HomeMy WebLinkAbout1366-zTOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 1366 Z
Date ..................... A~ri.t ....... ~t ............. ~-6t..
Permission is hereby granted to:
H.e.i~.~.~...H~ ~ ......................................................
................. ~e~n~rt V'"'~f~"~' ........................
to ....... Bui.~d...ne~..one-.~i.}y.-d~e.~'~i~ ...............................................................................
at premises located at ....~./S.....~O~Z,t;~..R.~j~ ....................................................................................
......................................................... ~Iff~" '"N::~;' ...................................................................
pursuant to application dated ....:,. .............................. ~';Peb'"'-~,]L ....... 19.6'L., and approved by the
Building Inspector
Fee $:'l'O,vOO"'"pd" ca~h
Building Inspector
TOWN []F SOUTHOLD
OFFICE OF BUILDING INSPECTOR
TOWN CLERK'S OFFICE
SOUTHE~LD, N. ¥.
Mr. H.F.Bishop
Commissioner of Public Works
Suffolk County
Yaphonk Ave., Yophonk, N. Y.
OR 27
Dear Sir:
In accordance with Section 2391( of the General Municipal Law of the
consolidated ka,ws of the State of New York, this is to notify the Commis-
sioner of Public Works of the County of Suffolk that ...... I:[e,,~lz~,..}~,s.a .....
...... ..#...,z. 5..6.. ,6. ............................................................
h~s applied to the Town of Southold for a permit to construct a building
'
a ..R;F..$..M¢.'~.~ ..~.0.¢,.d..~_.~./.~.....C..q,.u.~.%.Z...r.o.a.~...2..2/~ Southotd, N.Y.
Corner Beverly & 01d Cove Blvd (private rd~q)
as shown on the attached plot plan, submitted in triplicate, dated ................
......... ~.~?...~.....~,.~..z....]-..9.~,.]:. and titled ...~.~:..o.~....~..].,~,..~.o,,~,,,,~,~,,]_,,~.!,2_%...~....~.s
We shall withhold further action on this application for ten days or as
otherwise provided in the aforementioned Section 239K.
l~/17/6~ APP~OVED pursuant to Sec.
239K of tho General Municipal Law. Very truly yours,
No permit under Sec. 136 of 'the Highway
Law required as access will be from . /
private road for propose5 dwelling,l~ .r~
SUFFOLK COUNTY DEPT PUBLIC WORKS ,LxJ%
· p
~.F.BISH0_, C0mmissiomer Howard 2erry
Building nspector
Chief Engineer
TOWN OF SOUTHOLD
OFFIOE OF BWILDIN8 INSPEOTOR
T~WN CLERK'S OFFICE
'~Mr. H. Fo Bishop
Commissioner of Public Works
Saffolk County
rYaphank Ave., Yaphank, N. Y.
Dear Sir:
In accordance with Section 239K of the General Municipal Law of the
consolidated Lows of the State of New York, this is to notify the Commis-
,sioner of Public Works of the County of Suffolk that ...... ~{~.13,t;..~P,,-~ .....
...... ..~..r...s..h...a..m..o...m. ~ .q~ ,.....q?...e..e...n.~..o..r. ~ .~....?.~.: .~.~. ............................................
....... .0...~.....~.~!..$.~..¢~ .t..o..~,.~f... 13.6.¢~ ............................................................
has applied to the Town of Southold for o permit to construct a building
. as shown on the attached plot plan, submitted in triplicate, da,ted ................
......... .~.~.fl,~.~ .~....~. ~: ~....,.3:..?..6..3:. a nd titled.. ~..]:.0...t... ~..~. ]..~... ~.o..r....~ .3:..~;~..t....[.f.a.: .s.
'~We shall withhold'further action on this application for ten days or as
otherwise provided in the aforementioned Section 2391(,
Very truly yours,
building inspector
Town of Southold, N. Y,
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Exomlned...../..f¢~,~ y .......... ~,, ~. ............... / 19 ........ (¢/'
Approved.....(.~.~,~,:;~,:~.~....¢.~....( ............ 19_~.LPermit No. '~ / 3 ~ (~
Disapproved o/c .... ~ ~.¢ ~ ~] .....
(Building InSpector)
Application No. ,,../.,?.,~.,,(*. ..........
APPLICATION FOR BUILDING PE~',MIT
Date ............................................................ ] 9....A .....
