HomeMy WebLinkAbout3403-zFO.P,~WI NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
CERTIFICATE OF OCCUPANCY
THIS CERTIFIES that the build,ng located at {{/8 .M~Lddl~lt .JJot~J...{J~.~.]J ............. Street
Map No ~ ........... Block No..:i1:~1~1~ ........... Lot Nolt:I!I~I~ ........... O~1,t~O~%l~t..J.~ ............
conforms substanhally to the Apphcahon for Building Permit heretofore filed in th~s office dated
................................. ~, ... jL~l, ., 19 '67 pursuant to wh,ch Budding Perm,t No
dated .............. J~.~J~h"~J~ ........ .][.?.., 19....6~ was issued, and conforms to all of the requ,rements
of the applicable prowsJons of the law. The occupancy for which th~s cerhficate ~s ~ssued ~s .......
.... · ~ivate..e~e..f. amit. y. ~lvetlf~. ..........................................................................................
(owner, ~L~ssee or ten,ant)
The certificate is msued to .... ~.~]ta...j~el, d. ..........
of the aforesaid building
FORM NO. ~
TOWN 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? 3403 Z
Permission is hereby granted to:
................... .~ .e. ~.lt..e..e,.~.~ J..,..z..:. ........................
to ..... ~.~.?.~...?~....t..~,~.~....~.~ ...............................................................................
at premises located at ,..~../..~.....~z.,d.,~'.]:,e,.,...l~....a..~. ......................................................................................
...................................... ~t~ho~u~t...~.Z. ......................................................................................
pursuan¢ to application dated .......................... ..~.....~..~. ....... .6.. ............ , 19.6..~...., and approved by the
Building Inspector.
Building Inspector
S-9
SCHD
SUFFOLK COUNTY DEPARTMENT OF HEALTH
Date ,ll~m~ 9~ 19M7
Bldg. Permit No. 3403
TO WHOM IT MAY CONCERN:
The sewage disposal facilities for a structure located
at S/S ~iddle Road ~/0 Alvahs Lane, Cutchogue, N.Y.
(Give deed location)
have been inspected by this department and found to be satisfactory,
COUNTY OF.SUFFOLK
DEPARTMENT OF PUBLIC WORKS
R.M. KAMMERER, CQMMIB~ONER
YAPHANK,N.~ '
TYPICAL SECTION
FOR
RESIDENTIAL DRIVEWAY
ADJACENT TO: /'~'~ ~/~V'"/~--, ,,~oo._. ~,
FLEXIBLE TYPE PAVING)
~ PAVE ~ ROAD LINE
~o~/~g~ TYPES OF PAVEMENT
BITUMINOUS MACADAM BASE WITH ASPHALT
CONCRETE TOR
2. CINDER OR STONE SCREENINGS BASE WITH
ASPHALT CONCRETE TOP.
CINDER OR STONE SCREENINGS BASE WITH
BITUMINOUS SURFACE TREATMENT AND STONE CHIPS.
R:~65)
PORTLAND CEMENT CONCRETE WILL NO....__T BE PERMITTED
PIO TE :
· =MONUMENT
o: PIPE
SURVEY FOR
,JOHN T. 8i t_OUVINt/~ FORD
CUTGHOGUE
TOWN OF SOUTHOI O
SUFFOLK COUNTY, N. ~.
GUARANTEED TO:
FARMERS HOME ADMINISTRATION
SECURITY TITLE AND GUARANTY CO.
SCALE: 1"=40'
FEB. 1, 1967
JUNE 9, 1967
LA.ND SURVEYOR
N.Y.S. LIC. PlO. E8725
RIVERHEADi If.Y.
Permit No .................
PERMIT UNDER SECTION 136 of ARTICLE VI of HIGHWAY LAW
% Whereas, Section 136 of Article VI of the YIlghway Law provides "No street surface or other railroad shai1 be constructed upon any
portion of a road constructed or improved on acount) road system, nor shall any person, firm. corporation or munlclpahty enter upon
or construct any works il% Or upon such road, or constr~lct any overhead or underground crossing thereof, or lay or maintain therein
drainage, sewer or water pipes underground, except under such eorldltlOnS and regulations as may be prescribed by the county super-
intendent, notwithstanding any consent or franchise granted by any towr~ Or by the municipal authorities of any vlIlage or town Any
municipal corporation may enter upon any road constructed or improved ca a county road system for the purpose of widening the
pavement or for any other purpose authorized by this section, but only afler securing a permit as provided herein Notwlthst~ndolg
the limitations in any genera[ or special law, every municipal corporation shall have and is hereby given author}ty to deposit with the
county superintendent such a sum of money as may be required by the county superintendent as a condition precedent to the granting
of the permit provided in this section Any person, firm, or corporal:on ~olatmg this section shall be hable to a fine of not less than
one hundred dollars nor more than One thousand dollars for each day o£ such violation, to be recovered by the county superintendent
and paid in to the county treasury to the credit o£ the county road fund created under section 117 of Article VI. of thls chapter [or the
construction, reconstruction and maintenance of county roads Ca the county road system in accordance with [he provisions of said
Section 117 of Article VI, and may also be removed therefrom as a trespasser by the county superintendent upon petition to the
county court Of the county or to the supreme court of the State, and
V/HE~REAS, a certain highway known as the Middle Ro~d ~R No 27
has been unproved and is on the Suffolk County Road System and
WHEREAS, Rive~$fde Home~, Inc.
