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HomeMy WebLinkAboutApplication & Supporting Docsz HEARING BOARDS 444 SW 2nd Avenue, 7th Floor • Miami, Florida 33130 Telephone 305-416-2030 s Fax 305-416-2035 www.miamigov.com/hearin4 boards PUBLIC HEARING APPLICATION FOR A SPECIAL EXCEPTION Welcome to Hearing Boards! This application is intended to serve as a guide in acquainting you with our public hearing process. By any means, please feel free to contact us at the number above, should you have any questions. ORDINANCE NO. 11469, CODIFIED IN CHAPTER 2, ARTICLE VI OF THE CITY CODE STATES THAT ANY PERSON WHO RECEIVES COMPENSATION, REMUNERATION OR EXPENSES FOR CONDUCTING LOBBYING ACTIVITIES TO REGISTER AS A LOBBYIST WITH THE CITY CLERK, PRIOR TO ENGAGING IN LOBBYING ACTIVITIES BEFORE CITY STAFF, BOARDS, COMMITTEES AND THE CITY COMMISSION, A COPY OF SAID ORDINANCE IS AVAILABLE IN THE OFFICE OF THE CITY CLERK (MIAMI CITY HALL), LOCATED AT 3500 PAN AMERICAN DRIVE, MIAMI, FLORIDA, 33133. Copies of lobbyist documentation with proof of payment must be submitted with the complete application. Ordinance No, 12918 states that each person or entity requesting approval, relief or other action from the City Commission or any of its boards, authorities, agencies, councils or committees regarding any issue, shall disclose at the commencement (or continuance) of the public hearing(s) on the issue, any consideration provided or committed, directly or on its behalf, for an agreement to support or withhold objection to the requested approval, relief or action. The Disclosure of Consideration Provided or Committed for Agreement to Support or Withhold Objection Affidavit included in this package must be submitted with the application. The applicant must, at the commencement of any public hearing on the issue, if there is any disclosure to report, read the disclosure into the record. Also, the applicant must supplement the affidavit if there is any new information or additional information to disclose. The deadline to file the complete application with supporting documents is the first five working days (1-5) of each month from 8:00 am until 3:00 pm, and on the fifth day, at 12:00 pm. The responses to this application must be typed and signed in black ink. Please note that pursuant to Section 1304.2.2 of the Miami Zoning Ordinance, no application shall be deemed to have been filed unless and until the applications shall have been completed. All pertinent and accurate information/documentation; i.e., the plans, reports, exhibits, shall be presented at the time of filing, in addition to the paid receipt. The applicant is responsible for the accuracy of the information contained in the application and all supporting materials. If you like, you could bring the materials to our office for staff review before the deadline to ensure the application is complete. Upon submittal, this application must be accompanied with a signed Zoning Referral. You will be responsible, if needed, to bring an interpreter for the English language to any presentation before city boards, committees and the city commission. A valid power of attorney will be required if neither applicant or legal counsel representing the applicant execute the application or desire to make a presentation before city boards, committees and the city commission. An additional fee to record Zoning Board resolutions will be charged and it is determined contingent upon fees charged at the time of recordation by the Miami -Dade County Recorder's Office at 22 NW First Street, First Floor. Upon arrival, ask for a certified copy. Please have the original recorded document mailed to the address above and bring the certified copy to our office. Copies of City Commission resolutions can be obtained at our website through the "Legislative Hub", or for certified copies, contact the City Clerk's Office at 305-250-5360. Rev. 09-04-07 Applications given