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and su~omitted in duplicate to the Building
Inspector.
b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets
or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this location.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such
permit shall be kept on the premises available for inspection throughout the progress of the work.
e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy
shall have been granted by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
Regulations, for the construction of buildings, additions or a Iterations, or for removal or demolition, as herein described.
The applicant agrees to comply with all applicable laws, ordinances and regulations.
(Signature of applicant, or name, if a corporation)
.................... G~.ee~'lpolt 2 ~... j~r,, .~ ,. ........................................
(Address of applicant)
State wheth.er applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
....................... .-.. . llder. ..................................................................................................................
Name of owner of premises.,..~llt~..~(~l~ ......................................................................................................................
If applicant is a corporate, signature of duly authorized officer.
(Name and title of corporate officer)
1. Location of land on which proposed work wHI be done. Map No: ..~ .................................. Lot No: ...,~ ........
Street and Number ....~/~.....~Q~..~O~.I ........ 8.0~.....~.;~ ................................................................
Municipahty
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy.....~.~g.~..~ .......... .....................................................................
b. Intended use and occupancy....~..~:~.~...¢~¢~ ...............................................................................
3. Nature of
Repair .....
4. Estimated
5. If dwelling
If garage,
6. If busines:
7. Dimension:
Height ....
Dimension
Depth .....
8. Dimension'.
Height ....
9. Size of Io'
10. Date of Pt
11. Zone or u
12. Does prop.
13. Name of
Name of,
Nome of
Locate cleo
property lines. G
whether interior
~vork (check which applicable): New Building....31;X~ ........ Addition .................... Alteration ....................
............... Removal .................... Demolition .................... Other Work (Describe) ....................
.~ost ......... .~....~.~. ~...~..*~..~...~./~ .................. Fee .....~O,00 ......................................................................... '
(to be paid on filing this opplicatlon)
number of dwelling units ........~ ................ Number of dwelling units on each floor ............................
number of cars ............................................................................................................................................
, commercial or mixed occupancy, specify nature and extent of each type of use ..............................
of existing structures, if any: Front ............................ Rear ............................ Depth ............................
....................... Number of Stories ............................................................................................................
of same structure with alterations or additions: Front ................................Rear ................................
....................... Height .............................. Number of Stories ................................
of entire new construction: Front.....~O ................... Rear .......... '30 ............ Depth ...~1~ ...................
....................... Number of Stories ...... ~ ..............
Front '"'~0 ................. Rear ........ '~O ............ Depth '"'~0 .................
rchase ........................................................ Name of Former Owner ..../~.~...~.~.~ .........................
;e district in which premises are situated....#~,it..~tl~,:l~l~8~ ...............................................................
~sed construction violate any zoning law, ordinance or regulation? '"!~ ............................................
)wner of premises...l~,...~8~t .................... Address ....... 13~eelt~Ot~ ............... Phone NO .....................
.rchitect ........................................................ Address ............................................ Phone NO .....................
Contractor .................................................... Address ............................................ Phone NO .....................
PLOT DIAGRAM
iIv~;e and distinctly all buildings, whether existing or proposed, and indicate all set-bock dimensions from
street and block numbers or description according to deed, and show street names and indicate
9r corner lot.
STAT OF ) s s.
COUNTY OF ...... .%~..?..? ............. )
(Name of indivlduol signing opplicotion)
~bove m~ed, He IS the ........... ~ ..............................................................................................
of s~id ow~e~ or ow~e~s, ~d [s d~l~ ~f~o~ized fo ~er~orm or Hove ~e~formed SHe scid wor~ ~d fo m~ke c~d file
this opplicot on; that al statements contained in this application are true to the best of his knowledge and belief;
and that the work will be performed in the manner set forth in the app ication f led therewith.
Sworn to before me this J~DITH T. BOKEN
~ota~ Pubic. State of Hew York
~ - ~ No ~3 3 su ok Cou, (Signature of applicant)
, ,,.~ do of ~.w~ ..... ~.~.~ Y
.................... Y , ~Mm sm0n ~xp~ es Ma ch 30, tg~
........... ~.. ~nty ,
,o,o ......... , .............. . ...........
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y,
App,cot,on No.
APPLICATION FOR BUILDING PERMIT
Date .... ............... ......