Po0. Box ~?14, lC[verhead, N. Y.
requests permission to
Alvmh's Lane, Hamlet of Cutehol~e, Town of Southold
as per sket;h or. mal~ attach.ed.
revises plot plan & typical
NOW, THEREFORE, pet~nisslon is ~creby aranted to sa~d
Riverside Homes. Inc.
to do ~md work upon the following conditions:
CONDITIONS AND RESTRICTIONS
L When concrete is removed, cut concrete with concrete saw two feet outside the
limits of the propo~ excavation and for the full p~nel width. YVhen the cut is
made in pavement ~lthin 10 feet of the panel joint, the pavement shall be romp%ed
for full panel width from tko cut on the fay side of the e×c~vation to thc pane[ joint.
2. Backfill and thoroughly compact fill using POWER TAMPER, pla~ing soils so that
various types of soil axe in same relutive position as before excavating. Gmule to
original sur[aee.
3. I~epl~ce pavement, sidewalk or surf~'e same as exisHng; if concrete, replace using
1:1~:3~/~ mix stone mix concrete; if bituminous material, replace using sa~ne type
as removed.
$. If concrete curb is removed, replace with similar curb 1:1 ~,~ :3 ~ mix.
5. Edge of J~cking Pits or any other excavation shall be not less th~n 5 feet from Edge
of Pavement. No undercutting allowed in Pit.
6. Notify the Department at ¥~phank 4-3451 when the work is to begin so that
inspection can he made of the operation.
This permit shall not be assigned or transferred without the wn~en consent of the Commissioner of Pubhc Works
The work authorized by thru permit shall be performed under the superws~on and to the sahsfacUon o£ the Com-
missioner of Pubhc Works or his representahve.
Particular atlenhon ~s called lo the necesmty of thoroughly compacting the back /~ll, which wdl be required
by the Commissioner of Pubhe Works.
The Comrmssioner of Pubhc Works shall be g~ven one week's nohee by smd appheant of the date when ~t m-
tends to begin the work authomzed by this permit, and prompt not,ce of ~ts completion
The so~d apphcant hereby agrees to hold the State, County and Town harmless on account of damages of any
kind which may arose during the progress of the work auibortzed by th~s permit or by reason thereof.
Applicant certifies ali persons concerned with actual work under this permit are duly covered by Workmen's Com-
pensat~on Insurance and the State, County and Town shall be held harmless on account thereof.
The Commissioner of Pubhc Works reserves the right to at any t~me revoke or annul th~s permit should the
smd appbcant fall to comply w~th the terms and conditions upon which ~t is granted
The apphcant agrees to pay all necessary expenses mmdent to supervis,on and inspectmn by reason of the
granting of such permit as certtfied by the Comnuss~oner of Pubhc Works, such payment to be made within ten days
from the rendering of the certified account.
Work under tins permit to be commenced within tinrty days f~om the date of permit and continued m an
expedihons manner.
The applicant shall su~bm~t a detailed plan of structure to be bmlt, with a description of proposed method of
const~etlon.
It is understood that should future changes m the ahgnment or grade of the highway require changes m the
work covered by tl~s apphcat~on and permit, the appHcan~ shall on reasonable nol~ce f~om the Comrmssioner of Public
Works make such necessary changes at his own expense within the t~me so specified m notice.
Traffic shall be mamtamed by the apphcant on this section of the highway winle the work ~s m progress and
until its final completion.
m the sum of ..... payable to the County easurer of Su olk County
on file
deposited as security that the highway will be restored to ~ts original condition where d~sturbed at the expense of ~he
applicant, as soon as the work has been completed, and the said Comnussioner of Public Works is hereby authomzed
ond all or as much of such deposit as may be necessary for that purpose, should the said applicant neglect or refuse
rm ~ work.
n ct~ns]deration of granting this porm~t thean~ers~gned accepts it subject to eondihons described.
