HomeMy WebLinkAbout150 Anza Boulevard - Agency Approval Letter (8)�., "�
'STATE OF CALIFORNIA PETE WILSON, Govemor
� SAN FPANCISCO BAY CONSERVATION AND DEVELOPMENT COMMISSION
THIRIY VAN NESS AVENUE, SUITE 2011
SAN FRANCISCO, CALIFORNIA 94102-6080
PHONE: (415) 557-3686
PERMIT NO. 6-83
(Issued on Apri125, 1983, As
Amended Through June 19, 1998)
AMENDMENT NO. SIX
1. Within the Bay:
a. Place storm drain outfall pipes;
b. Place 4,500 cubic yards of new riprap for shoreline protection purposes and
repair and remove reinforced bar from existing riprap where necessary, along the
1,SOO linear feet of Bay shoreline; and
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Fe1Cor/CSS Holdings, L.P.
545 E. John Carpenter Freeway, Suite 1300
Irving, Texas 75062
ATTENTION: Jack Eslick
Ladies and Gentlemen:
On Apri121, 1983, the San Francisco Bay Conservation and Development Commission, by a
vote of 18 afiirmative, 0 negative, and 1 abstention, approved the resolut�on pursuant to which the
original permit had been issued. Moreover, on September 7, 1983, July 23, 1985, October 24,
1986, April 19, 1988, a� January 27, 1997, and June 19. 1998, pursuant to Regulation S�ction
10822, the Executive Director approved Amendment Nos. One, Two, Three, Four, a� Five, and
Six. respectively, to which this amended permit is hereby issued:
I. Authorization
A. Subject to the conditions stated below, the pernuttee is granted permission to do the
following within the Bay and within the 100-foot shoreline band, at 150 Anza Boulevazd, on
Assessor's Parcel Nos. 26-342-220, 26-342-230, and 26-342-240, immediately west of Anza
Lagoon in the City of Burlingame, San Mateo County:
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a.
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Construct and use a 4,300-square-foot portion of a 51,634-square-foot hotel;
Construct and use a 4,353-square-foot poRion of a 9,000-square-foot
combination restaurandpublic services building;
Construct and use an approximately 704-square-foot shop and storage building
attached to the hotel (Amendment No. Five);
c. Construct and use a 60-foot-long, 3,400-square-foot itshing pier.
Within the 100-foot Shoreline Band: �
Dedicated to making San Francisco Bay better.
, ,�
PERMIT NO. 6-83
(Is.�ued on Apri125, 1983, As
Amended Through June 19, 1998)
AMENDMENT NO. SIX
Fe1Cor/CSS Holdings, L.P.
Page 2
d. Construct and use an a�proximately 1 776-square-foot and 26-foot-high office
addition attached to the hotel (Amendment No. Sixl:
de. Place and use 100,260 square feet of paving for vehicle circulation and I03 of the
430 parking spaces;
ef. Place 8,300 cubic yards of clean earth fill, landscape and use 171,056 square feet
(3.92 acres) for public access including 109,336 square feet (2.5 acres) for a park
along the Bay shoreline; and
€g. Install, landscape, and use 54,050 square feet (1.24 acres) for public access
around the southeastern shoreline of Anza Lagoon.
B. This amended authority is generally pursuant to and limited by your application dated
February 14, 1983, and your letters dated August 31, 1983, requesting Amendment No. One, May
22, 1985, requesting Amendment No. Two, July 10, 1986, reqttesting Amendment No. Three,
February 22, 1988, requesting Amendment No. Four, a� October 23, 1996, requesting
Amendment No. Five, and December 5. 1997, rec�uesting Amendment No. Six, mcluding all
accompanying and subsequent exhibits, attached Exhibits A, B, and C, but subject to the
modifications required by conditions hereto a�ae-�e�.
C. Work authorized throug.h Amendment No. Five has alreadv been completed. Work
authorized'����;„ � Y+'�� �rA;� bv Amendment No. Six, must commence prior to £eg*�r^��-r
�354 August 1. 1998, or this amended permit will lapse and become null and void. Such work
must also be diligently prosecuted to completion, and must be completed by���••��� ','°4''
August 1. 2000, unless an extension of time is granted by further amendment of this amended
permit prior to its expiration. „'-���o ' a'� � ^ '''�' * "T �^"""""* " �"�
D. This project will provide approximately 5.16 acres (225,106 square feet) of landscaped
public access improvements within the 100-foot shoreline band, and in addition, will provide
approximately 5,600 square feet of landscaped public access outside the 100-foot shoreline band,
along 1,SOO linear feet of Bay shoreline and 2,0201inear feet of lagoon shoreline in the City of
Burlingame, San Mateo County.
