HomeMy WebLinkAbout3166-zFORM NO. 4
TOWN OF 5OUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
UPDATED
Certificate Of Occupancy
No. Z15426 Date November 26 - .86.
.................................................. 19 .
THIS CERTIFIES that the building .. pp.e., .f.a.m.i.l.y..d.w.e..1.1.i.n.9' .......................
Location of Property 1695 LEETON DRIVE SOUTHOLD --
House No. Street Hamlet
008
County Tax Map No. ]000 Section ...0.5.8. ...... Block .....02..........Lot ..... ..... ¥ ......
Subdivision ............................... Fried Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore filed in this office dated
.... J.u.3~y. ~.1 .......... }.9 .6.6. pnrsuant to which Building Permit No...3.1..6.6.Z. .............
dated . .Jul.y... 2 1 ................. 19..6.6, was issued, and conforms to all of the requirements
of the applicable provisions of the law. The occupancy for which this certificate is issued is .........
One family dwelling with attached deck.
The certificate is issued to ROBERT A. DVORAK
(owner~/~.~e~K~,Xt~
of the aforesaid building.
Suffolk County Department of Health Approval ...... .S.O.-~ 1. ,I .3 .............................
UNDERWRITERS CERTIFICATE NO ............. ¢1.6.3. Q $ .7.3 ...........................
Update of C.O. ~Z9130
Robert G. Dvorak
Building Inspector
Rev. 1/81
FOI~M NO. 4
TO~VN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificnte Of Occupnncy
No. ,Z~.~.O ...... Date .... .~..u~.y...27 .............. , 19.7..8.
THIS CERTIFIES that the building located at $./.~..L..e.e~.o.n...D?.t.¥.e ......... Street
Map No ............. Block No ........... Lot No ..................................
conforms substantially to the Application for Building Permit heretofore filed in this office
dated .J~-Y... 2.~ ............ , 19.6.6.. pursuant to which Building Permit No.. ~.3.6.6..Z.
dated .~Tt,~y...2.'l ............. , 19.6..6., was issued, and conforms to all of the require-
ments of the applicable provisions of the law. The occupancy for which this certificate is
issued is ... Pr.~v.~.~.e..0~.e.F..a~. ;L.3.y..]~.e.~.~. ~.r~g .....................................
The certificate is issued to ..... .R.o.b..e.x'.~..~..D~.qlT.a~.. ...............................
of the aforesaid building.
Suffolk County Department of Health Approval ..... 80.-.J .33. .......................
UNDERWRITERS CERTIFICATE No ..... N..~.O.~.7~ ................................
HOUSE NUMBER .............. Street ......... .s/.z..L..ep~o.~)..D.~.~.¥.e. .............
Sou'chold.~ N..e~. Yox'k
Building Inspector
TOWH OF SOUTHOLD
BUILDING DEPARTMEHT
TO'W~ CLERK'S
SOUTHOLD, H. Y.
~UILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 3166 Z
Permission is hereby granted to:
at premises Ia?ted at ...... ~/~....~.*D~,~Ver ................................................................ ..............
pursuant to application ~ated ~.,.......:....~ ...... ;?.......~t~.~h:~..Le~.;ili:.:, 19.~6~,, and approved by the
Building Inspector
Fee $...**tO~ .......
Build[no Inspector
FORM NO. 4.
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
CERTIFICATE nF EICCUPANEIY
No. Z. 27.62 ..... Date ............... ;Yu3~.y.. 2~..., 19 '67'
THIS CERTIFIES that the building located at 8/¢- .Leeton. D~,. ............ Street
Map No~ ...... Block No.. 'X1~;~ ...... Lot No:tKtg... '~Olll;l~o~d~' 'I~X'~ ...........
conforms substantially to the Application for Building Permit heretofore filed in this office
dated . 41%i~y' ' '2l ......... ' 1966' ' pursuant to which Building Permit N03166. Z ' '
dated ~ ,19 ., was issued and conforms to all of the require-
............ ~L1.y~ ' '2;;[' ' 6~
ments of the applicable provisions of the law. The occupancy for which this certificate is
issued is ........................................................................
~rivate one £a~tly dwelll=g
The certificate is issued to ........................................................
Rob1;, & Ma.vgare~ D,,'~er, Iessed)Wn$~ant)
of the aforesaid building.