Date
TO AVOID SE~{IOIYS DA1VfAGE TO VITAL UNDERGROUND FACILITIES, PLEASE CALL LONG ISLAND LIGHT-
ING COMPANY AT JUNIPER 2-9000 OR FOR T~DLEPYIONE FACILITIES CALL N. Y. TEL. CO. FLOP~A~ PARK
2- O~-~'ICIAL 25 B~FORE STARTING THE WORK AUTHORIZED BY THIS PERMIT.
FORM NO. I
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Application No......~....~.~...,~..~ .......
iX It~' 19...il...Permit No. ~ ~I' O
Approved .... t .................................. r, · ..... i ........................
Disapproved a/c _~ ...c~....~ ..... ~
.......... ....................
......................... ...... ................... :....'. ..............
(Building In~ector)
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
a. Th,s 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 odloining premises or public streets o,
areas, and giving a detailed descr,ption 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 wdl 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 budding shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy
shall hove been granted by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the
Budding Zone Ordtnance 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 opphcant agrees to comply with aH applicable laws, ordinances, building code and regulations.
(Signature of applicant, or name, ,f a corporation)
Box 27¢, Riverhead, New York (Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
............................... Ag. n. ......................................................................................................................................................
Name of owner of premises ........... ~..O]~J'A..~.O.Z'.c~ ...................................................................................................................
If applicant ~s a corporate, signature of duly authorized officer.
(Nome and t~tle of corporate officer)
I Location of land on which proposed work w, II be done. Map No: .~.flfl~.~.~..~.~.~.~YLot No: ....................
Street and Number ........ ~.~.~ ~. ~.~.~..~.~,...~.~.~.~...~.~...~...~&~;~.~.~...~.~...g~.~.9.~
Munic,pali~
2 State ex,sting use and occupancy of prem,ses and intended use and occupancy of proposed construction:
a Exmting use and occupancy .......... ~ ...............................................................................................................
b Intended use and occupancy ....... P.~.~.~..~.~, ..............................................................................
3. Nature of work (check which applicable). New Build,ng ...... ~r.~.~ ..... Add,t,on ................. Alteration .................
Repair .................... Removal .................... Demohtion .................... Other Work (Descr,be) .....................................
4. Est,mated Cost ..... .~..]:.]...,..0...0..0..?..0...0. .............................. Fee .........................................................................................
(to be paid on filing th~s application)
5. If dwelhng, number of dwelling units .......... 9..~..e. ............ Number of dwelling un,ts on each floor ...........................
If garage, number of cars ........ O.1~ ............................................................................................................................
6. If bus,ness, commercial or mixed occupancy, specify nature and extent of each type of use ...............................
7 D,mensions of ex,st,ng structures, if any: Front ...:~:.! ................Rear .....~:~.! .............. Depth ~?~..~...~...~t,.~ .....
He,ght ....... .~..?. .............. Number of Stones ....... ..~....~. ................................................................................................
D,mens,ons of same structure w,th alterations or additions: Front ................................ Rear ...............................
Depth .............................. Height .............................. Number of Stories ........................................
8 Dimensions of entire new construct,on' Front ....... ;5.5.! .............. Rear .....;5.5.t. ................ Depth ...22.!...&..24.!..
Height ........... .].5..~ .......... Number of Stories ..... O~e ................
9. S,ze of lot. Front ...... ;I.~.0 ............... Rear ....... ~1.~0 ............. Depth ....2'1.4, .....................
10. Date of Purchase ........................................................ Name of Former Owner .......................................................
11. Zone or use district ,n which premises are s,tuated ................................................................................................
12 Does proposed construction violate any zoning law, ordinance or regulation? ...... ~ .........................................
13. Name of Owner ~f premises ...~.9.~!~..~.Q~1, ...............Address .~.f}~..].~.~...~..~.0. QAq:~.~.... Phone No ...................
Name of Architect ...................................................... Address ............................................ Phone No ...................
Name of Contractor ..~Y..e.~.t~,$,~l..~...~fl~fl/~.~....~..~Address .~.QZ...~.~.~.~...~;i.Y.f~.l~.e. fkClPhone No. ].~..~..-.~..~I_'-
PLOT DIAGRAM
Locate clearly and d~stinctly all buildings, whether ex~sting ar proposed, and indicate all set-back dimensions fro,
property hnes. Give street and block numbers or description according to deed, and show street names and ind~cat
whether ~nterior or corner lot.
/~o ~
STATE OF NEW YORK, ~.
S
S.
COUNTY OF ................................
