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17 TRADERS WAY - SIGN PERMIT 17 Traders Way TJ. Max •YrW.- E -vC�r-1h B Permit Number R E E s D APPLICATION FOR PERMIT TO ERECT A 9GN DEC 2 1 2010 S�444ZWW NOTE:BUILDING PERMIT MUST BE OBTAINED BEFORE SIGN IS ERECTED DEPT.OF PLANNING& Location, Ownership and Detail Must ee Correct, Complete, and LegibleCOMMrUNIFY DEVELOPMENT Salem,Massachusetts i -a�- 6 v Date To the Building Inspector. The undersigned hereby applies for a permit to r3 Erect, o Alter, ❑Repair a sign on the following described buildings: AddressStreet ❑ Urban Renewal Area Entrance Corridor n Historic District ❑None (� 1 `t• Use of Building Telephone i sfolio 3 a A W 1 floor A, • floor Address `7 \chda to 3 floor Telephone _ 33 4 floor E-mail How many businesses are in the building? I If a corporate body,name of responsible officer I'M hn l..)0') ,r/ _,vo„( S, h+ Building I r linear feet Cans ruction Sups License No (.110 Applicant's Space(if multi-tenant) Ia, I linear feet Address Q Ch,fir S f- rQsjxlr h". in 15 Property linear feet Telephone 90s _ t]S - S r7 9Mad Sign Permit to E-mail M C N �J �n ❑Sign Owner in Sign Erector a Othe gcy C. Proposed Signs df mcre tlian three signs are proposed Si ntI Sign 2 1 Sign 3 oLSurface ❑Surface ❑Surface ❑ Right Angle to Building ❑Right Angle to Building ❑Right Angle to Building ❑Free Standing ❑Free Standing kFree Standing c Awning ❑Awning ❑Awning ❑Portable(A-Frame) in Portable(A-Frame) ❑Portable(A-Frame) in Other(specify) wOther(specify) Un a ec ('�.r n Other(specify) dZ rr J'. Sign Materials Sign Materials Sign Material Ib, lek.,n Le AIv, el VN Sign Dimensions , r �r Sign Dimensions , Sign Dimensions 5 kap - i t x4 3xCA -L Sign Area Sign Area Sign Area rl sq � ft S sft Sign Height(if free standigg Sign Height(if free standing) N� Sign Height(if free standing) Estimated Cost of Net tWork $ ") 0 U 0 Type 15"MArea To Be Removed? Sign Owner g.Surface 160 sq It Ayes ❑no 5Pt QtF.c.cC�. ❑Right Angle to Building sq R ❑yes ❑no a•Free Standing cq„p sq ft a yes ❑no Sign Owner's Authorized epresentati ❑Awning sq It in yes ❑no f,l �tn,.�i�.%y ❑Other(specify) sq ft ❑yes ❑no Property Owner o. internal Review ning&Community Development Department IHistorical Commission Approval Building Inspector OBi2M10 rev 1-15 TRADERS WAY 564-11 COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM GIS#: 1315 Map: �08 _ Q Block: Lot 10126 0 SIGN PERMIT Perms!: 'Sign iCategory: SIGN Pertnit# _ 564-11 ._ - PERMISSION IS HEREBY GRANTED TO: Project# JS-2011-000621 Est. Cost 57,000.00 Contractor: License: Expires Fee Charged:IS0.00 Mackoul Sign&Lighting/George Aha Balance Due:''S.00 Owner: HIGHLANDER PLAZA REALTY TRUST, PERECHOCKY MARK/RAPPA #of Fixtures Applicant: ;Mackoul Sign&Lighting/George Mackoul DigSafe# _ AT.