II. Special Conditions
The amended authorization made herein shall be subject to the following special conditions, in
addition to the standard conditions in Part N:
A. Specific Plans and Plan Review
1. Plan Review. No construction or use whatsoever shall be made of any facility
authorized herein, until iinal precise site, grading, architectural, and landscaping plans,
and any other relevant criteria, specifications, and plan information for that portion of
the work have been submitted to, reviewed, and approved in writing by or on behalf of
the Commission for work authorized through Amendment No. Four. No plan review is
required for Amendments No. Five and Six.
PERMIT NO. 6-83
(Is�ued on Apri125, 1983, As
Amended Through June 19, 1998)
AMEhIDMENT NO. SIX
Fe1Cor/CSS Holdings, L.P.
Page 3
2.
3
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a. Architectural Plans. Architectural plans submitted for review shall consist of
exterior elevations with building details which indicate the location, dimensions,
exterior treatment, and color of all structures, outside signs, and other fixtures.
b. Landscaping Plans. Landscaping plans shall be prepared and signed by a
licensed landscaped architect and may be submitted as part of the azchitectural
plans or submitted separately. In either case, such plans shall consist of grading,
staking, planting, and irrigation sheets showing the location, types and
dimensions of all pathways, public access areas, structures, parking spaces,
benches, tables, trash containers, lighting, and a list of the names and quantity of
all plant species to be used.
Architectural and landscaping plans submitted for review shall be accompanied by a
letter requesting plan approval, identifying the type of plan submitted, the portion of the
project involved, and indicating whether the plan is final or preliminary. Approval or
disapproval shall be based upon (a) completeness of the plan in showing the features
required above, (b) consistency of the plan's criteria and information with the specific
terms and conditions of this amended pemut, (c) maximizing the attractiveness of the
public access area, and (d) consistency of the plan with the recommendations of the
Design Review Board. In each instance, plan review shall be completed, by or on
behalf of the Commission, within 45 days after receipt of the plan or plans to be
reviewed, and shall consist of a letter specif'ically referring to the submitted plan or
plans which indicates whether it or they have been approved or disapproved
Changes to Approved Plans. After iinal plans have been approved pursuant to Special
Condition II-A-1, no change shall be made to such plans wrthout first obtaining wntten
approval of the proposed change by or on behalf of the Commission. Approval or
disapproval shall be made within 30 days after the proposed change has been submitted
for approval and shall be based on a iinding that the change complies with this amended
pernut and would not detrimentally affect public access, landscaping, open space, open
water, or other public benefits.
Conformity with Approved Plans. All leases, contract specifications, and alI structures
and improvements at the project site shall conform to the final plans approved pursuant
to this special condition. No structures shall be placed nor any improvement undertaken
that is not clearly shown and indicated on the approved final plans. After construction,
no noticeable changes to the exterior of any structure shall be made, no additional
structure shall be built, nor shall park, open space, open water, landscaping, or public
access areas be altered without first obtaining written approval by or on behalf of the
Commission pursuant to Special Condition II-A-2.
��roved bv or on behalf of the Commission.
PERMIT NO. 6-83
(Issued on Apri125, 1�83, As
Amended Through June 19, 1998)
AMENDMENT NO. SIX
Fe1Cor/CSS Holdings, L.P.
Page 4
B . Public Access
1. Area. Prior to the commencement of construction authorized herein, and including the
construction of improvements authorized by Amendment No. Four, the pemuttee shall,
by instrument or instruments acceptable to counsel for BCDC, dedicate to a public
agency or otherwise guarantee rights for the public for access or walking, sitting,
viewing, fishing, picnicking and other related purposes, to the areas generally shown
on Exhibits A and C as public access, and prior to use or occupancy of any facility
authorized herein and until this amended pernut is further amended such areas shall
remain available to the public for such uses.