, . .......................... be na duly sworn, deposes and says that he is the appllca,
(Name of individua signing app ~cat on)
above named. He ~s the ......................................................................................................................................................
(Contractor, agent, corporate officer, etc.)
of said owner or owners, end is duly authorized to perform or have performed the sa~d work and to make and
th~s apphcahon; that oil statements contained in this application are true to the best of his knowledge and behe
and that the work wdl be performed in the manner set forth in t,~application filed therewith/
Sworn to ,~fore me this
........... ....... o, ........ ....... . ,
Notary Pub',c,~ ~ ~ ~
~erm ExP~e* ~arcb
TOWN OF SOUTHOLD
OFFICE OF BUILDING INSPECTOR
TOWN CLERK'B OFFICE
clrlLITHDLD~ N. Y,
Mr. lEI., Xammez'rer
Commissioner of Public Works
Suffolk County
Yophank Ave., Yaphank, N Y
3/] ~/~?
Dear Sir:
In accordance with Section 239K of the General Municipal Law of the
consolidated La,ws of the State of New York, this is to notify the Commis-
sioner of Public Works of the County of Suffolk that .....~...~..e.~...~..Jr .~..e...~o. me..~
Boz..2~.t .Rt.verhea~l, .N.Y,.. ~.C. Jolm..Fo~d~ ..................
has applied to the Town of Southold for a permit to construct a buddmg
o, ..~/~..~&¢~e. ~o~d...(O~2)..~/..~s...~,..~cho~e., ~.~.
as shown on the attached plot plan, submitted in triphcate, doted .....
......................................... and titled .$~y,..~D~...~O~,.~...~..~O~&a Ford
We shall withhold fu~her action on th,s apphcation for ten days or as
othe~ise provided m the aforementioned Section 239K
App~OV~ tO t~ Te~ Of
pursuant to See. 2~9K of ~ Gene~ truly yours,
~c~pal L~ am per pla~; ~fpre
~ild~ access to CR 27, a ~it ?~
u~der Sec. 136 of t~
S~K ~ DE~. ~BLIC ~uildinfl Inspector
R. M. ~~, C~l~sione~ Town of Southold, N. Y
TOWN 13 F .c; El UTH [] LD
OFFICE ElF BUILDING INSPECTOR
TDWN CLERK'S BFFIBE
SOUTHOLD, N. Y,
Mr. ~* Xaa~aerre~
Commissioner of Pubhc Works
Suffolk County
Yophank Ave., Yaphank, N. Y
Dear Sir:
In accordance w~th Sect,on 239K of the General Municipal Law of the
consolidated Laws of the State of New York, th~s is to not~fy the Commis-
s,oner of Public Works of the County of Suffolk that .....~...~1~..~...~...~..~..~...~11 ;~l~e
lilts. ~,~'/~,...at~rh~6~..i~,'Z,.... I/.0..,.~.. ~Q~, .......................
has apphed to the Town of Southold for a permit to construct a building
as shown on the attached plat plan, submitted in triplicate, doted ..... ?..~..~....~ ~967
........................................... and titled .~..~...,,~..~...~. ,.~...0...~.... ~,,.~....~.'~'¢J~a ~0~
We shall withhold further achon on this application for ten days or as
otherwise provided ~n the aforementioned Section 239K
Very truly yours,
Building Inspector
Town of Southold, N Y
NOTE:
· = MOIVUIWENT
o = PIPE
SUF~VEY FOR
JOHN T. ~ LOUVINt/~ FOt~D
CUTCHOGUE
TOWIV OF $OU THOI D
SUFFOLK COUIVTY, IV. Y.
GUARANTEED TO:
SCALE: 1"-- 4~0' FARMERS HOIVIE ADNIINISTRATION
FEB, I~ ~967
SECURITY TITLE AND GUARANTY CO,
LA'ID SURVEYOR
N.Y.S. LIC. t~O. gs?gs
__ _Ri v~ .R~ ~ D~
J
t~OTE:
· = MONUMEI~IT
o = PIPE
/.
SURVEY FOR
dOHN T, G IOUVINI~, FORD
CUTCHOGUE
TOWN OF $OUTHOLO
SUFFOLK COUNTY, N. Y.
GUARAhlTEEO TO:
FARMERS HOME ADMINISTRATION
SECURITY TITLE AN/)GUARANTY CO.
SCALE:
FEB. I, 1967
LA,ND 3URVE YOR
N.Y.S. LIC. NO. 28725
RIVERHEAD,
b
/VOTE:
· = MONUME/VT
o = PIPE
SURVEY FOR
dOHN T ~ LOUVINI/~ FOt~D
CUTCHOGUE
TOWIV OF $OUTHOLD
SUFFOLK COUIVTY, I~l. y
~U~RA~TEED TO:
FARMERS HOME ~DMINf~TRATION
SECURITY TITLE AND GUARANTY CO.