to customers do not constitute action from the City of Miami without plans review and written comments from the Office of Zoning. Rev. 09-04-07 2 Within the City generally, or within certain zoning districts, certain structures, uses, and/or occupancies specified, are of a nature requiring special and intensive review to determine whether or not they should be permitted in specific locations, and if so, the special limitations, conditions, and safeguards, which should be applied as reasonably necessary to promote the general purposes of the Zoning Ordinance and, in particular, to protect adjoining properties and the neighborhood from avoidable potentially adverse effects. It is further intended that the expertise and judgment of the Miami Zoning Board be exercised in making such determinations, in accordance with the rules, considerations and limitations relating to Special Exceptions (see Article 16 of the Zoning Ordinance). I. Raimundo L Santamaria & Sonia Doris Trespalacios hereby apply to the Miami Zoning Board for approval of a Special Exception for the property located at 2453 SW 22 Terrace, Miami, FL. 33145 folio number 01-4115-006-0390 1. The property/location listed does not have any open code enforcement/lien violations. 2. One (1) original survey prepared by a State of Florida registered land surveyor within six (6) months from the date of application. 3. One (1) original 24x36" plan, signed and sealed by a State of Florida registered architect or engineer showing property boundaries and proposed structure(s), parking, landscaping, etc.; building elevations and dimensions and computations of lot area and building spacing. 4. Original plan needs to be stamped, dated and initialed by Hearing Boards designee first and then by (1) Public Works on the 8th Floor, (2) Zoning on the 4th Floor and (3) Planninq on the 3rd Floor, prior to submittal. Note: Plans are to be submitted to Zoning for first time review starting from the 8th through the 20th of each month. Zoning will not be accepting first-time review plans after the 20t'' day of the month. 5. After obtaining signatures from the above departments, two (2) 11x17" and one (1) 8'/x11" copies of the original plan, including the survey. 6. At least two photographs that show the entire property (land and improvements). 7. A clear and legible copy of the recorded warranty deed and tax forms of the most current year that shows the present owner(s) and legal description of the property. 8. A clear and legible copy of the subject property address and legal description on a separate sheet of paper, labeled as "Exhibit A" to coincide with the current survey's legal description. 9. Affidavit and disclosure of ownership of all owners and contract purchasers of the subject property (see pages 4 and 5). 10. Certified list of owners of real estate within 500 feet of the subject property (see pages 6 and 7). 11. What is the acreage of the project/property site? b t 12. What is the purpose of this application/nature of proposed use? Variance Rev. 09-04-07 3 13. Is the property within the boundaries of a historic site, historic district or archeological zone? Please contact the Planning Department on the 3`d Floor for information. NO 14. Is the property within the boundaries of an Environmental Preservation District? Please contact the Planning Department on the 3`d Floor for information. NO 15. For corporations and partnerships indicated, the following documents are to be submitted: a) Articles of Incorporation; b) Certificate from Tallahassee less than one (1) year old showing good standing; c) Corporate Resolution or a Power of Attorney signed by the secretary of the Corporation authorizing the person who signed the application to do so; d) Non-profit organizations: A list of Board of Directors less than one (1) year old. 16. Cost of processing according to Section 62-156 of the Miami City Code*: a. Special Exception