HomeMy WebLinkAbout11587-zFORM NO, 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Ha~l
Southold, N.Y.
Certificate Of Occupancy
No .... .Z.1,1.1.3.5. ....... Date ............... lY. August:. 1982 ......
THIS CERTIFIES that the building ................................................
Location of Property ,.. 465. P~iYa~:e. Rd,. ~t3~. Soul:hold ................................
House No, Street Hanllet
County Tax Map No. 1000 Section , , Off 0 ...... Block . . 06 ........... Lot 016
Subdivision ..... .X ......................... Filed Map No. X .Lot No. X
conforms substantially to the Application for Building Permit heretofore filed in this office dated
......... Maxcell .15. .... ,19.85. pursuant to which Building Permit No. 11587Z
dated ........... H~qh .23. ......... 19 .8.2., 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 .........
..... d~k .~ddi~i~'a .t;o..~i~ir~g .cl~.e. [.[.iqg ....... ' .......
The certificate is issued to . . .C ],a~;a .P.~;qq ~ ....... ~o~,n'e:4'l~'s~it~'r~ .....................
of the aforesaid building.
Suffolk County Department of Health Approval ...I~/.B ....................................
UNDERWRITERS CERTIFICATE NO ..... I~/R ................................... ~ ......
Rev. 1/81
Building Inspector
RM
~0. 2
FO~
BUILDING DEPARTMENT,~
TOWN HALL
SOUTHGLD, 'N~ ¥.
BUILDING PERMIT,
(THIS PERMIT MUST BE KEPT ON THE PREMISES
COMPLETION OF THE WORK AUTHQRIZED)
N°. 11587 Z Oote ~. ..,,d~...~, ............... 19...~,~
Permission is hereby granted to:
, ....~.~.,~./.c.~,.~.~..~.,i,... i.~..:..: ........ ,
.~.~.~/.,.~.~.~:.:....=.......~.,...~.... ~.. : ............ : ..........................
et,'.mi~,;'~at;--~'~at...~.'~. ...... ...~.~..~,.~i~,~.,,~ ............ ; ...................... .;
....... .......... ~. ................................................................ !...:....:....!,.: ..~...,.~....C
....... , ..................................................... , ..................... ?.,. .......? ~ .... .~. .... ~:~ · ,~ ! .....
~ .- ~ _, ./'
CouOty Taxx Map No. 1000 Section ...... . BIo¢l~ .~ ....... t No. ~. ........ ~./...~
purs~Jan, t(o~ application .~/,~,~.~/~.~' 9~"~~'~
dated .'?',~/"~i:"'~'"', 1 and 9pproved by the
Building In;$pector.
Fee $.. ;.....: .... //~ ~ ~ ' ~r
:' Re~. i6/30480
FORM NO. 6
TOWN OF SOUTHOLD
Building Department
Town Hall
Southold, N,Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This application must be filled in typewriter OR ink, and submitted in duplicate 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 Underwrite'rs.
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 peoperty 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.
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
//
New Building ............. Old or Pre-existing Building ............ Vacant Land .............
Location of Property., ¢/~:>..~.. .... .~.r. { .~J..~.-%... ~..~.; .~. ............ .S.(:3 .~,~/~ .
House No. ~_~ ~C/~,~L ~ ~Street Hamlet
Owner or Owners of Property .... ~. , ....... .~-.~..~ ..................................
County Tax Map No. 1000 Section . ..~-?..~.(,~ ..... Block .....C,,~..(:~ ...... Lot..~../..~:~ ........
Subdivision ................................. Filed Map No ........... Lot No ..............
........ ........
Permit No. ~l ~-~ Date of Permit .......... Applicant ...... ~.
Health Dept. Approval ........................ Labor Dept. Approval .......... ; .............
Underwriters Approval ........................ Planning Board Approval ......................
Request for Temporary Certificate ..................... Final Certificate ......... ,../~-~.. ;-. .......
