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Home My WebLink About3546-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. Certificate O[ Occupancy No .... Z. 7.1.6.5.8..3 ...... Date .... .J.a.n.q .a.ry.. !4. ,..1.9..8.8 ......... THIS CERTIFIES that the building ...C. ?.n.s.~. r..u.c.t..0..n.c..~ .a¢.i.l.y...dy.e. 1..1 .i.n.g. .......... 1120 Central Drive Mattituck, New York Location of Property ................................................... House No. Street ~l~rnlet County Tax Map No. 1000 Section I 06 .Block 2 . .Lot l 5 . S ..... M/o Captain Kid Estates 1672 95 uoa~mmon ............................... Filed Map No ......... Lot No .............. conforms substantially to the Application for Building Permit heretofore filed in this office dated July 17, 1967 pursuant to which Building Permit No. 3546 z dated J u 1 y 18, 1967 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 OPENED PORCH OLGA SARIDAKIS The certificate is issued to ..................... [o~n'e'r,'/~'gCrgt~J~X% .................... of the aforesaid building. Suffolk County Department of Health Approval ...S.O.-.6..6.7..-..~ .e.b.... ! .3.,.. ! .9 .7.4 .............. UNDERWRITERS CERTIFICATE NO... N 823307 PLUMBERS CERTIFICATION DATED: N/A Rev. 1/81 FOP~M NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT fi.HIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 3546 Z Date ........................................................ , 19...:~. Permission is hereby granted to: ~.~,ri~..Am~s~-us~s..A/~-....~nual..~ar~&_~kis & Wife ........... ~. o......~A?..~..~,~ ........................................ ........ .~..t.~..s.~,...~.:.~.:. ................................... to ~:~.x..%.~...~?.~ ..g..n..~:...~....~.e.~l .~.~ ..................................................................................... at premises located at ....~..O...~...~.~......~d~.[..~g~.~/[t~,t~ ............................................................. .......................... ~./..~....c.~..t.~.~.!.~.~?..?.~. ............ ~.t...s.~,..~...~... .......................................... pursuan¢ to application dated ............................... .*..'.-...t~.,..,...~.~'. ....... , 19..~.~/..., and approved by the Building Inspector. ]110~1 ~E[~ p~l~t, d~ll t~O~, ~,~¢1~1,~1.e O0~'tM3~iO~ Of lax'age Building Inspector APPLICATION FOR CERTIFICATE OF OCCUPANCY FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Hall Southold, N.Y. 11971 765- 1802 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 topograph c 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 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 property showing all property lines, streets, buildings and unusual natural or topographic featu res. 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: Additions $25.00 POOLS $25.00 l. Certificate of occupancy New Dwelling $25.00, Accessory ,$10.00 Business $50.00 2. Certificate of occupancy on pre-existing dwelling $ 50.00 3. Copy of certificate of occupancy $ 5.00, over 5 years $10.00 4.Vacant Land C.O. $ 20.00 [-/'/".~./.c?/.?. 5.Updated C.O. $ 50.00 Date ................. New C ohs tpuc t 1on..%... Old or Pre-existing Building ............ Vacant Land ............. House No. Street Hamlet Owner or Owners of Property ~'% County Tax Map No. 1000 Section ....J.~.~.~¢~ ....... Block ...... ~ ...... Lot.. ,/,~,'7 .......... II Health Dept. Approval ...~?//,-~./'?.¢...' ........ Labor Dept. Approval ........................ Underwriters Approval ,~,//7~...ff. N?..~...%~..o.7.Planning Board Approval ...................... Request for Temporary Certificate ..................... Final Certificate ...... ~ ............... Fee Submitted $..~.~.'., ?.~, .................... Construction on above described building and permit meets all applicable codes and regulations. Applicant .~...~.. ~ ............................ 10.10-78 S-9 SCHD SUFFOLK COUNTY DEPARTMENT OF HEALTH Date FE~ ~3 1974 gldg. Permit No. TO WHOM IT MAY CONCERN: The sewage disposal facilities for a structure located at (Giv~aeed locationO - have been inspected by this department and found to be satisfactory. Chief o£ ~eneral ~inee~ing Services $OUTHOLD RECORD' CARD OWNER FOR~ER OWNER VILLAGE N E S W TYPE OF BUILDING DISTRICT SUB. ACREAGE LOT F J'-- LAND IMP. TOTAL DATE i REMARKS AGE Tillable 'i BULKHEAD Tillable 2 / DOCK Wood land iwempland 3rushland "~'~ ~* ~'~ -{ouse Plot I'otal A. BIdg. xtension xtension xtension reezeway : ;arage Foundation Bcsement Fire Place Porch' Porch j :Roof Type Rooms 1st Floor Patio Driveway Dormer Rooms 2nd Floor ... % SUFFOLK COUNTY DEPAR'~MENT OF HEALTH ~ ~ ~, ~ ~.