SCALE:
FEB. I~ 1967
LA/VD SURVEYOR
r~.s. LIC.
R~V~ERH~Ap, tt.y.
FO~ ~O. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N, Y,
Examined .............. ...Z~.....*.. ........... , 19.. .
Approved .............. '.:. ......... ....... , No ....
Disapproved a/c ¢ ,'~ '..~..t...:..-; ....... :.j. ........... ]~T.....~.?..~...7...~ ..... ~ ...........
(Building Inspector)
Application No. PC- - h
..... · ~, ,~ ,/', ,.,,~ ,.~ .....
APPLICATION FOR BUILDING PERMIT
Date .......... ~..~.~,~g~:~...~..~ .................... , 19.....~.7...
INSTRUCTIONS
o. Th~s 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 d~agram which is part of this application.
c. The work covered by this application may not be commenced before ~ssuance of Building Permit.
d. Upon approval of this application, the Building Inspector will ~ssue 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
shall hove been granted by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the
Budding 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 apphcant agrees to comply with all applicable laws, ordinances, building code and regulations.
(Signature of applicant, or name, if a corporation)
Box 2'*/4.~, I~lYerhead, l~ew
(Address of applicant)
State whether apphcant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of prem,ses ......... .~.O...~..~....~..O....Z~.. .....................................................................................................................
If applicant ~s 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: .~..e...~.g...z~....~..e...~...~.~.9.]~..~.?...~.~. Lot No: ....................
Street and Number 3ou~;h eide l~dd~e ~Road~. 162~ Wes¢ of Alv~ht~ ~, Ou¢chogue
Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy
b Intended use and occupancy .
3 Nature of work (check which applicable): New Buddmg ...... ~.~ .... Addition ................. Alteration ................
Repair .................... Removal .................... Demolition .................... Other Work (Describe) ....................................
4 Estimated Cost ..... $~rO00~O0 .............................. Fee ........................................................................................
(to be pa~d on fihng th~s apphcation)
5. If dwelhng, number of dwelling units .......... ~i..~. ........... Number of dwelling umts on each floor ..........................
If garage, number of cars ........ O~ ..........................................................................................................................
6 If business, commercial or mixed occupancy, specify nature and extent of each type of use ..............................
7 D~mens~ons of exishng structures, if any: Front ...~.f. ............... Rear .....,~r.~ ............. Depth .~L~....~..:~II;?....
Height ....... J~il:,.~ .............. Number of Stories ....... ~ ..............................................................................................
D~mens~ons of same structure with alterahons or additions' Front ................................ Rear ..............................
Depth .............................. Height .............................. Number of Stories ........................................
8. Dimensions of entire new construction: Front ....... ~.~.,~. ............. Rear ......,~..~. ............... Depth ...2~.?...~;..~.~..~..
Height ............ :~i~ ......... Number of Stones ..... ~0~e ................
9. Size of lot Front ......~:~. .............. Rear ........ ~k~ ............. Depth ....~ .....................
10 Date of Purchase ........................................................ Name of Former Owner .......................................................
11 Zone or use district m which premises are situated ................................................................................................
12 Does proposed construction violate any zoning law, ordinance or regulahon? ....... ~O .........................................
13 Name of Owner o'f premises .....~..O..~...~....~..~.:~L~ ............... Address ..~.~.~...~,~.~.']'...:~.~.¢.9.~... Phone No ....................
Name of Architect ...................................................... Address ............................................ Phone No ....................
Name of Contractor ....~..~..~..e..~.~.:~..~.~..~.~.~...~:.~..O.~,ddress .,~7~...~J'.~.~..,t~.~.~1,~,~hone No..~.~.~..-.~..],9.!
PLOT DIAGRAM
Locate clearly and d~stinctly all buildings, whether ex~sting or proposed, and indicate all set-back dimensions fron
property lines. Gwe street and block numbers or description according to deed, and show street names and red,cat,
whether interior or corner lot.
#
STATE OF NEW YORK, 1 S.S.
COUNTY OF ................................
............................. :....: .......................................................... being duly sworn, deposes and says that he is the applican
(Name of mdwidual s~gnmg app ication)
above named He ~s 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 fil~
th~s application, that oil statements contained in this application are true to the best of his knowledge and behef
and that the work wdl be performed in the manner set forth ~ apphcat~on filed therewith.
Sworn to before me th~s
........... .....
Term Expires Nt~rch 30,