Fee Submitted $ ...... ~.,.. ~ . ./ ............
Construction on above described building and/p'~eets all ~aJ;~odes a~d regul~az'i~s.
TI(o('{ Applicant-. ~.~., ~.~ .............
FIELD INSPEC$TION-
FOUNDATION
(1st)
COMMENTS
FOUNDATION
2.
(2nd)
ROUGH FRAME &
PLUMBING
INSULATION PER N.
STATE ENERGY
qODE
FINAL
ADDITIONAL COMMENTS
PERMIT
UNO£~ THE ENVIRONMENTAL CONS[gVATION LAW
%AR'(ICLE 15, (Ftotection of Water)
AgTICLE 24, (Freshwater Wetlands)
'~7 15276-0367
ARTICL£ 2S, (Tidal Wetlands) .
RTICLE 36, (Cop~t~uction in Flood Nazatd Areas)
ADDRESS OF PEPOMII~EF'
_Lo cmeer: _ ,m v_2r,ork ....
0
;~OCAriO~ OF PROI[CT (S~rhoa of stream ~ dal wetland, dam, nuilding)
~ Sau~hs~_~_~g_C~231 feet ~~m.~~~~
D;:ScRmrtoN or PROJE( r lawn Avenue
ConsLrucL_ 1,7_ foot. X~__4__foo~_~tooden deck_a~-r~-~f-~×isi, ing--
_home_ as_par..
~':~MMUNIT¥ NAME (City, Town, Vdlage)
,( 9UNIt '~ --- lOAN NO.
GENERAL CONDITIONS
1. fhe ~rmittee shall hie m the office of the appropriate Regional
L The permitted work shall be subject to inspection by an authorized
ew~ suffere~, aqsing out of the projecl described her~in and has agreed to
bed of the wal~rway or flood plain or deep holes that may have a tendency
c~use injury to ,avigable channels or to the hanks of tlle waterway.
5. An~ material to be deposittd
the w~te~w~y vr on shore ~bove high-water mark, shall be deposited or dumped
at lhe k. cau(v shown o~ the drawing hereto attached, and, if so ~escribed
thereon, ~Hnn or behind a good and substautial bulkhead or bulkheads, such
wa:ercourse hereby authorized shall riot be completed, the owners shall,
8, Ihat the State of New York shall in no case be liable for any damage
or injury to the structure or work herein authorized which may be caused by o~
result from futere operation.~ undertaker by the State for the conservation or
9. lhat if the display of lights and aignals on any work hereby adthorized
modification of the wetland hereby autherized has not been completed, the
12. This permit shall nol be construed as conveying to the ap~[ica~l a~y
right to trespass upon the l~ods or interfere w~th the riparian rights of others
p~ojecl.
Part 500 of 6 NYCRR (Constr~ction in Flood Plain Amos having S~c}al ~]o~
free from flooding.
15. By acceptance 0t t~is ~mit the ~mittee agrees ~t t~e ~mit
(SEE REVERSE
I
N~ ¥c~ 9t~ ~np~;'~n! of Environmental Conservation
R.~ul~Cory A£~atrs Uut~
Bldg. 40, 2UNY~-Room 219
S~ony Brook, NY 11794
(..516) 751-7900
Rc~ert F. Fiscke
Commllslo;mt
November 20, i981
Clara Prout
107 Greeu~.cres Avenue
l~hite Pl. ain8, 1/Y 10606
LETTER OF J~DI~IT TO:
~ 152~6-G~67, Construction of Dec.rig
D~ }f~. Prout:
Yo~r r~cenC request Co ~y the above pe~C ~s been
pure.ut ~o 61~C~, Par~ 621. It Ms b~ de~e~ined t~t th~ proposed
aMaZe 'al! ~t substantt~ly change the scope of the peal~ted ac-
ctvky or pe~t conditions.