Suffolk County Department of Health Approval~,~ '6' '~ '~' 'tP' r~' ~ ~'~'i~.~; '~r_~
Inspector
S-9
SCHD
SUFFOLK
TO WHOM IT MAY CONCERN:
The sewage
at Leeton DriveI Southold
COUNTY DEPARTMENT
Date
Bldg.
OF HEALTH
Permit No.
disposal facilities for a structure located
(Give deed location)
have been inspected by this department and found to be satisfactory.
Owner-Builder - Robert Dvorak
District Engineer
District Engineer~%~
FORM NO. 6
TOWN OF SOUTHOLD
Building Department
Town Hall
Southold, N.Y. 11971
765- 1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
NOV 2 41986
Instructions
A. This application must be filled in typewriter OR ink, and submitted m~ to the Building Inspec-
tor with the following; for new buildings or new use:
1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual
natural or topographic featu res. -
2, Final approval of Health Dept. of water supply and sewerage disposal-(S-9 form or equal).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installa-
tions, a certificate of Code compliance from the Architect or Engineer responsible for the building.
5. Submit Planning Board approval of completed site plan requirements where applicable.
B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing"
land uses:
1. Accurate survey of p~Operty showing all property lines, streets, buildings and unusual natural or
topographic features.
2. Sworn statement of owner or previous owner as to use, occupancy and condition of buildings.
3. Date of any housing code or safety inspection of buildings or premises, or other pertinent informa-
tion required to prepare a certificate.
C. Fees:
I. Certificate of occupancy $5.00
2. Certificate of occupancy on pre-existing dwelling
3. Copy of certificate of occupancy $1.00
4.¥acant Land C.O. $5.00
~). Updated C.O. $15.00
$15.00
Date .................
New C OhS truc t i on ...... Old or Pre-existing Building ............ Vacant Land .............
Location of Property . /~:~ /~(~'(;~/~..~ .~.~.~. .....
House No. Street Hamlet
.......
Owner or Owners of Property ....... / ! (/f~ ~/~ '..
County Tax Map No. 1000 Section .~ .~.~ .... - ....Block . .~..~ .... ~; .....Lot..
Subdivision ................................. Filed Map No ........... Lot No ........
Underwriters Approval ........................ Planning Board Approval ......................
Request for Temporary Certificate ..................... Final Certificate .......................
Fee Submitted $ .... ~.: ~ [½
Construction on above described building an eel licable codes and regulations.
Applicant ....................................................
Rev, 10-10-78
Robert Dvork& Wife
5 Jessen Street
Deer Park, L.I.
TOWN OF SOUTHOLD
OFFICE OF BUILDING INSPECTOR
TOWN HALL
$OUTHOLD, N. ¥. 11971
March 13, 1981
TEL. 765-1802
Dear Mr. Dvorak,
This is to advise you that the job under Building Permit
No. ~l~g~ issued to Robert Dvorad on
Jfzly 21, 1966 for New'Fami±y owelling appears to be
completed as of our la~ inspection. Before you can legally
use or occupy this structure a Certificate of Occupancy must
be issued.
Please fill out the enclosed form and return same to
the above office. There is a fee of $5.00 for a Certificate
of Occupancy
Thank you for your prompt attention.
Very truly yours,
GEORGE H. FISHER
Sr~ Building Inspector
GHF:sm
encl.
YOBM NO. 6
TOWN OF $OUTHOLD
Building Delm~tment
Town Clerks Office
Southold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This application must be filled in typewriter OR ink, and submitted in triplicate to the Building
Inspector with the'following; for new buildings or new use:
1. Final survey of property with accurate location of all buildings, property lines, streets, and
unusual natural or topographic features.
2. Final approval of Health Dept. of water supply and sewerage disposal--(S-9 form or equal).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and
installations, a certificate of Code compliance from the Architect or Engineer responsible for
the building,
5. Submit Planning Board approval of completed site plan requirements where applicable.
B. For existing buildlngs (prior to April 1957), Non-conforming uses, or buildings and "pre-existing"
land uses:
1. Accurate survey of property showing all property lines, streets, buildings and unusual natural
or topographic features.
2. Sworn statement of owner or previous owner as to use, occupancy and condition of buildings.
3. Date of any housing code or safety inspection of buildings or premises, or other pertinent in-
formation required to prepare a certificate.
C. Fees: 1. Certificate of occupancy $5.00
2. Certificate of occupancy on pre-existing dwelling or land use
3. Copy of certificate of occupancy $1.00
$5.00
u L%. ....