requiring automatic City Commission review $ 2,000.00 b. Special Exception $ 800.00 c. Extension of time for Special Exception $ 500.00 d. Nonsubstantial modification $ 400.00 Public hearing and public meeting mail notice fees, including cost of handling and mailing per notice $ 3.50 Surcharge equal to applicable fee from item above, not to exceed eight hundred dollars ($800.00) except from agencies of the city; such surcharge to be refunded to the applicant if there is no appeal from the applicant or a property owner within five hundred (500) feet of the subject property. *Pursuant to Ordinance 1271 all planning and zoning fees in excess of $25,000.00, shall be paid in the oced �- cashiers check, or money order. Signature Address 2453 SW 22 Terrace Name:Raimundo L . Santamaria & Sonia Trespalacios Telephone 305-431-8261 E-mail The application submittal date is the date stamped by Hearing Boards' staff on the front page. STATE OF FLORIDA COUNTY OF MIAMI-DADS The foregoinialwas acknowledged before me this 131 day of _ 20 0 ` , by o \t-tk.%vlckt r '. _ `a is m 6. 'ri who is a(n) individual/partner/agent/corporation of a(n) individual/partnership/corporation. He/She is_paersonally knowntto_rne_Dr who has produced as identification and who did (did not) ta an oath. - LAC - Rev. 09-04-07 4 (Stamp) Signature 11171r 't"5. Rev. 09-04-07 AFFIDAVIT OF AUTHORITY TO ACT Before me, the undersigned, this day personally appeared Raimundo L, Santamaria & Sonia Doris Trespalacios who being by me first deposes and says: 1. That he/she is the owner, or the legal representative of the owner, submitting the accompanying application for a public hearing as required by the Code of the City of Miami, Florida, affecting the real property located in the City of Miami, as described and listed on the foregoing pages of this affidavit and made a part thereof. 2. That all owners who he/she represents, if any, have given his/her full and complete permission for him/her to act in his/her behalf for the change or modification of a classification or regulation of zoning as set out in the foregoing petition, ❑ including or 0 not including responses to day to day staff inquires. 3. That the foregoing pages are made a part of this affidavit contain the current names, mailing addresses, telephone numbers and legal descriptions for the real property of which he/she is the owner or legal representative. 4. The facts as represented in the application and documents submitted in conjunction with this affidavit are true and correct. Further Affiant sayeth not. Raimundo L. Santamaria & Sonia D. Trespalacios Applicant(s) Name Applicant( Signature STATE OF FLORIDA COUNTY OF MIAMI-DADE The foregoi g was acknowledged before me this k 5 day of 20 t , by ha,. L AAA yc„ s who is a(n) in J al/partner/agent/corporation of a(n) individual/partnership/corporation. He/She is personally known to me or who has produced as identification and who did (did not) take an oath. Rev. 09-04-07 6 (Stamp) A TM FERNANDEZ teAr 11, 2011 Rev. 09-04-07 7 DISCLOSURE OF OWNERSHIP 1, List the owner(s) of the subject property and percentage of ownership. Note; The Miami City Code requires disclosure of all parties having a financial interest, either direct or indirect, with respect to a presentation, request or petition. Accordingly, disclosure of shareholders of corporations, beneficiaries of trusts, and/or any other interested parties, together with their address(es) and proportionate interest are required. Please supply additional lists, if applicable. Owner's Name(es) Raimundo L. Santamaria & Sonia D Trespalacios Subject Property Address(es) 50% and 50% Telephone Number 305-431-8261 E-mail Address 2. Street address and legal description of any property owned by any and all parties listed in answer to question #1 located within 500 feet of the subject property. Please supply additional lists, if applicable. Street Address Legal Description 53 SW 22Tetrace Miami Fl 33145Lot 31 Block Silver bluff estates section A Ek." ,- , . "------- , .4, • ai undo L. antamaria Sonia D T spalacios _,,,.