INSTRUCTIONS
a, This application must be completely filled in by typewriter or in ink and su~)mitted in duplicate to the Building
Inspector.
b. Plot plan showing location of lot and of buildings on premises, relationship to ed}oining premises or public streets
or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this location.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d. Upon approva~ of this application, the Building Inspector will issue a Building Permit to the applicant. Such
permit shall be kept on the premises available for inspection throughout the progress of the work.
e. No building shall be occupied ar used in whole or in part for any purpose whatever until a Certificate of Occupancy
shah have been granted by the Building inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a E~uHding Permit pursuant to the
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
Regulations, for the construction of buildings, additions or a Iterations, or for removal or demolition, as herein described.
The applicant agrees to comply with all applicable laws, ordinances and regulations.
(Signature of applicant, or name, if a corporation)
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises....~.e.~G~...~-~.,~.,~ ......................................................................................................................
If applicant is a corporate, signature of duly authorized officer.
(Name and title of corporate officer)
1. Location of land on which proposed work will be done. Map No: ...~×~ ................................. Lot No: ..... ~×. .......
Street and Number ....~q.Z'.~......~Tf~,~..'b.b...Z~o~.c~.~ ........ ~'~g,I~.'Lcl..~,.....D,T.,.~ ..................................................................
Municipality
2. State existing use and occupancy of premises and intended use and' occupancy of proposed construction:
o. Existing use and occupancy......~.~,~.~.l~..~.~,~Zc]. ....................................................................................................
b. Intended use and occupancy......°..~...e'...~]~!.~...~..~.~..~.'v.~.?.-.].-..]..~,g,~ ..............................................................................
10.
11.
12.
13.
Nature of work (check which applicable): New Building....~ ......... Addition .................... Alteration ....................
Repair .................... Removal .................... Demolition .................... Other Work (Describe) ....................
Fstimated Cost ......... ~;,..~ ~ .~0. O. ?..O..~....P../. ~ ................... Fee ..... .~...0. ~...O..0. .........................................................................
(to be paid on filing this applfcetion)
If dwelling, number of dwelling units .........O.~e ................. Number of dwelling units on each floor ....... ~.; ................ :.
If garage, number of ~
if business, commercial or mixed occupancy, specify nature and extent of each type of use ..............................
Dimensions of existing structures, if any: Front ............................ Rear ............................ Depth ............................
Height ............................ Number of Stories .............................................................................................................
Dimensions of same structure with alterations or additions: Front ................................ Rear ................................
Depth .............................. Height .............................. Number of Stories ................................
Dimensions of entire new construction: Front.. 30 .......... Rear .......... 2q.O.. ............ Depth ...~ ......................
Height ............................ Number of Stories .......Cll'l~ ...............
Size of lot: Front ...l~°O. ................. Rear ........ 3.2.0 ............. Depth ...[L2.~ .................
Date of Purchase ........................................................ Name of Former Owner .... .~.,...P~iC:~DZl~ .........................
Zone or use district in which premises are situated....!!]~.!!...~.l~.J.~¢~.$. ...............................................................
Does proposed construction violate any zoning law, ordinance or regulation? ...D,~ ............................................
Name of Owner of premises..J~[.,...~?.~.~. .................... Address ....... G-~..~.~Zq~C~Z'.'[; ............... Phone NO .....................
Name of Architect ........................................................ Address ............................................ Phone NO .....................
Name of Contractor .................................................... Address ............................................ Phone NO .....................
PLOT DIAGRAM
Locate clearly and distinct/,/ all buildings, whether existing or proposed, and indicate all set-back dimensions from
property lines. Give street and block numbers or description according to deed, and show street names and indicate
whether interior corner lot.
STAT S S,
COUNTY' OF .......... f~k~- ........... }
.................................... ~.e...],l~.kl.~..~...~.~. .................................. being duly sworn, deposes and says that he is the applicant
(Name of individual signing application)
above named. He is the ................ .0,~/D,~.~...~....~.~.~.f~'. ........................................................................................................
(Contractor, agent, cor~5orate officer, etc.)
of sa d owner or owners, and s duly authorized to perform or have performed the said work and to make and file
this app Jcation; that a statements contained in this application aCe true to the best of his knowledge and belief;
and that the work will be performed in the manner set forth n the application filed therewith.
Sworn to before me this ~uofr~ T. SO~ (Signature of a~cant)
FOEM NO, 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OF~=ICE
SOUTHOLD, N. Y.
Approved ........................................ , 19 ........ Permit No ........... i..~6~E ..........