2. Instrument. An instrument submitted to counsel for BCDC's approval pursuant to
Special Condition II-B-1 shall create rights in favor of the public, at least to the extent
of the pernuttee's interest in the existing lease to the site, for the purposes indicated and
shall include a map that shows the property lines and dimensions of such areas, and
contains a metes and bounds description of the areas. The instrument shall be in a form
suitable for recording in the county where the property is located. Approval or
disapproval of the instrument shall occur within 30 days after submittal for approval
and shall be based upon the sufficiency of the instrument to create the rights and duties
indicated in the special condition. Within 60 days after approval, the permittee shall
record the instrument and shall provide evidence of recording to the Commission.
3. Improvements. Prior to the use or occupancy of any facility authorized herein, the
pernuttee or its assigns, shall complete the following public access improvements,
substantially in accord with preliminary landscape plans entitled "Granada Royale
Hometels (Embassy Suites)," dated August 24, 1986, prepared by Blunk Associates,
Architects and Callander Associates, Landscape Architects. The public access
improvements authorized by Amendment No. Four, and as described in (c) below,
shall be constructed and completed substantially in accord with the preliminary
landscape plan entided "Pazcel 10 Shoreline, Preliminary Site Development Plan,"
dated February 22, 1988, prepared by Callander Associates Landscape Architects:
a. Construction of a 60-foot-long, 3,400-square-foot wooden fishing pier on the
Bay shoreline as shown on Exhibit B, attached;
b. Placement of 171,056 square feet of landscaped public access improvements
along the Bay and Anza Lagoon shorelines, including a 2.5-acre park on the
peninsula as shown on Exhibit B, attached;
c. Placement of 54,050 square feet (1.24 acres) of irrigated landscaped pubIic access
improvements along the southeast shoreline of Anza Lagoon as shown on F�chibit
C attached.
d. Placement of a 3,520-linear-foot, 10-foot-wide pedestrianfbicycle pathway
system along the Bay and Anza Lagoon as shown on Exhibits B and C, attached;
e. Placement of benches and trash receptacles within the public access areas at
locations approved pursuant to Special Condition II-A-1;
PERMIT NO. 6-83
(Issued on Apri125, 1983, As
Amended Through June 19, 1998)
AMENDMENT NO. SIX
Fe1Cor/CSS Holdings, L.P.
Page 5
f. Placement of six public access signs, one public fishing sign, and approxirnately
seven public pazking signs of a size, design, and with information approved by or
on behalf of the Commission placed at locations approved pursuant to Special
Condition II-A-1;
g. Placement of not less than 20 designated public parking spaces at locations
approved pursuant to Special Condition II-A-1; and
h. The public restroom facilities shall be readily identifiable from the shoreline,
remain open during daylight hours, and be free of charge.
4. Maintenance. All areas and improvements required by Speciai Condition II-B
including landscaping, signs and public paths shall be permanendy maintained by, and
at the expense of, the permittee, any assignees, lessees, and sublessees. Maintenance
shall include repairs to all path surfaces, replacement of any plant material that dies or
becomes unkempt, periodic clean-up of litter and other materials, and assuring that
public access signs remain in place and visible. Within 30 days after notification by
staff, the permittee shall correct any maintenance deficiency noted in a staff inspection
of the site.
5. Riprap. Prior to use of any facility authorized herein, the permittee sha11 remove all
debris and any exposed reinforcing bar from the riprap along the shoreline and dispose
of such outside of the Commission's jurisdiction.
C. Permit Recording. Prior to the commencement of construction, the permittee shall record
this amended permit or a notice referring to this amended pemut in accordance with applicable
provisions of Government Code Section 27291.5 with San Mateo County and shall provide
evidence of recording to the Commission.
Iil. Findings and Declarations
This amended authorization is based upon the Commission's findings and declarations that the
work authorized herein is consistent with the McAteer-Petris Act, the San Francisco Bay Plan, the
Commission's Amended Management Program for San Francisco Bay, and the California
Environmental Quality Act for the following reasons:
A. Use. San Francisco Bay Plan Map No. 9 does not designate the site for any priority use.
However, a Bay Plan note for the City of Burlingame states: "Prepare precise plan and
development program for waterfront; include continuous public access to Bay shoreline for
viewing and fishing. Some fill may be needed." As the Bay Plan Map does not designate the site
for a priority use, the proposed project is compatible with the use requirements of the Bay Plan.