Dote ..J......~ ...........................
New Building ..../. ............... Old or Pre-existing Building ............................ Vacant Land ............................
Location Of Property ..................... ~ ............./ ....................... >'" · ;'
~ i ~,/o Rt~ ~
Owner Or Owners Of Property . .)~0.~..R,.~ .'..J~. ...................................................
Subdivision ....................................... Lot No ............ Block No ............. House No .............
Permit No..,~..!.~..~...~.. ..... Date Of Permit .................... Applicant ..................................................................
Health Dept. Approval ~,O.:L!.!..~. ............................ Labor Dept. Approval ................................................
Underwriters Approval I.~ ..~..~...0.~.?.~ ...................... P ann ng Board Approval ........................................
:../...
Request For Temporary Certificate ........................................ Final Certificate ........................................
Fee Submitted $ ....................................
Construction on above described building and~/ ,~:/ ~/~ ;.~) ,~,~permit meets all,,appli?~le codes and regulations.
,Sworn to before me this
................ day of ............................................
Notary Public .................................... County
(stamp or seal)
/
Instructions for Submission of Insealled Private SewaRe Disposal and Water Syste~ Application
Applications are to be submitted in duplicate. Required information should be
typed or legibly printed in ink. Inspectors are not permitted to make inspections
of installations until applications have been sub~itted to and accepted by this de-
partment.
The .item number on the application fo~m ahd item number listed below are the
1. O~ner's name and address - if o~ner and builder are same, so indicate.
2. Builder's name and address - approvals will be mailed to this addres,s.
3. Give name of filed realty subdivision map.
Section number of realty subdivision map.
5. Lot number of plot on which disposal unit is constructed.
6. ~uildint pet~it number assigned by the Building Department.
7. Name of person or firm who actually constructed the sewage disposal facilities.
8. (a) For example: s/s Jones St., 100' e/o Smith St. (b) Hamlet, (unincorporated
area in tom~ship), for example: East Morichas. Village (incorporated area),
for example: Northport. (c) To~nship, for example: Erookhaven, etc.
9. Give inside length and width in feet. Liquid depth is measured in feet from
bottom of outlet pipe to bottom of tank.
10. (a) State number of pools. (b) State number of blocks below inlet pipe for
each pool. (c) State length, width, and height of cesspool blocks in inches.
(d) Indicate by check if precast sections are used. (e) Give number of leach-
ing sections per pool. (f) Give height.and diameter of each leaching section.
(g) Give depth in feet from finished grade to cesspool cover. (h) Describe
backfill material used.
11. Indicate by check if water supply is public or private.
12. Name of person or firm who actually installed the water supply facilities.
13. (a) Give depth in feet from top of well pipe or casing to well point. (b)
Depth in feet from top of well pipe or casing to water level in well.
14. Inside diumeter of well casing.
15. Name of laboratory performing the examinations.
16. Describe method of disinfection, for example: quart of laundry bleach in ten
gallons of water poured into well and allowed to stand six hours.
17. State date on which installation will be ready for inspection.
18. Application must be signed by builder or owne~. Signatures of subcontractor,
supe=inte~dent, etc., will not be accepted._
19. Indicate location of Water & Sewerage Facilities with accurate dimensions on
sketch.
SUFFOLK COUNTY DEPARTMENT OF HEALTN
EASTERN DISTRICT
County Center, Riverhead, New York
PA 7-4700
H.D.Ref. No
APPLICATION FOR APPROVAL OF INSTALLED PRIVATE SEWAGE DISPOSAL AND WATER SUPPLY SYSTEMS
- ' ~nspection for approval is requested, pertinent installation data herewith.
1-Nam
Add
2-Nam
Add
~ of Builder ~<~,~n~. ~ Phone
3-Subdiv.
4-Section No.
5-Lot Number
6-Bldg.Permit No.
Phone
9-Se]
lO-Ce~
ll-Wat
If
12-Pr:
7-Sew
Add,ess
8-(a)peed location of property~z~,~.~?A~ ~' ~'/~r-~ LF-~ Z~z~
(b) ~=let or Village...~ ~ ,~' (c)TownJ6,~ = ~.
~ic tank-Gal L ft.W ft.Liquid Dept~ft.~ ~
(e)Block stze-L }l tn.W ~ ln.H ~, ln.(d)Precas: pool , (e)1__2__3
(f)H f~.,,, tn; Dtam__ft.__tn.(g)Ftntshed grade to cover ft.