--i,-1 -4 -4----i- --g- -, e — ' '4 Owner(s) or Attorney Name Owner(s) or Attorney Signature STATE OF FLORIDA COUNTY OF MIAMI-DADE The foregoing was acknowledged before me this Jk -:)---. day of 20 CA , bY 1410, k----i. --;,:, v. AZ> 1-- - .3 a_y-c\--o,V-u-s-X--- '',c.- -2 (.1 ,,,-, c,--- k.\---ff — who is a(n) individual/partner/agent/corporation of a(n) individual/partnership/corporation. He/She is personally known to me or who has produced as identificatidn alid-Whiidici-(denot) ta e an oath. (Stamp) Rev. 09-04-07 8 EXHIBIT "A" Lot 31, Block 2, Silver Bluff Estates Section A (10-59), Public Records of Miami -Dade County, Florida. iN THE CIRCUIT COURT FOR \ li-1-1 _ u c\ COUNTY, FLORIDA PROBATE DIVISION IN RE. ESTATE OF �l o - File No. Oi,t) s SU)'j1 C " l.) c- z- Division.l Deceased. ORDER DETERMINING HOMESTEAD STATUS OF REAL PROPERTY (testate - validly devised, heirs, no spouse or minor child - exempt from claims) On the petition of Y\ ,ten c1/4 S for an order determining homestead status of real property, all interested persons having been served proper notice of the petition and hearing, or having waived notice thereof, the court finds that: 1. The decedent died testate and was domiciled in f .. "> ; County, Florida; 2 The decedent was not survived by a spouse or minor child; 3. Decedents homestead is validly devised; 4. Decedent's homestead was devised to one or more heirs of the decedent; 5. At the time of death, the decedent owned and resided on the real property described in the petition; it is ADJUDGED that the following described property (the "Property"): e c! ., 0 -q ' (A c" - c_ (....: 4 -c ., s-.) c-, •-r) <---L--- \� \ e:- . -V-- - C. \e_c' C c:›.1 cte c71- \ ! 1 \ \C---N- \ 's(_)<:..)\<-, t0, FAC,.sju.,`nvC_:ZL'_C aar (-)1..1 fv1t -\--c«Q.,___ i Bar Form No. P-4.0466 - 1 of 2 © Florida Lawyers Support Services, Inc. January 1, 2007 Bonk 25603 Page 1774 Total Pages 03043-CP-02 CFN # 20070468213 Case # 06- Rec_ Date 05109/2007_ Mek< � M` , Ef IN RE.: Or' Raimundo Manuel Santarsiari, Deceased. 7_7) IN THE CIRCUIT COURT FOR MIANII-DADE COUNTY, FI,ORIDA,7 File ]No.: 06-3043 CP 02 Division: Probate ORDER OF DISTRIBUTION OF REAL PROPERTY Cri This cause came on to be heard before me upon the Petition of Raimundo Luis Santamaria, to distribute the real property presently in the name of Raimondo Manuel Santaxnaria, to him and his sister, Sonia Doris Trespalacios, as beneficiaries of this Estate, The Court, after having examined the pleadings; and, being fully advised in these premises, it is hereby ORDERED and ADJUDGED as follows: 1. That the Petition of Raimundo Luis Santamaria to distribute the Real Property in the name of Raimondo Manuel Santamaria, to Raimundo Luis Santamaria and Sonia Doris Trespalacios, is hereby GRANTED. 2. The following described Real Property is hereby distributed and conveyed to Raimondo Luis Santamaria and Sonia Doris Trespalacios, jointly as tenants in common. 2453 S.W. 22Terrace, Miami, Florida 33145 LOT 31, BLOCK 2, SILVER BLUFF ESTATES, SECTION A ACCORDING TO THE PLAT THEREOF AS RECORDED IN PLAT BOOK 10, PAGE 59, PUBLIC RECORDS OF MIAMI- DADE COUNTY, FLORIDA DONE and ORDERED this 25 day of 14N, cc: Lori Friedman, Esq. Attorney for Raimondo Euis Santamari The Herskowitz T.aw Firm 9100 So. Dadetand Blvd.,#1000 Miami, FL 33156 , 2006. Circuit Court Judge ATE OF FIA,ITZEJ — COUNTY OF DADE HER.ERY IVY that -the bong Is a true ar4 'ocTrect ccpy of the oi;1 f th'Is offtce;- --":"-Scry '-iPnd and offciai Se:Ica-so. di 1 Al11A r,:amvnc 3 ■ OFFICE of VITAL STATISTICS CERT?FfED COPY FLORIDA CERTIFICATE OF DEATH 1:6tr&0c,, es s, L ` •�.' tiai dP i aR Ifd i...n rra ri... ....,. f ExF µ 3 EVi W.. 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A .aau1a1rn.