Disapproved a/c ............. ~. ~.~ .~... :...~-. · ~.. ..................................................
(Building ~;~'~ r)
APPLIGATION FOR BUILDING PERMIT
REikL~MAL of
Application No, ...13.~.~ ...............
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted in duplicate to the Building
Inspector.
b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or
areas, and giving a detailed description of layout of propertymust be drawn on the diagram which is part of this application.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d. Upon approval of this application, the Building Inspector will issue o Building Permit to the applicant. Such
permit shall be kept on the premises available for inspection throughout the progress of the work.
e. No building shall be occupied or used in whole or Jn part For any purpose whatever until a Certificate of Occupancy
shall have been granted by the Building Inspector.
APPblCATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described.
The applicant agrees to comply with all applicable laws, ordinances, building code and regulations.
Helmut Hass
(Signature of applicant, or name, if a corporation)
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Owner- builder
Name of owner of premises ...... ~[2.1~U~..]~I~Jas ................................................................................. ...................................
If applicant is o corporate, signature of duly authorized officer.
(Name and title of corporate officer)
1. Location of land on which proposed work will be done. Map No: ......... ..x..~..~ ........................... Lot No: .....x.~ .........
Street and Number ...... ~/~.....]~ez,~..~:..R. eac~w....~'<),=~-bh~).]:</.:/...]~'.,.~. ...................................................................
rvtunicipahty
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ........... .V.A~U~.J;;...~,9,,q~ ..............................................................................................
b. Intended use and occupancy .............. Q13.(~..~ftt!L~J13,L..Clw. e.L'LEt3C. .....................................................................
3. Nature of work (check which applicable): New Building ..,~ ..... Addition .................. Alteration ..................
Repair .................... Removal .................... Demolition .................... Other Work (Describe) ......................................
(to be paid on filing this appfication)
5. If dwelling, number of dwelling units ....... O~e .............. Number of dwelling units on each floor ............................
If garage, number of cars ...........................................................................................................................................
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ................................
7. Dimensions of existing structures, if any: Front .......................... Rear .......................... Depth ............................
Height ............................ Number of Stories ...............................................................................................................
Dimensions of same structure with alterations or additions: Front ................................ Rear ................................
Depth .............................. Height .............................. Number of Stories ........................................
8. Dimensions of entire new construction: Front ....... ,~.Q ................ Rear ....... ;.....~RD. ......... Depth ........ 2,~ ...............
Height ............................ Number of Stories .....QBe. ................
9. Size of lot: Front ....... ~..0.0. .............. Rear .......... ~qf). .......... Depth .....~L2.~'...~?/.. ............
10. Date of Purchase ........................................................ Name of Former Owner ......... .~.,...~1,C];l~gZl,0, ....................
11. Zone or use district in which premises are situated ..................... .~. ....... .+.~.v. ..........................................................
12. Does proposed construction violate any zoning law, ordinance or regulation? ..... ~Q ............................................
13. Name of Owner of premises ...... .~..:...~.{.~.s...s. ................. Address .......... ~'.O.!4,t,~P.~f] ............... Phone No .....................
Name of Architect ...................................................... Address ............................................ Phone No .....................
Name of Contractor .................................................... Address ............................................ Phone No .....................
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from
property lines. Give street and block numbers or d?scription accordi~t,~ to,, deed, and show street names and indicate
whether interior or corner lot. -' , _ l" 4 ' "?".
STATE OF NEW ~ORK, 1 S.S.
COUNTY OF ....... .~$..t'.O. ~.~ .......... f
............................ ~..9.~!~.1~...~&~ .......................................... being duly sworn, deposes and says that he is the applicant
(Name of individual signing application)
above named. He is the ......... D.~tl~....~-....l~l.l..t3,8.~ ............................................................................................................
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file
th s ~pplicat on; that all statements contained in this application are true to the best of .his knowledge and belief;
and that the work will be performed in the manner set forth in the opglication filed therewith.
Sworn to before me this
.................. CL' ';' .......
Notary Public,~ .-.. ,, .,,,,, · ,~~L ~.~,~}~.~ ... County/~,(,~ ', ,,,,, (S.gnature of app cant)
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Examined .............. ..... R~]~,~AL of
Approved " 19 ........ Permit No ......~.~6~ ...............
Disapproved
a/c
~ ' .............................. i'~uilding In§~;~;;;i .........................
Application No....~-~.~. ...............