(h)Backfill Material ~a h~ ~
mr Supply: Public Syst~ ; Private Well ~
~rivate, the following questions are to be answered:
fate Water Supply System installed by Phone
Ad~ress
13(a)-rotal Depth of Well .(b)Depth to Static Water Level
14-Dianeter of well pip~ in.
15-N~ of Laboratory 16-Method of Disinfection
17-Da ready for inspection~;/d ~ .
/
The undersigned CERTIFIES: Abdve systems have been constructed and are
in c~mpliance with the Suffolk County Health Dep/a~ment's current Standards, Bulletins
and .~mendment. thereto, g~/~ ~ ~ ~
~ 18-Date Si ~ ~ ~
~er ~ Builder
19~Insert sketch of location of Water & Sewerage Facilities with accurate d~ensions.
STREET
S-Se
Insp,,cted by ~ ~ ~ Date /
Basef~'upon the info~ation stated above, satisfactory functioning of the
abow systems can be expected with proper maimtenamc~d"'care.
Dis trict ~n~ineer
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Approved ........................................ , 19 ........ Permit No .............................
Disapproved a/c ~~ ...............
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted in duplicote to the BuildingS.
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 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 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 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)
...... ........................
(Address of applicant)
State whether applicant Js owner, lessee, agent, architect, engi'neer, general contractor, electrician, plumber or builder.
Name of owner of premises .~.b:~...~,_~:..~.§~:~e.t~..~.~.O~.~ ...................................................................................
~f 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 ....... ............................................................
Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ............. .Y.~.~.t~..~0.(~ ...........................................................................................
b. Intended use and occupancy ........... Q~...~,~,~.~...~e3.]~,~. .......................................................................
3. NatUre of work (check which applicable): New Buitding ..~F,.~... Addition .................. Alteration
Repair .................. Removal .................. Dem01itian .................. Other Work (Describe)
4.
5. If d~velling, number of dwelling units ........ ¢~iO ............. Number of dwelling units on each floor
If g~rage, r~umber of cars
6. If b~siness, commercial or mixed occupancy, specify nature and extent of each type of use
7. Dimbnsions of existing structures, if any: Front ............................ Rear ................................ Depth
Height ........................ Number of Stories
Dimensions of same structure with alterations or additions: Front ....................................Rear
Dep~'h ................................ Height ............................ Number of Stories ................................
8. Dim~ensions[ of entire new c~nstruction: Front ........ ~..,.~(~ ............. Rear ...... ~)..~1.0 .......... Depth .....~1¢, ......
Hei~lht .................... Number of Stories ......
9. Sizeiof lot: Front ........ X.0.Q ............. Rear ......... ~,f).Q .................... Depth ..... ~O.CI ....................
10. Dat~ of Purchase ........ ].C~.~ ...................................... Name of Former Owner ...... ~1.~.
1 1. Zon~ or use district in which premises are situated ....... ..".A..~...~,~.~ .......
12. Doe~proposed construction violate any zoning law, ordinance or regulation? ...............
13. Nar~e of Owner of premises ..]~l~..D~.O~.lL~..&..~..Address ......... 1)~...P.&~r ............. Phone No.
Nam. e/ of Architect ...................................................... Address ............................................ Phone No.
PLOT DIAGRAM
L.oca , clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions fr
property nes. Give street and block number or description according to deed, and show street names and
whether ir 'erior or corner lot.
COUNTY .............
................ ~.....~¢~.~'~...[~1~.g~.8,~~ .......................................... being duly sworn, deposes and says that he is the applic
'.Namf~ of individual signing application)
above non, ed. ~e~s the .............~
(Contractor, agent, corporate officer, etc.)
of said ov her 'or owners, and is duly authorized to perform or have performed the said work and to make and
this opplk orion; t~af;ail statements contained in this application are true to the best of his knowledge and belief;
that the ~ ~rk will be ~prformed in the manner set forth in the application filed therewith.
Sworn to ~ efore me this~ ,~
............... ~da~ of ..... ~ ..............
..
Notary Pu~ lc, .~....~ .......... ~ ~ ,County (Signature of applicant)
I ~ ~,¢~,.,1~.~ ~x. ,.~, ,~1
~k No. 52~3233120 Sui[olk C~
FORM NO, 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Appro,ed ........................................ ," ........ Perm,t ...........
Disapproved a/c ....... ~ ........ ~,~ ....... 7~ ...................