B. Fill for Fishing Pier. The pernuttee has proposed a 3,400-square-foot fishing pier along the
Bay side of the project. Although the fishing pier does not extend to deep water, the Commission
finds that it will improve fishing opportunities along this section of shoreline which is now heavily
used by iishermen. The Commission further notes that this section of the Bay shoreline of the
Anza Airport Park Subdivision is approximately 2,000 feet long (of which about 1,500 feet are
PERMIT NO. 6-83
(I�sued on Apri125, 1983, As
Amended Through June 19, 1998)
AMENDMENT NO. SIX
Fe1Cor/CSS Holdings, L.P.
Page 6
within this site) and is essentially straight. The Design Review Board accepted the permittee's
assertion that the construction of the fishing pier would introduce some variery into this otherwise
long,'straight shoreline. Although such variery could be provided by other means, such as
excavating a portion of the shoreline, the Cor�mission finds that such an aItemative would not aIso
serve the purpose of improving fishing. Therefore, the Commission finds that the purposed fishing
pier constitutes a water-oriented recreational use for which some fill may be authonzed and minor
fill to improve shoreline appearance and public access.
C. Public Access. The 15.74-acre site is bounded by the Bay to the north, Anza Lagoon to
the east, and existing development is located to the west and south. The long, irregulazly-shaped
pazcel forms a peninsula at its eastern end and includes a strip of land totaling 1.24 acres on the
southeast shoreline of the Lagoon. About 4.6 acres of the 15.74-acre site are in Anza Lagoon. The
project site has 1,SOO linear feet of Bay shoreline and 2,0201inear feet of Lagoon shoreline. Of the
11.14-acre dry land portion of the site, 6.64 acres aze located within the 100-foot shoreline band.
The site is flat and supports no significant plant or animal life except within the Lagoon and in the
mazsh vegetation along its edge.
The permittee proposes a total of 5.36 acres of public access improvements on the I I.I4 acres
of dry land at the site. An additiona15,600 square feet outside the Commission's jurisdiction will
also be improved for public access. Approximately 6,000 square feet of the ground floor area of
the restaurant structure will be used for public services and some commercial uses. The hotel is
located, at its closest point, 60 feet from the shoreline, and the restaurant structure is located about
50 feet from the shoreline. The minimum width of the public access azea is 35 feet, adjacent to a
portion of the public parking. Public access improvements consist of a 10-foot-wide pathway
running along 3,520 linear feet of Bay and Lagoon shoreline. Public access improvements along
the southeastern shoreline of Anza Lagoon consist of a 54,050-square-foot (1.24 acres) landscaped
area including a 10-foot-wide, 720 foot long pedestrian/bicycle pathway system along the Lagoon
edge and a 4,600-square-foot paved plaza area furnished with benches and a trash receptacle.
Public access widths vary from a minimum of 30 feet to over 100 feet along this portion of the
Lagoon. A 2.5-acre park is located at the end of the peninsula and a 60-foot-long, 3,400-square-
foot fishing pier is located across from the combined restaurandpublic services building. The
remainder of the shoreline is landscaped, with public access widths varying from a minimum of 35
feet to a maximum of over 100 feet.
The Commission adopted public access guidelines for the Anza area. The guidelines state that
an important access area should be developed on the peninsula of this site. In addition, public
access widths along the Bay shoreline should average 75 feet wide with a minimum width of 40
feet or the height of the adjacent building. The minimum and average widths proposed are slightly
less and the public access next to the hotel is less than its height. However, the guidelines also
state: "Any exceptions to the minimum widths of public access azeas shall be allowed oniy if the
design of the building and adjacent public access is such that the public is encouraged to make
greater use of the shoreline and other substantial public access areas are provided to offset the
reduction in the minimum width...." An exhibit to the guidelines shows a conceptual plan for the
development of the site similar to that proposed in this application with a major public access area
on the peninsula which is the most important part of the site. The 2.5-acre park area on the
peninsula, the 3,400-square-foot fishing pier, and the 1.24-acre of public access along the
southeastern shoreline of Anza Lagoon offset the differences in the average and minimum widths
of public access listed in the guidelines and conform to the conceptual plan accepted by the
PERMIT NO. 6-83
(Is�sued on Apri125, 1983, As
Amended Through June 19, 1998)
AMENDMENT NO. SIX
FelCor/CSS Holdings, L.P.
