Protection as a registered e
` HOME IMPROVEMENT CONTRACTOR tit
'e
I Registration # HIC.0621848
Ies
ikt //3
• VISTA HOME IMPROVEMENT l
a
'.aEffective: 12/01/2015
Expiration: 11/30/2016 jor . 'alkh
3/4. J Winni,on A.IlCommissiaver
08/23/2016 2:47PM FAX 4135729191 WILLIAM MIS INSURANCE ®0001/0002
CERTIFICATE OF LIABILITY INSURANCE Frit "
MINO°"' I
/23/2016
TNIB CERTIFICATE IS ISSUED AS A MATTER OF WEORMATION OW.V AND COWERS NO RENTS UPON THE CERTIFICATE HOLDER. THE
CERTIFICATE DOES LOT AFFIRMATIVELY OR e1EGATFVELV AMMER EXTEND OR ALTER THE COVERAGE AFFORDED BY RE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CORRECT BETWEEN THE ISSUING INSURER(S), AUTHO I}EO
REPRESENTATIVE OR PROWLER,AND THE CERTIFICATE HOLDER.
IMPORTANT. It Ne centaur polder Ie an ADITMON*L INSURED, me RallCypes) mat be snamee& H SUBROGATION IS WAIVED INMRcl to
Me ten,. and eondEons of Ms policy. Certs pollcles may require an endorsement A Matsmnt on Els oerflcMa dam not confer Naha to the
=Era BOER la las ufsea endo mwnf(ah
PEWEE Nwe' mi ,7 MIS
WILLIAN J MTS INSURANCE w14s E.S (413) 568 - 6111 Iya,;.4413) 572 - 91.91
156 ELM RT LAW. _
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NRSTFIEtE, ea OlOBS ImBRNY51nFroRMm CONDUCE NM II
owes s:NATTXLAS INS CD
IRSWFAB:
SAMBRICO LLC DBA
Mune t _. . .-. ..—.
VISTA HOE TENT OWNER pe_ _ .•.• _•— •• _
2003 RIVERDALE STREET INIURME:
TEST SPREMEISED !A 01069 wwv.EeFI
COVERAGES CERTWTAITE NUMBER; REVISION NOMSER:
THIS IS TO f,T,RTP1 THAT tnM POLICIES OF INSURANCE, AIBELOW HAVE BEEN ISSUED TO THE INSURED LAMED AREVE PER THE MIXT Pawl
INDICATED. WEAN!STANDING ANT RLONL DENT. TERM OR CICS AFFORDED
OE ANT CONTRACT GP OTHER DOCENT WIN RESPECT TO WCH THIS
CXCLuSJATR MAT BE Swell OR IME PERTAIN, DIE INSURANCE AFFORD C &T THE POLICIES DESCRIBE NsRFN IS &ME4T TO AU 1W TERMS.
EXCLURONP NO CONOIn0N,or SUCH It ODDER LIMITS SHOWN MAT ERB SEEN REEVED DT PND CLAIMS.
Rair
LTII mespwmawe ABY eWO ewmrlgeER I @EWfrtYYR ,tattjmyttar
:.Elim I ENT. OCCRRENCE 1,000,000
A % I m.MaewerNrxivam 63679203 108/01/201608/01/2017 PA ero¢ammm„) 100,000
__fCWtittuXE I..1 occw AMER Wyoe.RnMI 5000... .
PERSONALIACIINJURY
•— ._._—...- COMM'.AoaEaTy 2,000,000
GEIn AomEIk4tEnnort, Peal: PlSsum.coe,MAnG 1,000,000
wunr ✓CT lGc 1
MITGPmLEWYNM C '• ( .•.. GCMCNEDWNIlE DAR
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OEECIaPMNOFOPIRAD]KnmmulwV iVF'Ns®yeeeNACORO IPI,MtlNwtl RecaNv%neart.neen yma N.Msrysl
CERTIFICATE HOLDER CANCELLATION
SAemRICO LW DBA ..
VISTA HL41G $MPROV85N'l SEEN MT OF THE ABOVE OSSCWBEO POIAONT BE CMCMLED BEFORE
T12 EYPlATIDN GATE DIEIIBOe, NOTICE WILL BE OGLIVSRED IN
200'3AIVEAOALB ROAD
ACCORDANCE
WW,TLO
HH THE POS PROVIMS
ON
HEST SPRINGFIELD IEA 01089 AlMIC.teo/g .MME 4 ..
I IuP
N Eli 3P10AOORP CORPORATION. All riots reserved
ACORES SS f2010A1B) The ACORD ORM and MeV are retatered sntka 0 '-CORD
The Commonwealth of Massachusetts
Department of Industrial Accidents
-` L
-hill 6 Office of Investigations
" ==::e'=
e= 1 Congress Street, Suite 100
Boston, MA 02114-2017
�''+�• www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information `' ,- �pPlease Print Legibly
•
Name (Business/Organization/Individual): V 15A-0$ , \\e2el Q
Address: 20W1 79 \-Nt, kt 1
City/State/Zip. % 1;m-•_ • �}01059 Phone #: a --p Zl4C1
Are you an employer? C ecllt • appropriate box:
�,�r (� 4. am ageneral contractor and I Type of project(required):
1>�r I am a employer with I❑ 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g, ❑ Demolition
workingfor me in anycapacity. employees and have workers'
a y. 9. 0 Building addition
[No workers' comp. insurance comp. insurances
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
9 1
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL I H'9oof repairs
insurance required.] ' c. 152, §1(4),and we have no h`
employees. [No workers' 13.0 Other
comp. insurance required.]