-rEieEPP.w1.3.3e4, rmisvni AA., uew awt>n. w,ID>a ceirsel:7.arq rrx2eu .r.P:nf '-:F PA. _SlatafP MA,yil 00 74 AUGISSTO M. ENRTQ4;EZ, M.D. f,EkT0 STATE i3i. GTt' OR TF,'NFi FLORIDA CORAL GABLES u5':ct?5IR0F. 6ry+urer`I CLv:r ,J q'.0 i ��//i /,/l/ y.Cl4 ••ii! I► SMCI, p4Qr4ES9 76 a2.1.NE OF Ota11i fYa'v.7 i9 Htpi)AF. FA,3tINYi15GSE 1allh!4E0 0900 ' nsSt0 30441 nnrfl0T0,a fduns,.,F)]1 tee ci,t EON BLtiD- PPAPE qqyy (( {` jR}!,F {f��a 331.34 PE AAPN1PtELA,wEs o06EArn.oA...o-4.. P.A* .i1. ••.�..+... [v.,.uI.I,P.a mREPC%1a0brol+ea3.1LCw11PY'.N ylfElO X�w.ma Amivra _S.ww 4,r.00. P,r.+rgo--.atv �" ..._ .M4ECFiFem> r,. A ra I1. CALIW 9F Mar,PANl! FnN,+1N #IO.b ta.YaGlaY tta.aw.. 3R'ene.n ccoVumry ;N.A. Aso,. to MY, .3. WYo-+s M.""anA VA T ApP3Airr•u Adorn. 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Rawl 1 aa.i4WNYAI-P.43o _4. _Ih as.Eofar;pra0RP4,kr-GTATE W apt: C11'A0R10414 .ec S)A1E' AG4RESS 144-4T.04. IAw. ZIPCGCE m It W Yk kaE5r3u.0 WM SyiSPir L'i-'Guafl b 4 &t7 I 6.1. Plc F3 100..1. in.,. E4y. 4,14 00 f emt, K TR4440.C41ATEpA wwP. SAE Awxo,6le..n _ PnIM .12414 __P..w4+ _,rPEen'l.,: ...... Otw(_w Cyl ... E. A..' Psma Polo, .33 _... Y .,_. P.Ao•SY444 __ PrJur TNSA4c.* ;,': _ &m ..._ norm,... _ tlt'11, 4,...4 2 WARNING; 32587566 MAR 2 2 2006 F:M; W f r �, H.. �N 5 PAPER w-N .4 4y4TA�9P4 0,: 5NE r��.41 HEALTH 5E,1 OF. - 03 R3a13A. Ki a 00 ^7F'r 4TH.DAA rF1)3405- r1 £SENCE OF T1E WATE0574SPv 1 =11t I t>vu AENT FqC= CON hlNS c A+t[r �_3.3.4 -[+ nnu(Giii3M) AND Goo F044.35SEC1 7544 TN£ PACK Crair:1t39 .SPEC1M_ i l*E$ e.4 3 T1EX' <dv seAls oN i„fnur�G4141' 7 ,;. m'K ilk ON FORM f907 (044id) Wil Jr[X!Ii�W71Y!'IG4 OWS:StA:R 98� 411 suiwAs ?w G4115 AMCO FOrt:� g , �{ $• Ouit'1aim tedr €;arch€ 4 At. e / ay n: Febru Y RAIMU O 'L.'SANTAMARIA f turf party, to - 1 AIMUNDO ••M. SANTAMARiA and MARIA de 1a LUZ• SAtf'1rAMARIA , . his wife whoa* poalofrtcawhirlers it 2453 •S,4t.' 22rd TfErftf t3'r Miamir Florida 33145 Set6rerr &ni: • • ` . • . 1Wbreev.r e..i Mnen M{br,i trarw, a.t e"4e[twadorn._ .lYkea, rr' •i..<d scir'4412 ierlede deeler ele1 tetet eedM.ec.le/e. `el e..ieee el reepeedeme, ..Mrh.. for .e•.4ei .Lair, M r.aeim. 160itssith} Thai the laid Jtraf pity. for end in ranelderailon of the rum of S LOVE i AFFECMCIN In hand paid by the said second party, the receipt whereof 1a hereby oebnowledged. doer hereby rooftree. to- Ll.,E turd Will -dram onto Ibe raid second torts forever. all the right. nay, faience. Alters and demand whirls Ills sad fine patty has hi and to flan fallowing de:crthed lot. piece or parcel of fond, Wing*, lying and being In die Ccwity of Dade Seau of Florida �� Lot 31, in Block 2, of SILVER BLUFF ESTATES, Cti SECTION "A", according to the Plat thereof, o as recorded in Plat Book 10, Page 59, of the Public Records of Dade County, Florida; commonly ttitolla known by address as 2453 S.W. 22nd Terrace, !.1.7.- Cr- JMiamir Florida.eamesd r errecrt ao%L•Mii.6 Subject to a mortgage aF record.RtC�ii This is not the homestead of the Grantor, he~". r. resides elsewhere. z rn The Grantor is the son of the Grantees. a flit Ij w Viactlnitill rki E ,_r_jl-'.f..).-'\ 4,.-.• iirdrl:rApy =ruff-: IA.:' 1 17sac 13ADE i JtifFi:Y ' t-ties io- fl a. 3 t) To Moot and to told €Ire rr r t,r„eater With all nail r€ngetrar ihr eppeithenanrcr thee-new-dobelonging er in nnyioler npperininenit. antirifffire .•.tole, riaht, t€fiv, internel, fern, etraffy and CInirri what saener of llir raid fiat j irte. zither in intone equine, to the nnfv prnly, air, Itrnrfit Had hrh.xrf of 11ir said eecortei pally farevor. In 1InMS 1.11h£reof, d'it .nld:ir.l pnrH hen stein,") Hurl .natal tiles prrernfa the. dal. and year :test ahooa written. Signed, Noted anti delivered €re preserve o(: if STATE OF FLOP A. COUNTY er tave� Raimundo L. Santamaria 1 HEREBY CERTIFY that on ehii day, before toe, an f M�r officer duly wre d ehoitxd In the Sum and in the County aforeuid to take .ctna*fediliataU^ Pa X y t'Iw" R MUNDO L. SANTAMARIA . r• to ai9 known to be the lm>im dexrlbed in and whet executed the lorrltolnr in.teu. c t sad•%'9 before ma am he cowed the sense: WITNLSS my haul and official sect In the County and State February A. D. 19 no sty Ceausissiori expires : Tki ftlltitiatrcrtt'pr ints!by LES • _ NESTOR ill RVEHUE Addirs ' • not sit Nag Sty or rtwMilS t .e nn>ib iMlt'r>AH N / N I IZt:) 'IiWS) (3R CO i i 11#It.)I.;1) t.)BJECl ) R A(;RtE °TENT The 4;itb of MititM •es any relief €nr uthcr action ivoin the t_ity. (ontrni:••sion or any of its hoards_ authorities. eori =1;i€.tL'C.