• 1-15 TRADERS WAY �UseGroup_ ConstClass ISSUED ON. 06-Jan-2011 AMENDED ON. EXPIRES ON. 06-May-2011 TO PERFORM TME FOLLOWING WORK: SIGN PERMIT AS APPROVED FOR(TJ MAX)jhh THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fee Type: Receipt No: Dale Paid: Check No Amo t SIGN REC-2011-000731 06-Jan-II x $0.00' GeoTMS®2011 Des Landers Municipal Solutions,Inc. City of Salem Sign Permit Application Worksheet 28•Dec•10 TJ Max 17 Traders Way Zoning(reslnon-res) B2/1 Entrance Corridor(YIN) Y Lot frontage 380 feet Building or tenant frontage 129 feet #of businesses on site 3+ Bldng dist from street center 650 feet Multiplier 1.5 Building and Blade Signs maximum area permitted 193.50 sq ft for 2 sides total proposed sign area 131.90 sq it sign 1 127.90 length 293.50 inches height 62.75 inches sign 2 4 length 48.00 inches height 12.00 inches sign 3 0 length 0.00 inches height 0.00 inches sign 4 length 0.00 inches height 0.00 inches sign 5 length 0.00 inches height 0.00 inches Freestanding Signs maximum area permitted na sq ft(per side) maximum#of signs permitted 1 signs maximum height permitted na it tall sign 1 proposed sign area 3.44 sq ft length 41.25 inches height 12.00 inches proposed sign height na ft sign 2 proposed sign area 0.00 sq ft length 0.00 inches height 0.00 inches proposed si n height ft Application meets guidelines set forth in the Salem Sign Ordinance yes Recommend approval yes New TJ Max sign to replace AJ Wright sign will be 28 inches wider. Blade and freestanding signs to be same dimensions as previously approved for AJ Wright signs. COMMONWEALTH OF MASSACHUSET',�, T ,eu. ASAELECTRICIA MASSACHUSETTS - .CISME-ICIAL 05rv_ER'S LICENSE' Q \ Sll._�Dv04 '� GEORGE MACKOUL I ,ell X 28 WALES STREET 1& . MIL LBURV MA 01527-2116 16371 E 07/31, 291530 • "'S55�rr _ ;` M..i� �:R,1<. �/�• IFS.. - - -""' - - COMMONWEALTH OF MASSACHUSET<(S� V( REGIS ER 6. A�LE�� im*s TMSU EN TO \la•.achuwn.-Ih-panmcmalPublic Sareq MACKOUL ELECTRIC INC Onanl nr RuililinP RaKULrtGm.nnJ StanOanl� GEORGE M MACKOUL Construction Supervisor License 28 WALES STREET 4cenu: CS 78318 Rsrrkfee m: MIL LBURV MA 01527-211 60GEORGE HORN M MACKOUL 13335 A 07/31/10 291531 50 MORNE WAY MILLBURY.MA 01527 �_-G'.:ic` E.pralron: 218201i —f rmn1..4ne� Tre: 1539 SrATP Or NLW HAMPSHmI, UUWAU OF 2LEICTKK'.Ai:SAFS7 Y ' AWO LMINSING CEKTiFlE'4 LHAT I i •` l�L�Fib11NA� 17 '141�R�yty�,•AAA.NA�'SR>t Yf�OC�RPffi[R1831aG .. t LK{9T�q txr+�e3` 9,20 A� CERTIFICATE OF LIABILITY INSURANCE 7/29/201YI) 7/29/2010 PRODUCER (203)269-2469 FAX: (203)269-4048 