Page 7
Commission as a reasonable alternative. Furthermore, during the Commission's review of the
public access guidelines, the conceptual project plan for the site involved a restaurant on fill. The
restaurant was perceived as an obstacle to public access, however, and the Commission stated that
no portion of the structure should be located on �ll. In iinalizing the design of the project, the
pernuttee relocated the restaurant so that not only was no fill involved but is now 50 feet from the
Bay allowing unobstructed access along the shoreline.
Therefore, the Commission iinds that the 2.5-acre park, the public aznenities provided in the
restaurant structure, the fishing pier, and the 1.24-acre public access area on the southeastern
shoreline of Anza Lagoon will provide a variety of public access amenities, will provide
continuous public access to and along the shoreline and will improve a significant fishing area
along the Bay and, therefore, is the maximum feasible public access consistent with the proposed
project.
D. Public Trust. By this amended pernut, the Commission deternunes that the proposed project
is consistent with public trust needs.
E. Tratfic. Working with Commission staff, the Metropolitan Transportation Commission
(MTC) has recently completed a study relating recently proposed developments east of Highway
101 with the already strained capacity of that freeway. Highway 101 is already at capacity in
several sections and the study concluded that if all the projects proposed for development east of
the freeway are completed, traffic on Highway 101 may exceed capacity by 40 percent at peak
hours. If that takes place, there will obviously be pressure to either widen the freeway or construct
a new expressway to the east of the existing freeway. Either would require extensive fill in the
Bay.
The Commission finds that this project should not be treated as a precedent or encouragement
for the authorization of such fill beyond that considered by the Commission in adopting the public
access guidelines for this subdivision. No policies have yet been adopted to deal with the overall
issue of traffic generation east of Bayshore and there is little evidence to suggest that this project by
itself will lead to additional fill in the Bay. Moreover, the public access proposed is consistent with
the Commission's public access guidelines for this area. Consequently, the Commission fnds the
project to be consistent with the Bay Plan and the McAteer-Petris Act. However, the Commission
also recognizes that some policies will have to be developed in coordination with affected Iocal,
state, and regional agencies to deal with the overall problem to avoid the major fills that might take
place if no other transit or planning alternatives are chosen
F. Environmental Impact. The City of Burlingame, the lead agency, certified the
Environmental Impact Report for the proposed project on January 3, 1983. Pursuant to Regulation
Section 11501, Amendment Nos. One, Two, Three, Four a� Five and Six are categorically
exempt from the requirement to prepare an environmental impact report. �
G. Conclusion. For all these reasons, the project provides maximum feasible public access
consistent with the proposed project. The Commission further finds, declares, and certifies that the
activities authorized herein are consistent with the Commission's Amended Management Program
for San Francisco Bay, as approved by the Department of Commerce under the Federal Coastal
Zone Management Act of 1972, as amended.
PERMIT NO. 6-83
. . (ISsued on Apri125, 1983, As
� Amended Through June 19, 1998)
AMENDMENT NO. SIX
Fe1Cor/CSS Holdings, L.P.
Page 8
IV. Standard Conditions
A. All required pernussions from governmental bodies must be obtained before the
commencement of work; these bodies include, but are not limited to, the U. S. Army Corps of
Engineers, the State Lands Commission, the Regional Water Qualiry Control Board, and the city
and/or county in which the work is to be performed, whenever any of these may be required. This
amended permit does not relieve the pernuttee of any obligations imposed by State or Federal law,
either statutory or otherwise.
B. The attached Notice of Completion and Declazation of Compliance form shall be returned to
the Commission within 30 days following completion of the work.
C. Work must be performed in the precise manner and at the precise locations indicated in
your application, as such may have been modified by the terms of the amended permit and any
plans approved in writing by or on behalf of the Commission.
D. Work must be performed in a manner so as to minimize muddying of waters, and if diking
is involved, dikes shall be waterproof. If any seepage returns to the Bay, the permittee will be
subject to the regulations of the Regional Water Quality Control Board in that region.
