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Home My WebLink About8079-zlrO~M NO. 4 TO, tN OF 50UTHOLD BUU.r~ING DEPART~IT Town Clerk's Office $outhold, N. Y. Certificate Of Occupancy No..Z68?JS ..... Date ............. .F. eb .... if ...... , 19.~.~. THIS CERTIFIES that the bufldi~ located at . ~it~ersweet. Lane ....... Street Map No, lass, .Pigs,. Block No ........... Lot No. ~art. 56 .&. 57. .... ~tt~hqg~...~. ,¥. conforms substantially to the Application for Building Permit heretofore filed in this office dated ............Juror...1.~;, 19.7.~. pursuant to which Building Permit No. 8079Z ·. dated ........J. ul~ ..... 16.., 19.7-~, was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which thl, certificate is issued is . pr~.vat~, .one..famJ-~y. dgell~,lg ................................. ...... The certificate is issued to .~alt®r. · .Lol~tto. ~onk~n ...... o~r~ ............. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval Ja~..29...197~...by. ~,. Y~lJ, a ..... UNDEEWRITERS CERTIFICATE No. ]~2.~'7B98 ..... Nov...2~... 1~75 ............... HOUSE NUMBER .... .~0 ...... Street. B~tte~.s~ee.t .Lane ..................... -- Building ~ , INSTRUCTIONS ~ This aPPlication must be cgmple~ely filled in by or, in ink and submitted in triplic~to to the Building~ a. in by typewriter Inspector, with 3 sate of plais, accurate plot p~ to scale. Fee according to schedule. b. Plot plan showing 4~btion of lot and of ~dings on premises, relationship tO adjoining premises or public streets or areas, and giving a detailed deSCription of lbyout ofproperty 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 permlti shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose whatever until a Cefl'ificote of Occupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the BuildingDef~rtment for the issuance of e 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 alteratiom, or for removal or demolition, a~ herein described. The applicant agrees to comply with all' applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in b~ildlngs for necessary inspections. George Ahle~S But!der, lne, (Signature of applicant, or.name, if a corporation) 250 Cox Lane~ ~u~hol~uebt lqov Yo~k (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Builder · Name of owner of rem ses Mre Walter Conk. in If applicant is a corporate, signatur, e of duly authorized officer. ' ............... ; ............................... George Ahlera, l~re.ident ~ (Narde and title of corporate officer) 170 HI ' .- Builder's License No. ' ''. . ' Plumber's License No ................................................. Electrician's License No ............................................. /DO~ - /~)~- ~ -_~' Other Trade's License No ............................................... 1. Location of land on which proposed work will be done. Map No.: ...~..a..~.~...a.~....~..a....z~....e. ......... Lot No.....5.,,6.,5.,T., ........... Street and Number ......... ..B..i..t....t..e...r..e..?..e..e.t....L...~.n...e.a...O.l$.t;.g.h..9. Egff .......................................................................... Municipality 2. State existing use and occupancy of premises and in:ended use and occupancy of proposed construction: a. Exisiting use and occupancy Vacant 1 F~tly dwell/ng b. Intended use and occupancy ..%, ........................................................................................................................... 3. Nature of work (check which applicable): New Building.. .......... IlL .... Addition .................. Alteration .............. Repair .................. Removal .................. Demolition .................... Other Work ................................................... 4. Estimated Cost .........l~lj.Jl~.,l~. ........................... Fee ~ 7 ~''~' (Description) (to be paid on filing this application) 5. If dwelling, number of dwelling units ....... J. ................... Number of dwelling units on each floor ............................ If garage, number of cars ........................ J ............................... . ..... 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 df Stories Dimensions of same structure with alterations or additions: Front ....................................Rear ............................ Depth ................................ Height ............................ Number of Stories ................................ 8. Dimensions c/f entire new construction: Front ....... .~.e. ...................... Rear ......~.?. ................ Depth ..... ..J~...?. ....... Height .................... Number of Stories ..................................................................................................................... 9. Size of lot: Front ........................... .J..:J..~.?. .................... Rear ........ ..J..J.~? ......................... Depth .........J....e. .................. 10. 'Date of Pbrchase ........................................................ Name of Former Owner ................... il...i ..................... '..ii ...... 11. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ~lt 13. Will lot be regraded . ........... U ........... Will excess fill be removed j~ _ ~rJ~jl~ '~e (I) No 14. Name of Owner of premises .....~..~...1~.. ............. Address ;~11~.~.. ..... Phone No ....................... Name of Architect ~' .............................................................. Address ................................ Phone No ....................... ~-.-..~-~.*.-..-~....~ '-'~'~-~ Address ................................ Phone No ....................... Name of Contractor 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 number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YOIJ~tlJ~l ~¢ S COUNTY OF ......................... ....... .................................................................. · ..,.. ................... :....b~eing duly swgrn, deposes and says that he is the applicam (Name of individual signing cOhtracf) above named. He is the ....... (Contractor, agent, c0rparate 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 ti,ar the work will be performed in the manner set forth in the applicatio~ith. ,~ ~ Sworn to before me this ..... ..... Notary Public, . ............ :.'[.' nty ~~;';; ' :~c' '~ ' ' "[ [~:;~')' ............................. NOTARY PUBLI~. S~ate of New York ~o. 52-8~25550, Suffolk ~ou~jy Term Expires March 30. TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTH'OLD, N.. Y. BUILDING PERmiT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 8079 Z Permission is herebY granted to: ~..e..o...../~.,z. ~,-~: ~...~ ~:~ r...! ~,~ ...~/. ~. .......................... ............... ~.~..o.~.?. ........................................... pursuant to application dated .............. , ....... .~.,,~.,,~.Y......~..~. .............. , 19.~.~...., and approved by the Building Inspector. Fee $..?y..:..o..o. ........... FOEM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy THIS CERTIFIES that the building located at . .~itt.c~;zwe.~t. L~ne ....... Street Map No~ias.s.,. ?'~a,. Block No ........... Lot No, ~.art..~.6 .~,..~... ~$~qg~...I~.Y. conforms substantially to the Application for Building Permit heretofore filed in this office dated ............ J'u&F.. ~.~, 19.75. pursuant to which Building Permit No. dated ........ J~ly ..... ]~.., 19.7.~, was issued, and conforms to ~1 of the require- ments of the applicable provisions of the law. The occup~cy for which this certificate is issued is . ?~.~va.t.~ .o~m..ffa. r~.ly, d~alling ....................................... The certificate is issued to .~fe~ter. ~'..Lor~tte..Gonk~i~ ...... Q~r.~ ............. of the aforesaid building. Suffolk County Department of Health Approval (owner, lessee or tenant) Jaa . 29...1. 976.. YY..,..~. ,. ~..~ ;kll~.~ ..... UNDERWRITERS CERTIFICATE No. N2.%7.895 ..... No.v... 2~... 197.~ ............... HOUSE NUMBER .... l.~D.0 ......Street . B:Itte2.sXcee.t .Lene ...................... ! .... /~.~. ,-. ~ .... (~2~ .~: '~':~:1 ............ -- Building Inspect(ir TOWN OF $OUTitOLD ~ Building Deportment Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructlons A, This application must be filled in typewriter OR ink, and submitted in DUPLICATE to the Building Inspector with the foBowing; 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 dispasal--(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 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 features. 2. Sworn statement of owner or previous owner as to use, occupancy and candition 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 $5.00 3. Copy of certificate of occupancy $1.00 New Building .~. ............ Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Location Of Property ........................................... Owner Or Owners Of Property ...~..a...]=..~..e...~.....~..~.~.,~g.~..e.,~,..~..g...~.9,~.EkSD, ...................................................... Subdivision ...N..a..f.s.a...u.....F..a..r..m..s. ................................. Lot No ............. Block No ............. House No......~...O-O.. Permit No..8...O.~.~.~. ........ Date Of Permit ...~../.[.~./..'[.~..Applic~m~t GF~0E.GE..~KLER$.,...BiIZLDEIR,...ZAIC.. Health Dept. Approval ......... .~...~..0.,~..~. ....................... Labor Dept. Approval /~/~ Underwriters Approval .... .2.~.Z.~..~.8. ............................ Planning Board Approval /J'(-~' Request For Temporary Certificate ........................................ Final Certificate .......... ~ ........................... Fee Submitted $ ...~...~ ............... Construction on above described building and permit meets all applicable codes and regulations. Applicant ......................................................................................................... George Ahlers, Sworn to before me this 3- . Noto~ Public ...... ~..