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Corcoran 6 Mann Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 111 South Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 1469 Wallingford CT 06492 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A.Peerless Insurance 24198 Arnco Sign Company, Inc. INSURER B: 1133 South Broad Street _INSURER C. INSURER D' Wallingford CT 06492 INSURER E' COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OISUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 10N 5D POLICYEFFECTIVE POUCYEXPIRATION LIMITS TR POUCYNUMBER GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000. $ _ 800 X 000, COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES/Ea a ,,gnael A _ CLAIMS MADE X OCCUR CBp8304266 7/22/2010 7/22/2011 _ME_D EXP(Any ma person) S 5,000. -- _ PERSONALS ADVINJURY_S 1,000 000, - — - — _ GENERAL AGGREGATE $ 2 000 000. GEN'L AGGREGATE LIMIT APPLIES PER ? PRODUCTS:COMP,OP AGO 5 1,000,000. X POLICY PRP LOC - AUTOMOBILEUASILITY '--- COMBINED SINGLE UMIT $ 1,000,000 ANY AUTO (Ea amden0 A ALL OWNED AUTOS "8301866 7/22/2010 7/22/2011 ? BODILY INJURY X SCHEDULED AUTOS (Per Parma) 5 X HIRED AUTOS BODILY INJURY $ X NON-0WNED AUTOS (Per a ,ienq X COMP-$1,000.DED__ PROPERTY DAMAGE $ X LOLL-$1,DOO.DED (Per aoddent) GARAGEUASILnY _AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC 5 AUTO ONLY'. AGO S _ESS/UMBRELLA LIABILITY _EACH OCCURRENCE 5 .1 000 000 X -- T.- . OCCUR CLAIMS MADE AGGREGATE $ 1,000 DDD A i DEDUCTIBLE CUB309466 7/22/2010 7/22/2011 X RETENTION S 10,000 S A WORKERS COMPENSATION ORTTATU OT AND EMPLOYERS'LIABILITY YIN X TER ANY PROPRIETORIPARTNEIVEXECUTIVEF-] E.L EACH ACCIDENT _ S _ 500,000. OFFICERMIEMSER EXCLUDED? (Mande tory In NH) WCB309258 7/22/2010 7/22/2011 EL.DISEASE-EA EMPLOYEES 500,000. I as,de=W aper SPECIAL PROVISIONS 6Mow E.L.DISEASE-POLICY LIMIT 5 500 000, OTHER DESCRIPTION OFOPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Gerry Mann/MENNON ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(2Do9Duo1 The ACORD name and logo are registered marks of ACORD AUTHORIZATION AND CONSENT FORM Dunces Adtja old ��Y ,r� �t dtt ;: j Inn Telepi one Aiwetbet: �I ✓L Leo Lca ed PremLze: s5'9 d i 3 I0 TJ tvlaxx H gfiuW Ave&Tmders Way Sakm..e*fr1 Ren TJ Mzxx's Signage To Whom It May Concern: I a+m a d,§y zut6o;sed rcze�-�:e�ive p{ ..j-}i,i� (�'��"J� .sSLse Landlord�car._n ak ahe ref=rmced kese gremisex "• ^-tc �{-f — `C"r''L. In my capacity as T sndiord's ofic..I repre mtaaive,I do hereby authorize Service Srk.Vc Inc and ks vantractars to perform alt work associawd with TJ Mm's nese signage progress. I approve the PmPosed si.