`6. ti:1 d?t_i(0o it the 2o111) cncer2°alit tOr 202tithiitiil2e) of the hearih{S) on the iSauc, any oonSideriat401 p15 0idcd or committed. ;1iiC !l t>E on its behalf, to any eslti15 or 1)215on i0r an agreement to support or withhold objectiott ip the rr(,aestcd approval. rciier or <1 :1i0,,. "C_t1!isider .tion" includes 211) slit, payment_ contribution, donation, Ice, commission. mission. 1?I"t)ri315 C' or Simi-., [3f tti1@ 111031Ci prOptlC SC1'4'!CC. C'!"C.diI. Or filllll4Gi2E aSSISilliC.0 ill 1?1}' kind or value, Avita:ter direct or implied, or any (1r titireetnent to !:rt-:hire ails of the Ii1I titoinei in the Suture. roily duals retained or err plot ed i 11 principal as a iobily'i.st as (kilned in Sec. 2-653, and appearing boRkre Me City- Comm kssion Or any of its boards, auth i1 itios. ,i22}lcies. councils (3r committees soiety in We capacity of ai lobbyist and not tis the applicant, or oWnerS` legal representative tare i1(;t ri. uircd to fill out tiii1 Conn. NA E: 4I Art flitted _ . V 1 S 3ar11e) (Middle) How ADf)R(-: ; _13 1, / 5 14/ 4A- (Address Line 1) GI`I'Y: giro S4M7 /; (Last Narne) 0 (Address Line 2) STATE: Florida GIP: 3 3,a 3 HOME PHONE: 305;2 s D 2V9t) C;t"IL)., PEiONi1 3t'J 1/2/ gf EMAIL: FAX: fatiSSEIs1ESS or l\PPLI AN or EN"fl"I'Y NAitI. BUSINESS ADDRESS: (Address Line 1) (Address Line 2) 1. Please describe the issue for which you are seeking approval, relief or other action from the City Commission, board, authority, agency, council, or committee. IfIg yiN6 f° fZ. 5 eigciA. t: c 'PTr 0t1 373 hi 22 2. Has any consideration been provided or cum1'11itied, directly or on your behalf, to any entity or person for an agreement to support or withhold objection to the requested approval, relief or action? YES rNO of your answer to Question 2 is No, do not answer questions 3, 4 & 5 proceed to read and execute the Acknowledgment. if your answer to Qnestio,® 2 is Yes, pease answer questions 3, 4 & 5 and read and execute the Acknowledgement. Doc. No.:1254 .5, l'99.`ask. l ro-s,'it OF COMM Acidd?iE€lilf.l� 4. Please. deScrilxc the nature o the c€ntsiden if he lid.: s'.' in(4 { iihonet{ 5. Describe what is being requested in exchange for the consideration. ACK!' OWLEDGEMEN7' OF COMPLIANCE I hereby acknowledge that it is unlawful to employ any device, scheme or artifice to circumvent the disclosure requirements of Ordinance 12918 and such circumvention shall be deemed a violation of the Ordinance; and that in addition to the criminal or civil penalties that may be imposed under the City Code, upon determination by the City Commission that the foregoing disclosure requirement was not fully and timely satisfied the following may occur: I. the application or order, as applicable, shall be deemed void without further force or effect; and 2. no application from any person or entity for the same issue shall be reviewed or considered by the applicable board(s) until expiration of a period of one year after the nullification of the application or order. PERSON SUF3.1\., 11NO DISCLOSURE: i4 1/Yj Ui d a 4 41 tint 5,441�T�4-/44' /4Name Sworn to anar s,r rcr ( before rase this „qv r)J 200 T'he.foregoing instru ten? u�.�..: �, lee? e�c< b ore r U b.: has produced +ho cs rrl..°;_..,cat,c>ra axnri or is personally ki7c n to me and who did/did not take an oath, 3c---Ito-4S-2-?-t -0 STATE c1 ,h.()RI CITY Y OF 1\11 3 Y Doc, tie-:S655 Fmni Name Page 2 It