~--/--~.-- County Builder, Inc. (stamp or sea ) ~yORKI, BOARD',: JOHN STREET NEW YOR SUFFOLK C~UNTY DEPARTMENT'OF HEALT~t sE~v[cE~ ~"": ~ :' XHeaTth Services. '. Refe~Bnce Number _~q~O ~PPLICATION F~R APPROV~ TO CONSTRUCT A. PRIVATE SEWAGE DISPOSAL SYSTEM. AND~'A WATER SUPPLY ~. ~ Amqicant ~ ... ~ ~ Phone 7~ ~/0 Address ~ O~ ~ ~ ~y ~?xe~... ~, Section 2, Property Location2~F~.~-~m~; 'C¢~"&~" Lot Numar ~ .., , . , Pmivate Welt ,;~ 3. Public Water Company Nam~. ~ , . , -~,' ........ "-- ~ 4. Lot size: Width' feec Length..., ,, teet . ' 10. Sewage Disposal System: , (~Health Servi~. U e) A. gallon septic %ank: '-- Precast/Equivalent Block ~ 1 _ , .... ~ ~ B, teaching pools: > Number of pools I ~--'~ '-' Precast ~ ~ Block Special '~ ~ t&P~-- Il ~f private well, fill in the fol- ~"~' · J ~ '__~ lowing blanks: ~F .~_ ~ A, Tank capacity ~ _gallons ~ ~. T~l well depth, D~th to ground wate[. ~,'E. ~Ount o~ water in well ~ .... , .z~ T6e.unde~gned CERTIFIES: "Construction of authorized installations will be in accordance Wi~ the ~ffolk County Depart~nt of Health Services' current standards thereto." This ~plicatf~ will be valid for one year from the. date of approval indicated below and may 6~ reneW~ if a current local Building Department Permit is in ~ffect. n, te '7~ / ~.~ Si gned FOR THE DEPARTMENT OF HEALTH SERVICES' USE ONLY, Based on the information presented here- with, i{' is the opiniO~ 6~the Department of Health Services that an adequate and satis- factory Sewage Disposal System and Water Supply can be installed on this plot, APPROVAL DATE. . __ ?/(.~_~'?~_____ SIGNEB , ~ -- S-15 Rev, 4/1/73 TOWN OF $OUTHOLD / r' AR TO/< BUILDING DEP TMEN TOWN C:LERK'$ OFFICE ~ ... , ........ Disapproved a/c ................. ~ ..................... ~ .......................... ............................ ................................. ........................ ............................ ':: oot ..................... ......... ....... , INSTRUCTION~ o. This opplicotion must be c~mpletely filled in by typewriter oe in ink ~nd submittod in triplicote to the Buildin~ lnspector, with 3 set* of pi*ns, occumte plot plan to ~1~. Foe ~ccordin0 to schedule. b. Plot plon showin~ Iocotion of lot ond of buildings on premise% relotionship to adjoinin~ premises or public streets o~ oreos, ond ~ivino ~ detoiled doscription of I~yout o{proportg mus~ be drown on tho dioorom which is port of this ~pplicotion. c. The work covered by this opplicotion moy not be commenced before issuonce d. Upon ~pprowl of this opplicotion, tho Buildin~ Inspector will issue o Buildin~ Permit to the ~pplicont. Such permit~ sh~ll be kept on the promises ovoilable for inspoction throughout the work. e. No buildino sholl be occupied or used in whole or in port for ony purpose whotever until a Certificote of Occupancy sholl h~ve been oronted by the Buildin~ Inspector. APPklCATION IS H[R[BY MADE to the Buildino Doportment {or the issuance of o Buildino Pormit pursuant to the~ Buildin~ Zone Ordinance of the Town of Southold, Suffolk County, ~ew York, and other opplicoblo ~ws, Ordinonces or~ Re~ulotions, for the construction o{ buHdinos, odditions or olterotion% or {or removol or demofition, os horoin described. The opplicont o~rees to comply with oll opplicoble laws, ordinonce% buildin~ codo, housino code, ~nd m~ul~tlon% ~nd to odm~t outhorized inspectors on premises ond in buffdlnos for n~ess~ry lnspeetions. George Ahlers Builder. Inc. (Signature of opplicant, or nome, if a corporation) 250 Cox Lane, Cutchogue~ New York (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Dui ld er Name of owner of premises ........... ~!~.,....~.~..n.q.l...~..e..¥....O...o.p...l~.l...i..n. ............................................................................................. if applicant is a corporate, signotur, e of duly authorized officer. ........... ..~..~.~.~,~/...~,~....~.~: ........................... George Ahlers. President ~ (Nar~e and title of corporate officer) Builder's License No ........ 1.~.7....0....I.].~ ............................... Plumber's License No ................................................. Electrician's License No ............................................. Other Trade's License No ............................................... Location of land on which proposed work will be done. Mop No.: Nassau Farms Lot No. 5657 Street and Number ......... ..B..l.~..t..e..¥..s. Fy.e.e...t....I;'..a..n...e..~....C.'P.t.e.~..qg.t!9 ......................................................................... Municipality State existing use and occupancy of premises and intended use and occupancy of proposed construction: Vacant a. Exisiting use and occupancy ................................................................................................................................ I Family dwelling b. Intended use and occupancy ................................................................................................................................ 