-- ...; ................ .............................
(Building Inspector)/'
APPLICATION FOR I~UILDING PERMIT
Date ............................. ~..~...lq..~.......2. ~ ........... , 19...6..6. ......
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 property must be drown 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 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 $outhold, 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 cdrporation)
5. Jessen St~ Deer Parks L.I. (Address of applicant)
State whether applicant is owner, lessee, agent, architect, engi'neer, general contractor, electrician, plumber or builder.
Owner
Name of owner of premises ..~Q~.t.,...E~.t...~...~..&.~.~P,~..e.~...D.~.°..T..a.~ ...................................................................................
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.: XXX ~
........................................ Lot No.: ........................
Street and Number ........ ................................ ..........................
Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use end occupancy .............. ~..a:.o..a..~.t....~,.~..~..~ ..........................................................................................
b. Intended use and occupancy ............ l:),,,'O.¢...;~,~t~'...~L.~.¢~.2¢~..~ .......................................................... ; ............
3. Nat[ute of work (check which applicable): New Building ..~glf.,,%lf~.... Addition .................. Alteration ..............
Repair .................. Removal .................. Demolition .................. Other Work (Describe) ....................................
4. Est ~oted Cost 2-600 shell ~ 10
~ (to be paid on filing this application)
5. IF d~elling, number of dwelling units ........ o~e ............. Number of dwelling units on each floor ........................
If g<~rage, number of cars ................................................................................. ~ .......................................................
.I
6. If 9usiness, commercial or mixed occupancy, specify nature and extent of each type of use .....................
7. Dimlensions of existing structures, Jf any: Front ............................ Rear ................................ Depth ...................
Height ........................ Number of Stories .............................................................................................................
Dimensions of same structure with alterations or additions: Front ....................................Rear ........................
Dep}h ................................ Height ............................ Number of Stories ................................
8. Dimensions of entire new construction: Front ........ 2.9...*,;10 .............. Rear ...... 2c).?10 .......... Depth ...32.-..[k. .......
Hei!lht .................... Number of Stories ...... D~. ...................................................................................................
of lot: Front ........ ~-.0.Q ............. Rear ......... ~-,.~.Q .................... Depth ..... .2..O..Q ....................
of Purchase ........~9.(~6 ...................................... Name of Former Owner ...... ..P.6.~..~. ....................................
or use district in which premises are situated ........ I.t..A..~.~....~.i...S..~. ......................................................................
proposed construction violate any zoning law, ordinance or regulation? ............... ~.Q ....................................
13. Na~e of Owner of premises ..~Ob.~..D.¥1D.:~ak..~..l,~..Address ......... D.~f~...J~.a~'~ ............. Phone No .................
Nanle oF Architect ...................................................... Address ............................................ Phone No
/
Na~e of Contractor ..~.~'e.d...~:tg..~3,e ....................... Address ....... S.'bo~'..l~z'.aok .......... Phone No ..................
/
/ PLOT DIAGRAM
Locate! clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions fro
number or description according to deed, and show street names and indica
9. Size
1 O, Dot,
1 ]. Zen
1 2. Doe~
property lir~es. Give street and block
whether interior or corner lot.
STATE OF h EW~YO, J~I(, } ¢ ¢
COUNTY O1~: ....~.tt.Z.'.Z.i.O...1..l¢. ............ J'
................... ~....~P. f~.'i;;...~.'f. QZ'A]~ ......................................... being duly sworn, deposes and says that he is the applicar
~ame of individual sign ng appl cation)
above name< He is the ............... O~r,,'q.~.[ .............................................................................................................................
~ (Contractor, agent, corporate officer, etc.)
of said owne'r or owners, and is duly authorized to perforFn or have performed the said work and to make and fib
this application; that all statements contained in this application are true to the best of his knowledge and belief; an<
that the wor~ will be performed in the manner set forth in the application filed therewith.
Sworn ta before me this
................. o,o, ......................... .........
'? ~r~/~ - .<. ~ ~ ~ .~---- ......... .WO...L~.. ff..~.. :...~.:~..Yt-../(..~'.../..¢~'...t. .......... : .........................
Notary Publi~, .~.r..{ .,¢_.,z,.,,¢.4~..~. ......... ~-,,¢F...~County (Signature of applicant)
NO~/~Y PUBLIC, State of
~ 52-3233120 Suffolk County
:Term ~pires ~arch 30,