*My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who.submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
l-Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. Q 1,� ;� 1 /��,
Insurance Company Name: Ji rr\w`UQ1_ ��� (A9 1t\ct `'NnS_ I
Policy#or Self-ins. Lic. #: Ux: J- ZG o I [ k ?-13-\\.9 . YU'.Expira'ti/on Date:GSI relay
Job Site Address: 2Z C) Sc\ Q C• City/State/Zip:`\G4'€ \Q'ZI Lc- 01 VI,y�
Attach a copy of the workers' compensatitiI policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify.+ er the pain ed penalties of perjury that the information provided abovebo� is trueueand correct.
Signa p2� /� Date: �A� (l\ W\`Q
Phone#: C�QU� l>" 7.J— \.'R' 1 V
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
•
0-4 3/15/2016 5 :36:45 AM PAGE 2/002 Fax Server
ri CERTIFICATE OF LIABILITY INSURANCE I DATE I MIODN 'n
FIOATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
OR PRODUCER AND THE CERTIFICATE HOI DFR
IMPORTANT.lithe certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject so
the terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to
the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME'
SOUTHWICK INS AGENCY INC mom 'FAX
562 COLLEGE HIGHWAY INC,No,Eat): (A/C,Not:
E-MAIL
SOUTHWICK,MA 01077 ADDRESS:
28TKC
IN9VRER(9)pFFOROIN6 COVERAGE WIICY
INSURED INSURER A; TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
SAMBRICO LLC DEA VISTA HOME IMPROVEMENT INSURER B:
INSURER C:
INSURER D:
2003 RIVERDALE ST INSURER
WEST SPRINGFIELD,MA 01089 INSURERS:
COVERAGES CERTIFICATE NUSWFR: REVISION NUMBER:
Das 6 TO CERMET TWT TEE roma M N$MANCE LISTED B@OW RAVE SEMI ISSUED TO THERM-MED NANO?MOVE FOR THE POLCY PEPOD INOCAT®. r61}RTTNSTANONO
ANY RW VIREmart-TERM ORCONOtON OFMir cm/TRACT OR 0T1461 DOCUMENT WITS RESPECT TO WINCH THIS SE RERCATE MATBE mum OR MAT PERTAIN.THEINSMAKE
AFFORDS:BY THE P WADES DESCRIE®MIMEO SusJEcT TO ALL THE TIMER RCUSON$MID CCNDR10N60F sm.POUCIW.LRR6 Sows MAY HAVE Bea REDUCED BY
PAC amis.
NA ADD susPOLICY En
EDUCT CY ERP DATE
Nswan LIR TYPE OE JMCE L R POLCY NUB (MAPCrTTI (•SDOWYTY) LMTS
GGEEIJFRAL LIABILITY =ACH OCCURRENCE $
COMMERCIAL GENERAL',mourn,
CLAIMS MADEOCCUR PREMTO NT $
O PREMISES(Ea occurrence)
NEO EXP(Any cue Person) $
SEUL AGGREGATE LIMIT APPLES PER
GENERAL AGGREGATEADV INJURY $
POLICY 0PRO.:ECT O LOC PRODUCT -CaM / $
RiWLICTS-CIXAP/CP AGG $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY ALTO LIMIT(Ea acciwn)
—
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Per person)
MIRED AUTOS
BODILY INJURY $
tYMJ.ONNED AUTOS IPerarcMBM)
1— PROPERTYAGE $
IPer accident)
UMBRELIAhAS OCCUR
�
EACH OCCURRENCE S
EXCESS LIAS IF-11 CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTIONS S
A WORKERS COMPENSATION AND X wC STAMm cDIRER
EMIPLOYERSUABILITY Y/N UBZEOT2183-AS 03/122016 03'12'201] OMITS
Aw FROPERnrnmutnEFrETE0.rtIVE 0WA E.L EACH ACCIDENT S 100,00
CFEIU WMEIMER E1CLlOEO?
ISSsawaris NM E.L.DISFA6-EA EMPLOYEE $ IDO,000
Eyes.sesame way:
EL DISEASE-
$ 0wowPOOCY LIMY 500,0
osscincn®J CA arsnciQ.5 b
DESCRIPTION OF OPERATMNIaILOCATONSNEOcLESMeTMCTON&SP%IAL ITEMS
THE REPLACE^ANY PRIOR CERTIFICATE ISSUED TOTEM CER I MCATE HOLDER AFFECTING WORKERS COMP COVERAGE
CERTIFICATE HOLDER CANCELLATION
TOWN OF WEST SPRINGFIELD-MA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
26 CENTRAL ST BEFORE THE EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED
IN ACCORDANCE WIN THE POLICY PROVISIONS.
AUTHORISED RFPRESEM/ a •'s.c- ! ,
WEST SPRINGFIELD,MA 01089 (vI[,�`r
ACORD 25(2110/04) The ACORD name and logo are registered marks of ACORD 1986-2010 ACORD CORPORATION. All rights reserved.
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: 220 PAre
The debris will be transported by: �t\*RrJ "n- �Q.�3\\ �tC
The debris will be received by: \- (k)( \� t�9CA\ JYk
Building permit number:
Name of Permit Applicant Q\ WIN.
Date Signature of Applicant