3. Nature of work (check which epplicable): New Building.. .......... ~1 ..... Addition .................. Alteration ................ Repair .................. Removal .................. Demolitior, .................... Other Work ................................................ ~,_ ~ 7 ~ (Description) 4. Estimated Cost .........~..~le.~.~.0.~. ........................... Fee ....................................................................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ....... ~, ................... Number of dwelling units on each floor ............................ If garage, number of cars .................... :...II,Iii .......................................................................................................... 6. If business, commercial or mixed occupancy, specify nature and extent af each type of use ............................ 7. Dimensions of existing structures, if any: Front ............................ Rear ................................ Depth .................... Height ........................ Number d'f Stories ................................................................................................................. Dimensions of same structure with alterations or additions: Front ....................................Rear ............................ Depth ................................ Height ........................... '.Number of Stories ................................ 8. Dimensions o~f ~nti~e new construction: Front ....... .~0. t ....................... Rear ......~..~. ................ Depth ....... ..~... ............ Height .................... Number of Stories ..................................................................................................................... 9.~ Size of lot: Front :l.~m . Rear l~l,~e Depth ~00' 10. Date of Pbrchas~ ........................................................ Name of Former Owner ............ '..'.L.; ....... i.' .................. ~..ii ...... !11. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning Iow, ordinance or regulation: I1~ 1,3. Will lot be regraded. ........... 1~¢~ ........... Will excess fill be removed ~r~i~rl~ljj~l~ '~l~e (I1) No 14. Nome of Owner of premises .......~....~..~..?.~....~#..~..~. ............. Address ..,,1~.~.1~.~.t~..... Phone No ....................... Nome of Architect .............?. ............................................... Address ................................ Phone No ....................... Nome of Contractor ~..~..~... &l~J¢t~I~-.~.~...~..~.~.... Address Phone No. ................... ................................................................ PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all 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 lot. STATE OF NEW YO~JJO[II [S S COUNTY OF ........................ ::....'...f ' ' ' : ' .', ; ..~ .................................................................. ~ ..... ,........,,. ........ beiqg du y sw~m, dppgses and says that he Js the applicam (Name of individual signing conffacf/ ' ' ' above named. (Contractor, agent, cOrpo,ate officer, etc.) of said owner or owners, and is duly authorized rto p~rfqrm or haxe perfq(med the said work and to make and file this application; that all statements contained in fhis applic6tion are tkue to the best of his knowledge and belief; and tha~ the work will be performed in the manner set forth in the application fil~therewith. ~ Sworn to before me this /~ ,. ~ ~ ~ ~/~,, 4 ..... ..... o, ..... ....................... , ................. ...... ............... ....................................................... ~. .~ / z// (S~nature of applicant) NOTARY PUBLIO, Sto~e of N~w York No. 52-8~25850, Suffalk 19~t~ Cou y T~rm Ex~ires March 30, FOlg~ NO. TOWN OF $OUT8OLD BUILDING DEPARTMENT TOWN C~LERK'$ E,,am,ned ............. ................................... ...... Disapproved q/~ .... ~ .......~ ............... ~ ............................ Application No .............................. INSTRUCTIONS a. This application must be completely filled in by typewriter or~ in ink and submitted in triplicate to th~ Building Inspector, with 3 sets of plans, accurate plot plan to scale. Fee according to schedule. 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 ofproperty must be drawn on the diagram which is part of this app!ication. c. The work covered by this applicatio0 may not be commenced b~fore issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building 'Permif to the applicant. Such permit shall be kept on the premises available far inspection throughout 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 Bud ng Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws Ordinances or Ragu arians for the construction of buildings, additions or alterations, or ,for remova~ or demolition, as herein described. The applicant agrees to comp y w th all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections. (SignatUre of applicant, or name, if a corporation) (Address of applicant) State whether applicant is owner, lessee, agent, archit~ect, engineer, general contrec~cor, electrician, plumber or builder. ................................................. ..................................................... .......................................................................... Name of owner of premises .......... .