~here!ore~ ~M pe~ is ~ended ~o au~rize ~he cons~ction of a
16' 1.f. X 28~ 1.f. ~oden deck onto r~r of existing h~a as per
~e~J. sad plau~ submi~ed Nov~ber 18~ 1981.
~is letta~ Is an ~en~ent Co ch~ original pe~it, ~d as such.
is ~o be attached
tll o~hev conditiou~ ~min as ortglmlly sta~ed in ~he pe~t.
~arles T. H~ltou
~te~ate
Pe~t Ad~nistrator
CTH:RNT:cz
Imm
: I
.j'ii'
I /
/ I // /
*¢4z.4 (s,'80~ N~ vv York State Department of Environmental Conservation
EI~B
$ ,.,e/tott,l NOT CE OF COMPLETE APPLICATION
U.S, Fish and ~fe S~;.v,~ce '
P~ E. R, C. ~H~ {S NOI A
F~e
Applicant C,~J,'to:'Pr0u./6 Date ~_~__q_22, 1981
Address _.]J~Z._C_~._~.,~_~g~E. ....... ~pp, NosTW15276:~__
...... ~~~_york 10606
{P~rmit(s) applied ~or: ~~ ,
Co~ ~7'X24' deck s~ o~ ~ng ho~e. A v~ence ~ requited for
no~h of Pine Neck Road, 467' ~t of O~n Avenu~ on the soutk side of Jockey
Cre% So.old, Town of So.old, Co~y of Suffolk.
PLIt:~!_{C COMMENT: Applications may be reviewed at the address listed be{ow and specific comments on the proj-
ect, ,ar a request to become a partydn-interest ifa public hearing is held, must be submitted in writing to the contact
person named
below eo later than _Augu~s_t~lg~ 1981
(By la,,',,, this date must be at least 14 days (30 days for a SPDES Permit) from the date the notice will appear in the
Environmental Notice Bulletin.)
LEADAGFNCY: N~ York S,tz;t-te._.~g~paJt,0tleL'~.~_ef [J~L~',~LOJ2~lg.J~3J'j,~0.,to~.,t./:on ....
SEQR DETERMINATION: (check appropriate box)
["~ SEQR-1 Project is not subject to SEQR because it is exempt, excluded, or a Type Il action.
[] SEQR-2 Proje,~. is a Type ! action; it has been determined that the proiect (may, will not) (circle appropriate)
',',~:.c a s~g~,;f~c;mt effect on the environment. A Negatiw Declaration has been,~repared and i~ on fi{e.
~EQR-3 Project is an unlisted acdon; ~[ has been determined that the project will not have a significani effect on
the environmeet.
Q SEQR-4 A draft environmental impact statement has beer, prepared on this proiect and is on fire.
g SEQR-5 A final environmental impact statement has been prepared on this project and is on file.
CONTACT' (name, agency, address, tele[,hone number)
Reg~to~y Aff~ U~
Da~ J. L~n
B~ng 40, SUNY--Room 219
Stony ~ook, N.Y. 11194
(516J 751-7900
healing is held, the' final decb~on wdl be made within 60 days after the heanng is completed
APPLI(~ANT
FORM NO. 3
TOWN OF SOUTHOLD
BUILDING DEPARTJ~ENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
NOTICE OF DISAPPROVAL
F' . ....................................... ~. ............. /: ~tc.~f: ....................................................... , 19 .......
,JULY
PLEASE TAKE NOTICI~ '~nc/E y~u~iapl~'q9~ dated .................................................... , 19 ........
~oll~F~it l;~<~t~,7~c~....;~.......~ ..................... ot t~,~,~ loc~ted at ....................................
...................................................................... Street
Map .................................... Block ............... '; ............................ Lot [. ~x~. _~ET.i~.F. 1. t~,.~..~. ~-, ......... is
re~E~'erewi~d ~i~.~sopproved on t~eT~eC~ow~ound~ O~D-.._.~/ ..............................................
