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<br /> • _ - .briny bar me tint duly swan,if for himself,deposes end tpyf;thin ft, Ihti .' "-i
<br /> Can .. .,.}$e~Dial-be it j •A 3 A...2;iC'L of the above noted t aporation;thin M read the
<br /> egpilt ebon etalhatlti knows the contents t{+rrioi,and that ell miters and thing therein eat forth w true i( own • '� 0C .
<br /> 4,...* ,and he donut to conform to all rules and regulations ptomulyated by the DIPARTMENT Of REVIEW/11R CONM it:.
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<br /> suiacesadb*No swoon TOOtfOwl wit TWO _ `l -
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<br /> wawa Neat MY COMM1113,0M exnOatr /l ei tr1'1 �MtM1«itt►MMY:. 1
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<br /> IN$TRUCTIONfi: it ter psalms em looted"deign a etty a tom,HO sse rove)therm below should be tined by the sir. and Clerk If the Breath
<br /> M homed in a sootily.shut We worovel Mooed bit Nose by the 6Tteitnten of the$oard or County Conrnl.siontn and the Clem M bind keel N,tier _. .
<br /> adoeoce es othuwNt.the toed heenaina authority r some otetw official.than such epprowl should be s./nfd by such Obeid. - /.. .a,-
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<br /> REPORT AND APPROVAL Of LOCAL LICEM$IMG AUTt10RITr '' ''• .t•' :.
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<br /> The fortipoinc applieatitin has been i*.nti/ted iftd thi prrrttistt,bushel's;conducted and cfiaraeter of the fppficant k nth pry, FY•
<br /> rat do report that such permit,if panted,will comply with the provision of Title 12,Article N,C A.S.1973,as amended.4' ,r# ,
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<br /> _ heriore the f We9oiny epptigtion it hereby aportd.
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<br /> DATED AT - THIS DAY Of .A.D.t$ 1/'
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<br /> NAME Of TOWN,CITY 00 COUNTY ~' y J- w •1 ' r
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<br /> mow 04_41--..•$ 1(4.1 e«wy c.atwt+wwnarr- - ,,,' .
<br /> r Tito d Otnes L/t.adee Authority . ..'4- ',
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<br /> ATTEST- •
<br /> Core or sec/Mery of*toe.Offi 0 wring ,:4.:4 11k
<br /> Orrick,/Sena or Me Lkenyry Authority t ../ 1,
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