~;k) EASTERN DISTRICT R.D.Ref. No. ~_~ ~t;-' '~ . County Center, Riverhead, New York APP~~U~A~OVAL OF ZNSTALLED PRIVATE SEWAGE DISPOSAL AND WATER SUPPLY SYST~S ~n~pe~"~r approval is requested, pertinent i~stallation data herewith. , '~ ~, &~ ~ 0~ Phone ~ &- ~/~ 4-Section No. Address ~/-9~ ~ ~ -- .A'ddr~s~ ~ ~J ~ND 6-Bldg.Pe~it No. 7~gewa'~Syst~ in,tailed by .~. ~, ~'~(~o~ Phone ~%~- 8-(a)~ed loc~tion of property ~/~' C,~T'~wt, ~, (b)Hamlet or Village ~ ~T~/~ ~F~ ~'~5~ (c)Town 9-Septic tank-Gal ~<2... L ~ ft.W ~ it.Liquid bepth ~ ft. lO-Cesspools-(a)No.pools J (b)B1ocks below inlet-l) 2)__.3)__ (d)Blo~ size-L in.W in.H in.(d)Precast pool (e)l 2 3 (f)H /~.ft......in; Dian ~ ft. .. in.(g)Finished grade to cover .f ft. (h)Backfill Material ~ ll-Water Supply: Public Syst~ C~ ~ ;~ ~ bO~ . ; Private Well If Private, the following questions are to be answered: 12-Private Water Supply System installed by Phone Address 13(a)-Total Depth Of Well 14-Diameter of well pipe 15-Name of Laboratory 17-Date ready for inspection .(b)Depth to Static Water Level in. 16-Method of Disinfection The undersigned CERTIFIES: Above systems have been constructed and are in compliance with the Suffolk County Health Department's current Standards, Bulletins and Amendments theretoL._~ /~ .' . / 18-Date 4,4 ~ ~1,5 Signed ~-~,~.~ k~ 19-Insert sketch of location of Water & Sewerage Facilities with accurate dimensions. o_ .... ....... : ..... II[iff .......................... _ ............... ...... ] FOR ~L~ DEPOSIT USE ONLY / Basad upon the tnfo~tion~ated above~ satisfactory ~unc~ontn~ of the above systems can be expected with pr~r maintenance and care. Chief of General ~gineering S~rvioe~ S-Se Instructi~ns for Submission of Installed Private Sewage DispdSal and Water System Application pplications are to be submitted in duplicate. Required infot~nation should be typed~or legibly printed in ink. Inspectors are not'permitted to make inspections of inlstallations until applications have been submitted to:'and accepted by this de- partment. iThe item number on the application form and item number listed below are the 1. q~ner s name and address - if owner and builder are S.~e, so indicate. 2. ~uilder's name and address - approvals will be mailed~o this address. 3. ~ive name of filed realty subdivision map. ~,, :~. ' i,. ~ection number of realty subdivision map. . ,~',~ 5. ~ot number of plot on which disposal unit is constructed. 6. Building permit number assigned by the Building Dep~ment. ?. ~ame of person or firm who actually constructed the~.~age disposal facilities. 8. a) For example: s/s Jones St], 100' e/o Smith St. (~)Hamlet, (unincorporated [rea in township), for example. East Horiches. V~llage (incorporated area), !or example: Northport. (c) Township, for example':~;~ookhaven, etc. 9. live inside length and width in feet. Liquid depth .t~ measured in feet from ,ottom of outlet pipe to bottom of tank. ,.: 10. ia) State number of pools. (b) State number of bld~ below inlet pipe for ~ach pool. (c) State length, width, and.height of c~.spool blocks .'in inches. ~d) Indicate by check if precast sectionsare used, '~':'~e) Give number of leach- ing sections per pool. (f) Give height and diameter~f each leaching section. ~g) Give depth in feet from finished grade to cesspool cover. (b) Describe backfill material used. il. ~ndicate by check if water supply is public or priva(e. 12. ~ame 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 fee~ from top of well pipe or casing to wate~ level in well. 14. ~nside diameter of well casing. ~ 15. ~ame of laboratory performing the examinations, ". 16. Describe method of disinfection, for example: quart~ of laundry bleach in ten ..,. ~allons of water,poured into well and allowed to sta~d six hours. 17. ~tate date on which installation will be ready for inspection. 18. ~pplication must be si~ned by builder or owner. Signatures of subcontractor, ~uperintendent, etc., will notb-~accepted-~ 19. ~ndicate location of Water & Sewerage Facilities with accurate dimensions on ~ketch. ,-. SUFFOLK COUNTY DEPART~NENT OF HEALTH H.D.Reference EASTERN DISTRICT, RIVERHEAD, N. Y. APPLICATION FOR APPROVAL Tq .QO. NSTRUCT PRIV.ATE S.EWAGE ..DISPOSAL. SYSTEMS Date .