APPLICATION FOR BUILDING PERMIT
RE~AL ~
Date ........................ Ns~ch ....... ~ ........... , 19..6~ .....
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted in duplicate to the Building
Inspector.
b. Pl9t plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or
areas, and giving a detailed description of layout of propertymust be drawn on the diagram which is part of this application.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d. Upon approval oF this application, the Building Inspector will issue a Building Permit to the applicant. Such
permit shall be kept on the premises available for inspection throughout the progress of the work.
e. No building shall be occupied or used in whole or in pa rt for any purpose whatever until a Certificate of Occupancy
shall have been granted by the Building Inspector.
APPLICATION tS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described.
The applicant agrees to comply with all applicable laws, ordinances, building code and regulations.
(Signature of applicant, or name, if a corporation)
.................... ]~.th.. Road...~mthol~l ............................ (Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
O~ner - ..b..u,~.lde~ ....
Name of owner of premises ........ J~r/i~..J~T~fi.~ ..................................................................................................................
If applicant is a corporate, signature of duly authorized officer.
(Name and title of corporate officer)
1. Location of land on which proposed work will be done. Map No: ......... ~r~.. ...................... Lot No: ...;Y~g~f .....
Street and Number ..... ~/.~....~O~.¢~..R~ft¢.~.....~O~¢}~l¢l, ..................................................................................
Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ..... ~.~.~TL$...],.8,1~.~. ...................................................................................................
b. Intended use and occupancy ..... ozie....C~,~J.].~t...l:].we~.lzLrl~ .............................................................................
3. Nature of work (check which applicable): New 13uilding ........ ~ Addition .................. Alteration ..................
Repair .................... Removal .................... Demolition .................... Other Work (Describe) ......................................
4. Estimated Cost ..... .~.~.~0.,~/.~ ................................. Fee ........ .~...~...-.~.~.~.e..~...~..~.. ....................................................
(to be paid on filing this application)
5. If dwelling, number of dwelling units ........ al;la ............. Number of dwelling units on each floor ............................
If garage, number of cars ...........................................................................................................................................
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ................................
7. Dimensions of existing structures, if any: Front .......................... Rear .......................... Depth ............................
Height ............................ Number of Stories ...............................................................................................................
Dimensions of same structure with alterations or additions: Front ................................ Rear ................................
Depth .............................. Height .............................. Number of Stories ........................................
8. Dimensions of entire new construction: Front ........ ~0 ............... Rear .....,~.0.. ................. Depth ....... ..2..~.. ...............
Height,. ........................... Number of Stories ...... O~e ...............
9. Size of lot: Front ...]J~gt ................. Rear ....... ].l~t0 .............. Depth ..]~,~0. ......................
10. Date of Purchase ........................................................ Name of Former Owner ......... W.,...~.::I.~'J~I~'ll]. ....................
1~. Zone or use distriot in which premises are sffuoted ........... ~......~.~.~ .....................................................................
12. Daes propased canstruction vialate any zoning law, ordinance ar regulation? ........... ~ .....................................
13. Name of Owne~ of premises ..... ~,...~.8.~ .................. Address ......~..O...~..t,.,,~.,O.]...~. .................... Phone No .....................
Name of Architect .......................... ?.. ......................... Address ............................................ Phone No .....................
Name of Contractor ........................ ..". ......................... Address ............................................ Phone No .....................
PLOT DIAGRAM
Locate clearly and distinctly all buildings, ~hether existing or proposed, and indicate all set-back dimensions from
property lines. Give street and block numbers o1~ Jescril~tioG~according to deed, and show street names and indicate
whether interior or '"""-'-.~. ..... ~
cc rner I¢.,,, I't~
STATE OF NEW YORK,
COUNTY OF ...$:~'~.O~.]l; ............~ S.S.
.......................... ~l.ml~t,..]~&~.l~ ............................................ being duly sworn, deposes and says that he is the applicant
(Name of individual signing application)
above n~med. He is the ............ ~...~...~. ........................................................................................................
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file
this application that all statement~ contained Jn this application are tru~to the best of his knowledge and belief;
and that the work will be performe~ in, the manner set forth in the ~li~a[ionjiled t~rewith.,
Sworn to before me this ..~.....~.....,
. ,,'Z~d ~ ' .~ ,.~ ~', r ~ . ..~ ............ . .............. : ...................................
Notary Pubhc,~A;...t ............ ~.~..~..~ ........ County (S~nature of apphcant)