—a a ss umchad,aM$trtLn xnhorizt Service Se6tt Inc and it repft—edatim to ohrein A p=71hs assn law WA this side Progmn,as hereby-eorrerted m bIi I,apd?otd. I..endlor6'Owr4x- 9 By:' raft: Z 1v�yf4lal� C3 Please Ado Sign and Date the Proposed Dra sand Fax Them Bach Wal This Form PE eFaaduect]yin:2S5-"8B-ss88..'i ^t: Juiti-nLavinsay Of asad to- Aar_- Jattia Lavinsky Laadlorel Conrdirt9ticz Depa amen ,Service Seita,Inc 400*Mack Dive Croydon,PA 15021 'I sank you JAGER MANAGEMENT_ , INC. bt0 f!'C Y(���.Sarre 220 )2ntf)ndaiLn,PA t Te--Dqa:,he:215-69-3-322D Fauveat': 215b4D-3236 December 16,2310 VLA UPS GROUND AM- 3ustinlavinsky Landlord Coordination Do-ariment Service Select. Inc. 400 Mack Drive Cro)-!un,PA 19021 Re: TJ Maxi's Signage H ghkoder Plaza,sA Enclosed please find a copY of your Sign Drawings for TI Maxx, lor.,ated at Highlander Plaza, wmm ah I have-Approved-" Please note this approval states that teasut repair the facade Prior to installation of$e sign. Also,all's that is completed is at tenant's expense. Please note, however, that mY checking -Apprvverr is only for conformance with the sign corse„-pt of the project and compliance with the information given in(he lease specification,. It is not intended,in anY way to relieve either tlne tenant or tenant's agmt of Urex ceFponsibilitg ftnr coordination and compliance with all requirements of conanicdon processing necessary to properly execute work and acquire app.-ovats from all legal anthorines having jurisdiction over (his project. Also,should the lease require any approval for the name change,tenant shall suhm€t the appropriate paperwork to the Landlord Please be advised that the sign must have a 171,listing in order to be installed in the mall, the use of a:aceway is prohibited,and Tenant is responsible for repairing the fayade before insstailing new signage.ifneu:ssary_ Pieaee contact Dave McKee at 717-761-2604 to schedule installation of the sign. If sou should have any questions or if 1tnay be of 1146er assistance,please contact tie a^, 215- 690-3320. Sincerely youns gan d Direvor of Operations Cc: Dav-a-NkKee,Property-Manager ©EXISTING PYLON SIGN_IOCATIgy i - inn,d:Commands, - — - Wall Sign:00A 41111,ward•sq II aldwenca In I sq If m Ripnpgn Im scary i. It of hhlg homage•may IS"DrdlnWlm•de nar mount shove tits root fine 130'nt Irnntago Allows for 130 Inderr,Iea1 of signage Orhund Sign:to add or change a 400 sign We do need u permit pill on lama app na wall sign BI4 Signs:yes Won permit�mm 32 aq It Temp Simmons;yes wee permit•Grand Opening-good for 2 wages only —_ IAITRICATE&INSTALL(1)SET Of d"FACE-LIT O ILLUMINATED CHANNEL LETTERS ., DOUBLE FACE ILLUMINATED UNDER CANOPY SION PETsMART 1, r 0 © ' © CEILING MOUNTED 0 COVERED