~ Approval tn construct said systems is requested,pertinent data herewith: 2-Detailed proper~locat~on ~ C ~, ~ .... ~ .5 ~ ~-Lot No. ~-~blic water suppky name C ~-~ ~. ~ ~ ~. D~nce to nearest ~in ~-Lo5 Szze: Width~ft. Len~t~{. (also enter on center plot plan 5-~ellfn~: Singl~amlly ~ Two Family? ~./Cellar? ~lab? ~ ~ Crawl S~ce? lO-Pro~sed system: Septic tank ~Precast ~Cesspool~ ~Shallow pools il-Septic ta~ inside dimensions} ~Vol~e~G~.Length~ ft. Wi~th~f~. Liquid depth~ft. 12-Precast sections: /~;Number/ /Square'%. Cesspools~ Block szzeL~ zncs.D ins. H ~ins. Total blocks below inlet: ~1~2_.__~3 PLOT PLAN Capacity / ./' /- o._ Gals. Street CI No~th T~st ~ Data ?ee,t 0 2 k 6 %\ 8 / ~l 12 18 The Undersigned CERTIF]]~S: "Construction of authorized installations will be in accordance with the Suffolk County Health Departments' current Standards, Bulletins, and amendments thereto, covering Private Sewage Disposal Systems". FOR HEALTH DEPARTMENT "USE QN~Y. Based On the information presented herewith, it is ~he opinion of the Health 'Department, that an adequate and satisfactor~ Sewage Disposal System can be installed on this Plot. Date ~(,~,?~,g~,, Signe~~~ (10/65 Revis.) APPLICATION FOR APPROVAL TO CO.NSTRU~T PRIVATE SEWAGE DISPOSAL SYSTEMS INSTRUCTIONS: Applications must be submitted in triplicate 1-Mean~ Owner or Builder. Address to which mail should be directed. 2-Mean~ detailed description of property location, together with street name and distance to nearest intersection of main thorofare, also Hamlet/Village & Township 3-~te~ name of Public Water Supply District, together with the distance to their main. ~-~hte~ Length and Width of Lot under appropriate heading, also enter these dimensions on ce~nter plot plan shown on the face of this application. 5-Dwel~ings: C.heck-mark "V" items applicable to the proposed new dwelling. 6-Name lof sub-division 7-Section Number 8-I~t ~umber 9-Private well: Enter "No" if Public water supply is available. Enter "Yes" otherwise. P___ROPOS~D SYSTEMS: Answers to Items number 10, 11, & 12 please consult the Suffolk County Heal%h Department's Standards, Bulletins and Amendments for Sewage & Waste Disposal Facilities. i.e., Pa. rt II-Residential Sub-surface Disposal Systems covering Cesspools PArt III " " " " " " Septic Tanks P~rt IV " " " " " " Unusual soil conditions P~rt V " " " " " " Shallow Leaching Pools PIXy: The following information is required concerning the Applicant's Lot: Iht size-Length and Width in feet to be mndicated at the Lot lines of the hgavy lined square in the center of Plot Plan shown on face of this application. Surface waters-Streams, Lakes, & Bays, etc., located within a distance of 50 fset of Applicant's Lot lines, must be shown on the plot plan also. ~ Wells and Cesspools now on adjacent lots must be shown on the Plot Plan w~gether with the distance to the Applicants proposed Sewage Disposal Systems and ll. I Where no Buildings exist on adjacent lots, state "Vacant" on the plot plan. I Streets adjoining applicant's lot to the right, left or rear, enter street name. WEL~L~ D)CATION: To locate the well & sewage disposal systems on Applicant's lot, the f.~llowing Standards must be observed: Well-100 feet minimum distance from the nearest cesspools Well-25~ feet minimum distance from rear, and rear sides of property lines Well-10 feet minimum distance from front, and front sides of property lines Well-50 feet minimum below grade for well point Well-40 feet minimum into ground water for well point | Well-4 fe.et 6 ins. minimum below grade to well head and lateral water pipe CESSPOOLS LOCATION. Upon determination of the Sewage & Waste disposal "type of systems" required, the following Standards must be observed for the location of same: Cesspool-lO feet minimum distance from lot lines to center of cesspool Cesspools exterior must be 100 feet minimum distance from nearest well Septic tank exterior must be 75 feet from nearest well Cesspool "Center" must be 12 feet minimum distance from nearest water line Cesspool "Center" must be 15 feet from house foundation Cesspool exterior must be 50 feet minimum distance from surface Waters, Streams~ Lakes & Bays, etc. Cesspools must be 20 feet minimum distance from large trees Cesspool center to Cesspool center must be at least 16 feet Cesspool cover top to grade must be held to minimum of i food to maximum of 2 feet Bottom of Cesspool to ground water must be held to minimum of 1 foot OTHER ~ARATUS: : ,- , ~ ~Furnace~s: 1-1/Shp. ~l-1/12hp.,' ' ~ ~-~ - Joseph Carrabus Middle Island, L.I. STAT~ENDE~T This certificate must not be altered in any manner; return to the office of the E~oard If incorrect, Inspectors may be identified by their credentials. FORM NO. 1 ?I~OWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. ¥. Examined ....................!i...