E. The rights, duties, and obligations contained in this amended pernut are assignable. When
the pernuttee transfers any interest in any property either on which the authorized activity will occur
or which is necessary to the full compliance of one or more conditions to this amended permit, the
pernuttee/transferor and the transferee shall execute and submit to the Commission a pernut
assignment form acceptable to the Executive Director. An assignment shall not be effective urnil the
assignee executes and the Executive Director receives an acknowledgment that the assignee has
read and understands the pernut and agrees to be bound by the terms and conditions of the
amended pernut, and the assignee is accepted by the Executive Director as being reasonably
capable of complying with the terms and conditions of the permit. _
F. Unless otherwise provided in this amended permit, all the terms and conditions of this
amended pernut shall remain effective for so long as the amended pernut remains in effect or for so
long as any use or construction authorized by this amended permit exists, whichever is longer.
G. Unless otherwise provided in this amended permit, the terms and conditions of this
amended pernut shall bind all future owners and future possessors of any legal interest in the land
and shall run with the land.
H. Unless otherwise provided in this amended permit, any work authorized herein shall be
completed within the time limits specified in this amended pernut, or, if no time limits are specified
in the amended permit, within three years. If the work is not completed by the date specified in the
amended permit, or, if no date is specified, within three yeazs from the date of the amended permit,
the amended permit shall become null and void. If a pernut becomes null and void for a failure to
comply with these time limitations, any fill placed in reliance on this amended permit shall be
removed by the permittee or its assignee upon receiving written notification by or on behalf of the
Commission to remove the iill.
PERMIT NO. 6-83
(Issued on Apri125, 1983, As
Amended Through June 19, 1998)
AMENDMENT NO. SIX
FelCor/CSS Holdings, L.P.
Page 9
I. Except as otherwise noted, violation of any of the terms of this amended permit shall be
grounds for revocation. The Commission may revoke any amended pemut for such violation after
a public hearing held on reasonable notice to the pernzittee or its assignee if the amended permit has
been effectively assigned. If the amended permit is revoked, the Commission may deternune, if it
deems appropriate, that all or part of any fill or structure placed pursuant to this amended permit
shall be removed by the permittee or its assignee if the amended permit has been assigned.
J. This amended pernut shall not take effect unless the pernuttee executes the original of this
amended pemut and returns it to the Commission within ten days after the date of the issuance of
the amended permit. No work shall be done until the acknowledgment is duly executed and
returned to the Commission.
K. Any area subject to the jurisdiction of the San Francisco Bay Conservation and
Development Commission under either the McAteer-Petris Act or the Suisun Mazsh Preservation
Act at the time the amended permit is granted or thereafter shall remain subject to that jurisdiction
notwithstanding the placement of any fill or the implementation of any substantial change in use
authorized by this amended pernut.
L. Any azea not subject to the jurisdiction of the San Francisco Bay Conservation and
Development Commission that becomes, as a result of any work or project authorized in this
amended permit, subject to tidal action shall become subject to the Commission's "bay" jurisdic-
tion.
M. Unless the Commission directs otherwise, this amended pemut shall become nuIl and void
if any term, standard condition, or special condition of this amended pernut shall be found illegal
or unenforceable through the application of statute, administrative ruling, or court determination. If
this amended permit becomes null and void, any fill or structures placed m reliance on this
amended permit shall be subject to removal by the permittee or its assignee if the amended permit
has been assigned to the extent that the Commission deternunes that such removal is appropnate.
Any uses authorized shall be ternunated to the extent that the Commission determines that such
uses should be ternunated.
Executed at San Francisco, California, on behalf of the San Francisco Bay Conservation and
Development Commission on the date first above written.
WILL TRAVIS
Executive Director
San Francisco Bay Conservation and
Development Commi�sion
PERMIT NO. 6-83
, , (Issued on Apri125, 1983, As
Amended Through June 19, 1998)
AMENDMENT NO. SIX
Fe1Cor/CSS Holdings, L.P.
Page 10
�
VEN A. McADAM
Deputy Director
SAM/JGJ/vm
cc: U. S. Army Corps of Engineers, Attn: Regulatory Functions Branch
San Francisco Bay Regional Water Qualiry Control Boazd,
Attn: Certiiication Section
Environmental Protection Agency, Attn: Mike Monroe, W-3-3
City of Burlingame Planning Department
State Lands Commission, Atm: Fred Sledd
Kendall G. Petterson, Architect
Embassy Suites, Attn: Bob Burns
* * * * �x �x * * * * * * * * * � � * x� * * * :�
Receipt acknowledged, contents understood and agreed to:
Executed at
Applicant
On
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