WALKWAY ACTpAuLOCpaii,TITO, IWISTINODIF ILIUM PYLON TENANT PANEL ( © FACE REPLACEMENT ALL SIZES T.B.D. e I i ._ ' shavesAll ° S1GtiL�GATION SITE PLAN PRELIMINARY DRAWING NOT FOR FABRICATION ��IAY II�Ecw�mvov, cn 9oz� iJw.laa �� �� ELECT cru PLAN s s.vee aeve MI1NA 0AV[ TMOEfla WAY u INC u1111 Wiliam I I OACKGNIIUNC PLANT€O -- - - - --- --C"INAWHIIEURIVII A9I0 RED(ACTUAL PNMT WATCH(00) - Y� Yd'-11/2" _--_- - Ep / cel:t_HNIF xwoe WISRiJneav -_ __. ._�._ _ —__ y WjITN-ceu:sAr JEMISN:3 wnu - - - - w.at t TON OF RUUE$MUWN 0ASNf-0 -. a z --If@NJAh9N AiUUII€[Il;aI CIAYN€TUE - } ~ 41 � s w EXISTING FRONT ELEVATION WITH LUMIACE ATOIT NIN[L LETTERS WI7N L{D ILLUMINATION Yd',11/2' ---f I 61: I � « BOXED NOTAL:127.92 sq,h. Y-28;4" .,.� ILLUM.SIGN ELEVATION TJMW 4 ----- ------- ---scute 14 =1'.O' ACTUAL TOTAL:07.1sq.ft. PRELIMINARY DRAWING NOT FOR FABRICATION �ERVICE Aoo"A"Owvc ceovoow. rA iaoai TJA% NMNELECT7RAPEAq WAY AVf fYIIPIOflf(OHE U11I � yy INC SAL{MMAfiLNlu � m PHEFERRED MOUNTING?",V" 3,11- - - - 140a MOUNIINO DEMI(ABN H PER LTH REDID)HELD W(BIT GAIN.THEO NILTB A ALUM BPACEA } ! AFOR T WALL IIUICRAMOAINA AMC 11 L '1 /�"� \ /' A AT WALL ITM104 CTUALWLHYIARF [�,^ t `l} (IF ry DANCON,RUtTINUM AE URNRII ` ,`� Si 11 , IFS°" �. CONBTRIICTMN � � '� {r r I In • - A PHI FINISHEO MAITF OLACR -- I'owl 1EWI[HE fOIMiM IMLIRE DR 11831 --� r'MAIN[u Ulf NMCAPHAND,,Q•LIRA ILLUM.SIGN ELEVATION 3115-INK WHITf ACRVIIC - r TJMW-48 ..-_.------.—'--_�---__-- WN1rE NO 5141"W PER AT14';,ON cix1ER.No LE:B SCALE1 1/4"A 1•U" THAN E 1'r"PODIA HEFIIHNA LEO BTAM MI B TO BACK OF LFCIER WNNB CAN ✓ j ANO MEIINANICALLY EAA1fNf.O IN,RWITI AI IT", A ENO OF EACH 61RM6 EVERY 16"CLOTH '6"IEM.111I AB HEO'0 — Ettc.CUT OFF Bw0GNTMRAIIMN ri- I - ! CMN Kph WM.L 1,EI01RAT1ONB ---. .---- " -.� PO VIRPAGk AS HEWH1OD fUS 1P01 -- AQQ AIUMINUAISACKPIOWNIIF r INRHIUR OFLI'TIEIIP111.w11GE ------ - t - - - NOTCHED RETIIIINdPOP.NYRUltOBACK BOXED TOTAL: 127.92 sq.h. ICAULA AROUND PLAIMFIERI N 1'E'UM.IWMI HEI I IMW,E PER RRA ILOLXINU BEHIND BTUIM AS RLO'O. - NIKE;ALL ELECTRICAL PENETRATIONS TO IE ON ONE LINE(HOMICIDALLY) PRELIMINARY DRAWING 1Y0 VOLT 20 AMP PRIMARY ELECTNIL ACTUAL TOTAL:97.1 sq.11. NOT FOR FABRICATION CIRCUCI6 480116H TO SIGN AREA W AINAL L—ry'•`'---... L1 IP IINNFL110N OF OTHER&111'WHO-I ENUfH � III xrlxnRED 7 1AAA LETTER SE6TION(WNf_M FACIES1 ONYVfR WALL (120 VOLT) NOT TO SfwE �ERVICE 'C'""°`M`- YOYOON. M 1402'. 1 11 MAXS1 ('/LECT >N:s�s.960.3N4e INIUHIAHD AVE FIDS iIAP& �� ��� INC sA1An.MA Nlvrn I 4,•B,. - - -------- �---- ..