~.~e...~&Z~..,~k~ .............................................................................................. if applicant is a corporate, signature.of duly authorized officer. ................ ~"~i;de of corpora~:~"officeri ......... ~tle~'~e Builder's License No .......;I,."i'.O..~]l;. ............................... ' " Plumber's License No ................................................. Electrician's License No ............................................. Other Trade's License No ............................................... 1. Location of land on which proposed work will be done. Map No.: .~/alt~&~..~l~ .......... Lot No...~6,~.....: ...... Street and Number ........ ~ll,.~.l~/~..~l~,...(}~'~It]l~ ............................................... ........ 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ................. .~.~1~1~i,~ ................................................................................................ b. Intended use and occupancy .................. .]....~ .t~...~.'~2'.....~..~.~..~..~1~.~..~ ........................................ 3. Nature of work (check which applicable): New Building.. ......... .~ ..... Addition .................. Alteration ................ Repair .................. Removal .................. Demolitior. .................... Other Work .................................................... ........................................................ c~ ~ (Description) 4. Estimated Cost ~33~39G,00 Fee ....... 2 .............................................................................. (to be paid on filing this application) 5. If dwelling, number of dwelling units ...... ,I, ................... Number of dwelling units on each floor ............................ If garage, number of cars ....................... ~IIP~I~. ........................................................................................................... 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 ...... .40~ ...... , ................ Rear .....40 ................... Depth ...... ~.~.~ ........... Neight .................... Number of Stories ..................................................................................................................... 9. Size of lot: Front .......................... ~,...~. ...................... Rear ........ ~..~.~.~ ......................... Depth ....... .0.0. .................... 10. Date of Purchase ........................................................ Name of Former Owner ............... 11. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zonfng law, ordinance or regulation: 13. Will lot be regraded . ..........~. ........... Will excess fill be removed J~i,~-~pr~l~ ~, (il) No 14. Name of Owner of premises .....W..~.~..~..~...~...~.~..I,..~ .............. Address ~l~ttl~.~. ..... Phone No ....................... Name of Architect ............?. ................................................ Address ................................ Phone No ....................... Name of Contractor C~lllt~r~ll ~JJ~/'ll~ f:'~dllt~j .. Address ................................ Phone No ....................... .................. lii' ; ........................... 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 number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YC~I~.¢,,,~, ~e c COUN-[Y OF .......... .~.~ff~.....~' ~'~ ................................................................ , ......................... ~ ...... bei~ drily swgrn, deposes and says that he is the applicant (Name of individual signing CantFa~ ' ' above named. He is the ...... .~.~Z~.~.Z.~,~,~ ............................................................................................................................... (Contractor, ageqt, gorporate 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 bra true to the best of his knowledge and belief; and tk, o~ the work will be performed in the manneF set fo~h in the applicatio~led therewith. ~__ Sworn to before me this ................ .............. .......................................................... ., ~ ~/ /~ / (Signature of applicant) }~OTARY P ]BLI~ State m ~ at: NO. 52-8125850, Sullol~ ~ml ~, lmm Expires Msrch 30, 'F APPROVED 'AS NOTED DATE:' k_~.~ l(~ FEE= ~7 B~ NOTIFY "BUILDING DEPARTMENT AT 765-2660 9AM TO 4PM FOR REQUI~- ~D INSPECTIONS: J BEFORE BACKFILLING d~N OR START FRAMING z BEFORE COVERING PIPELINE 3. FINAL WHEN JOB COMPL~I~ p,OT RESPONSIBLE FO~ DESIGN ~ C~- 5TRUCTION