Building Inspector
,4
SUPPLBP~NTARY SPECIAL CONI)ITIONS
The following conditions apply to all permits
A. If any of the permit conditions are unclesr~ the permittee shall contact the
Division of Regulatory Affairs at the address and telephone noted below.
B. A copy of this permit shall be available at the project ~ite whenever author-
ized work is in progress.
Co
The permit sign enclosed with this permit shall be protected from the weather
and posted in a conspicious location at the work site until completion of
authorized work.
At least 48 hours prior to commencement of the project, the perm/tree shall
complete and return the top portion of the enclosed receipt form certifying
that he is fully aware of and understands all provisions and conditloms of
this permit, Within one week of completion of the permitted work the bottom
portion of that form shall also be completed and returned.
For projects involving activities to be accomplished over a period of more
than one year the permittee shall notify the Regional Permit Administrator in
w~iting st least 48 hours prior to the commencement or resumption of work each
year.
If project design modifications take place after permit issuance, the per~ttee
shall submit the appropriate plan changes for approval by the Regional Permit
Administrator prior to undertaking any such modifications. The permittee is
advised that substantial modification may require submission of a new applica-
tion for permit.
All necessary precautions shall be taken to preclude contaminatio~ of any wet-
lands or waterway by suspended solids, sediment, fuels, solvents, lubricants,
epoxy coating~ p~ints, concrete, !eachate or any other environmentally dele-
terious materials associaned with the project work°
Any failure to comply pr~c:t£'ely with all of the terms and conditions of this
permit, unlesG authorized in writing, shall be treated as a violation of the
Environmental Conservation L~w.
The permittee is advised to obtain any permits or approvals that may be required
from the U.So Department of Ar:ay Corps of Engineers, New York District, 26 Fed-
eral Plaza, New York, New York 10097~ (Attention: Regulatory Functions Branch),
prior to co~encing ~0ork authorized herein.
The granting of this permit does not relieve the permittee of the responsibi-
lity of obtaining a grant~ easement~ or other necessary approval from the
Division of Land Utilization, Office of General Services, Tower Building, Em-
pire State Plaza, Albany~ New York 12242, which may be required for any encroach-
ment upon State-owned lands under water.
Regional Permit Administrator
NYS Department of Environmeotm~
Building 40, SUNY - Room 219
Stony Broo~, N~w York 11794
516-751-7900
DEC f~ TW 15276-0367
NYSDEC Reg. Permit Admi~istrator
Bldg. 40, Room 219
SUNY Campus
Stony Brook, N.Y. 11794
Permit No.
Issued to
(Agent) _.
Dear Sir:
Pursuant to General Condition Uo. 1 of the above referenced pemmit you are
hereby notified that the authorized activity ~all commence on
This notice is to be Sent at least two days in advance g~ com-
mencement of the project.
The permit sign will be posted at the site and copy of permit will be avail-
able at site for inspection.
Submitted by
Failure to notify or post sign will leave owner and/or contractor subject to
applicable pemalties for non-compliance with permit conditions.
NYSDEC Reg. Permit Administrator
Bldg. 40, Room 219
SUNY Campue
Stony Brook, N.Y. 11794
Permit No .......
Issued to
(Agent)
Dear Sir:
Pursuant to General Condition No. 1 of the above referenced permit you are
hereby notified that the authorized activity was completed on .... . .......