-- - 9'•81/4„ b CAT WALK RETAIL q L- WNIF€IAGO 51YLE COPY NEW IL J.WRIGN7 REVERSE WEEDED FROM TRANS •/ RED VIM BACKGROIIND -33 EO _ 49" F EO -- -- - - © DIP-MMIbAi AUND.EHDANOPYS14N � 4 i n 81.7112" COVERED WALKWAY EAN311NGGANOPYLECTIAlI PRELIMINARY DRAWING / ICALE Lt=r4• NOT FOR FABRICATION \) cwcovoow vn 1-21 1J MAX% �ERVIQE _ `� w+:x1 s-rae.aeve NIDXIIND AVE NNDER IIINIIPY iNiN m� 'C� S c..W ..n. @EL[.CT 'vee.°see TRADEXA WAY... i � � V INC 4AIEM.MAD) X 0'-81/4" - - - , PRIMARY CONNECTION - - - - - MOUNTING HARDWARE AS REOUIRCD FOR CEILING. �< • 000 M.A.HIGH OUTPUT FLUORESCENT ILLUMINATION - I.F46 TIY/O/HO LAMP. I•148 H.O.BALLAST. `? "' T • , A' (TOTAL AMPS..55) �+ WHITE LFNAN FACE WITH y1NVl.APPLiF.9 TO I'IIIST SIIRfACI. w L. L7WE.ILLIIN_IINA.TEQ UNUMANDPY ON / -WHITE LUDO S'IYLE COPY S1DE.SECT.U7N SCALE.117 .0' REVERSE WEEDED FROM TRANS DOUBLE FACE ILLUMINAIEO UNDER CANOPYSIGN RFD VINYL BACKGROUND CEILING MOUNTED(Dr COVERED WALKWAY #3800.33 A O., n' FORMED WHITE LEKAN us.I SURFACE APPLIED WNINYL WRAPPED AROUND SIGN LENSE ALUMINUM TOP 6 ENDS FINISHED CLEAR ANODIZED 15Qf_YIE:CRIG_V1�IK._QLF_14kUMINA7�G �INQ�R.CANQ_PY,S1&N PRELIMINARY DRAWING (� NUT FOR FABRICATION �.`ERV ICE ��M<CK DRNE v CROYOOn. Rl .9021 TFAMV l �� �� ELECT '"`2,��a.3asa NIDNUMDAVE UNUEACAYOYYSNN � '>�+� TMOEA/WAY O • INC glEq,A41 81414 sn.. p pI►oza CVS/PharMRCY • Shaws Shaws SnUarmnrkul ;unnrmarkel ' p�mywerl6 IpOtW'worNA 'Y. �se�.sapp5n5 UAIRY CUT- L.fu��ns DUALITYCUT EXISTING PYLON NRUNUSFU PANEL RE'FACF. T.r& , I ` CUT SIZE T.B.D. © PYLON V.O. T.B.D. INSTALL NEW SIGN FACE TG EXISTING MATERIAL T.B.D. ..-C'1_ _ _ - _ _ _ _ _ ;. _ _ DIF ILLUMINATED MONUMENT SIOk 3i III"ihk.LEXAN W!IN SURFACE TRANS VINYL RED#3630-33 ALL SIZES T.0.0. r f_ENAN7 NANEL_ L sear.Nrc !zl Re9'U - WHITE LOGO STYLE CONY NEVl:RSF:WEEDED FROM 1113X5 REN VINYL BACKGROUND PRELIMINARY DRAWING #3630.33 NOT FOR FABRICATION 6ERVICEM�K oA nix PaorooH. rn ivoz� iJ.MAAA INIlfl1011iRON ELECT NIANLANOAVE vrxraeosae TRNOEAE WAY • - Y INC NALtN.MA City of Salem Department of Planning & Community Development Check/Cash Receipt and Tracking Form Please complete form and make two copies. Date Received 1 I– I C-) Amount Received 7,s—. Form of Payment Check ❑ Cash Sign Permit Application Fee ❑ Conservation Commission Fee Payment received for what ❑ Planning Board Fee/ ZBA service? ❑ SRA/DRB Fee ❑ Copies ❑ Other: Name of staff person receiving payment �I^ L Additional Notes 1840 stato-ztt 1 ARNCO SIGN COMPANY,INC. PERMIT ACCOUNT 16 1133 S BROAD ST. PA I I a� V WALLINGFORD,CT 06492 li rnYT. _Tk of DOLLARS e o..� -• j rm it El WACIHOVIA l Wachovia Bank,N.A. 1 ? wach0v18.00M L1:0MFMI W '21 &011081: 20000 &9447487I's 184 ,_..-„�,�,,.--_�_--�.�.-ams-�-:,�---:- -,.>-�,-_-.�,aa�--�• Original Check and Form: DPCD Finance Copy 1: Client Copy 2: Application File