~......., 19 Approved ................. I ...................... , ]9.~..'.... Permit No ............................ Disapproved Application No ............................. APPLICATION FOR BUILDING PERMIT /7' /7 Date .............................................. , 19 ............ INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in duplicate to the Building Inspector. b. Plot ptan 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, ordlnance~, building code and regulations~ _ ............ : (Signature of applicant, dr name, if a corporation) (Address of applicant) State w~h~ther~/j~~ner, lessee, agent, architect, engineer, generql contractor, electrician, plumber or builder. ................................................. ........ ............................... Name of owner of premises ..................................................................................... ~ .............................................................. If applicant is a corp4lr~el ~ignature of duly authorized officer. (Name and title of corporate officer) 73 1. Location of land on which prp~,,~d wgri.~.vj~12e do~.e..Map No.: ........ ~ .............................. Lot No.: ..~...... ....... Street and Number .................................................................................................................................................... M i~li~ a. ....... ............................................................... b. Intondod use ond occuponcy ................................................................................................................................ 10. 11. 12. DoE 13. Na~ Na~ Na~ 3. Nature of work (check which applicable): New Building ...V....... ...... Addition .................. Alteration Repair .................. Removal .................. Demolition .................. Other Work (Describe) (to be paid on filing this application) 5. If c~welling, number of dwelling units ............................ Number of dwelling units on each floor 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use 7. Dim~ensions of existing structures, if any: Front ............................ Rear ................................ Depth Height ........................ Number of Stories ...... J(~...f~....~. ............................... Dir~ensions of same structure with e.lterations or additions: Front .................................... Rear ! DeAth ................................ Height ............................ Number of q~tories 8. Dntensions of entire new construction: Front .............. ~..~........~..'... Rear ........ ~.~...~........~.. Depth Heibht .................... Number of Stories Zor Locat property I whether in or use district in which premises ore situated proposed construction violate any zoning law, ordinance or reaula~ion2 ne o~ Owner of premises/~'.~.~.~.~-~...~]).~.vA~r~ss~.~.'.i..~...'.'..'~..~.~. ....................... Phone No. ne of Architect ..~.O./.'!...Y~........~.~.)./~...~.Z2~.~'...]. ....... Address 3.~....~..~' ......... ~.~..~.~..¥ ........ Phone~l~No of Contractor ......... Address ............................................ Phone No. PLOT DIAGRAM clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions nes. Give street and block number or description according to deed, and show street names and :erior or corner lot. .........~, ,H~ ~~,,~,~~[~i~~C~i ................. being duly sworn, deposes and says that he is the applk above nerved. 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 this applic~ation; that all statements contained in this application are true to the best of his knowledge and belief; that the v/ork will be performed in the manner set forth in the application filed therewith. Sworn to b[efore me this //) ~ ............7'."7/ ...... ......... LL ..... ................. Notary Public, County (Signature of applicant) L ~/ M~RJON A. REGENT k~ NOTARY pUBLIC, State of New Yer~ No. 52-3233120 Suliolk County Term Expires M. srch 30, 19~_~ ~ Y~'~ ' TOWN OF SOUTHOLD . ~ BUILDING DE[~RTMENT , TOWN CLERK S OFFICE SOUTHOLD, N. Y. A roved . . ~ · S ~ ~ ~ed =l~~~~~ .............................................................................. ........................................................................ ........ ....................... ....... (Bui~ing In~ector) · INSTRU~IONS 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 o detailed description of layout of property must be drown on the diagram which is port of this application. c. The work covered by this application mo,/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 in part for any purpose whatever until a Certificate of Occupancy sholl have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Buildi.ng Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other apphcable 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 r.~ulatio~ns~/~./e/~ ~. ......... : .......... ........ ......................... .......................... :... (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Nome of owner of premises /~/'~ .~..~. ~ )~$ /~1 I/~Z_. If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) r(_,/vi, ~/~'~-- 1. Location of land on which proposed work will be done. Map No.: .~ ....... ' t Street and Number ............ .C.;'~'.£.I..'~....'J'~....~...L. ........ ~....1'~..) ~,, ~; ...(~ ..~...~...'~...,~...!.J~l,....~:-.../...'.~.....~.~..'"~..,~....~.....~.. ..... 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: o. Existing use and occupancy .....~/.~...~..~...~....~.. .......... ..~...0....~... ............................................................................... 12. 13. Nature of work ~'~ 3. (check which applicable): New Building ............ i.... Addition . ................. AlterotiOr~ j~ ................ Repair .................. Removal .................. Demolition ............ J ..... Other Work (Describe) ........................................ 4. Estimated Cost .......... ..~..,.O...~. ...... ..J~.....~...O..../~..~...~,.~'...?....Fee ......... .......... ~' ~; '~;i~ '~"~i~"~ ~J~ ~';~'~ .................. 5. If dwelling, number of dwelling units ............................ 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 ~pe of use ............................ 7. Dimensions oE existing structures, if any: Front ............................ Rear ................................ Depth .................... eight Numar of Stori~ ....... ~..~..~ ............................................................................................ imensions of same structure with alterations or additions: Front .................................... Rear ............................ Depth ................................ Height ............................Number of S~ories ............................. ' ~e~r 8. Dimens ohs of entire n~ construction: Front ............... ~J~..~.......~. .......... ~.~.......~th Height ................... Number of Stories ...................................................................................................................... s~,~ of ,o,: Fro~.~ ........... ~--~.~. ...... R~, .......... ''~...~.'~. .............. ~,p,, ...L.~.~. ................ ' .................. ............. 'za :' D~e of Purchoso ~ ~*me of Former Owner ~"~'Z~ Zono or u*o district in which promi~ ~r~ ~ituoted ..................................................................................................... Does proposed construction violate ~ny ~onin~ I~w, ordinance or reoulotion? ............................................................ ~ma o, ~r o* p~*~,~..~ ........ ~.. ~.~...~J;~ ............................................ ~o~ ~o ..................... ~o~ o* ~,~5~....~r~.~.~ ~O~esJ.~.~.~ ........ ~.~.~t~:.~ ....... ~.~:~.,. ...... ~ame of Contractor ......................... ~.....i .................. ~aaress ............................................ ~none ~o ..................... PlOT DIAGRAM Locote clearly and distinctly all buildings, whether existing or proposed, and indicate oil set-b~ck dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lat. r ~'~ (Name of individual signing application) above named. He is the ........... C,~.i~'.~/~......~....~-- -- ~$ (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 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 application filed therewith. Sworn to before me this /) .......... /...~..~. day of ..../~.~j,...;,,~ ................ , 19..~..7 /~._. t MARION A REGENT U NOTARY PUBLIC, ~ale of New York NO. 52-3233120 Sutlolk County Term F. xp res March 95 J. C~T=~.~...,~.FJ_v r- ,, /. THE O,,vA~:~ 54U, LL FUD, fltG~ ALL cu~,'4Ef5 ~VE LAND ~LeA~P' ~/~ oF ~!~ ~p~/?, ~oof e~t~&~ ~LL ~oT ~E a D~L~CUO~ , . ALL ~Hc~u~ Lu~P, su~Lt ~ ~¢1 COIMLO~-".o ~TT~.. .:'-. Ckp ,~ D~E P~AT~ ~ A/A~O? ~ L~q ~e~ ~R~ To ~ u~.~ . T~E CG~TgIZD~, .._ ~ ~goviP~ A %EpE~AT~ Fgt~E fOF~ FflTUF~E' L pRoVtp~ A~ IT~,,A~z~D mid Fo~T~ pUrPOSE .... G ~VO~ UOT IUoLUOEO I~ "4 ~UgLVl~ ~U TUE~ ~vlLL ~ 4LkOT~O To~ Oxvr__, I