Submitted by .... ~
(This notice is to be sent to above address promptly upon completion of
project). Failure to notify will leave ovraer and/or contra~toZ-subJec~-~o,applic-
.ahla~penaLties_ for. no~-compllanc~..w~ith perm~con~ition ·
Southold Town Board of Appeals
MAIN I~IDAD- C~TATE I~I'IAD 25 ~[3UTHrlLD, L.I., N,Y, 1t971
TELEPHONE (516) 765-1809
ACTION OF THE ZONING BOARD. OF APPEALS
Appeal No. 2724
Application ~ated July 28, 1980
TO:
Mrs. Clara Prout
Private RoadNo. 3 (off Pine Neck Road)
Southold, NY 11971
[Appellant(s)]
At a Meeting of the Zoning Board of Appeals held on February 26, 1982
the above appeal was considered, and the action indicated below was taken
on your [ ] Request for Variance Due to Lack of Access to Property
New York Town Law, Section 280-a
[ ]
Ix]
Request for Special Exception under the Zoning Ordinance'
Article , Section
Request for Variance to the Zoning Ordinance
Article III , Section 100-31
[ ] Request for
Public Hearing: 2/26/82: 7:30 p.m. Application of Ciera Prout,
107 Greenacres Avenue, White Plains, NY 10606, for a Variance to
the Zoning Ordinance, Article III, Section 100-31 for permission
to construct deck addition to dwelling with an insufficient rear-
yard setback at 465 Private Road No. 3 (off Pine Neck Road),
Southold, NY; bounded north by Jockey Creek; west by Dyer; south
by Norris; east by Shector; County Tax Map Parcel No. 1000-70-6-16.
By this appeal, applicant seeks permission to construct an
16' by 28' deck at the rear of the proposed dwelling, leaving an
insufficient rearyard setback of 28 feet. The prior dwelling is
claimed to have had a small deck area. Applicant has applied to
the N.Y.S. Department of Environmental Conservation and received
approval for this construction under Permit #TW 15276-0367 on
November 20, 1981. Upon inspection, the board found that the
applicant has limited buildable area, which would be to the rear
or to the front yard areas. The board agrees with applicant's
reasoning.
In considering this appeal, the board determines that the
variance request is not substantial in relation to the code require-
ments; that the circumstances herein are unique; that by allowing
tke variance no substantial detriment te adjoining properties would
be created; that the difficulty cannot be obviated by a method,
feasible to appellant, other than a variance; that no adverse effects
will be produced on available governmental facilities of any increased
population; that the relief requested will be in harmony with and
promote the general purposes of zoning; and that the interests of
justice will be served by allowing the variance as applied for.
On motion by Mr. Grigonis, seconded by Mr. Goehringer, it was
RESOLVED, that the relief requested in Appeal No. 2724, appli-
cation of Clara Prout to construct a 16' by 28' deck with a rearyard
setback of 28 feet, be granted as applied for.
Location of Property: 465 Private Road No. 3, Southold, NY;
County Tax Map Parcel No. 1000-70-6-16.
· Vote of the Board: Ayes: Messrs. Goehringer, Grigonis, Doyen,
Douglass and Sawicki. , , ,
DATED: March 4, 1982
Form ZB4 (rev. 12/81)
~/~'~rSOUTHOL~ TO~
OF APPEALS
ZONING BOARD ~.~'\~~
~OKM NO. !
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN GLERK'$ O~FICE
SOUTHOLD, N. Y.
E×om,ned ......
Approved ~.~%.C../.?......~..5 ...... , 19.~.ii..-~. Permit No..X../~,,.~..c~...2. Z .......
Applicatian No ...............................
Disapproved a/c
..................................... ::;;~..~,..~Z~~. ........~'" ....... ~ ................
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
Date ......... ~ ...... i'"'" 19 ............
INSTRUCTIONS
o. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the 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 o~
areas, and giving a detailed description of layout 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 permit
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 Certificate of Occupancy
shatl 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, bulk]lng 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)
· .................. ........................... .c
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engin~er,~eneral contracto9 electrician, plumber or b~ilder.
,, - - r-o -f "" '
marne ot~gwne~ or premises .........../,¢,,:.L..~ ........... L/ ........... 9.~..~ ............. .~,,.~,,.~.,¥, ...................................................................
If ol~li/~car}t '~)g c~J'~,/~,ig~nature of duly authorized officer.
........ .............
(N,a,~ and title Of.~co'rp~rate officer)
Builder's License No ............. .~...../..c/.. .................. .~:..C....
Plumber's License No .................................................
Electrician's License No .............................................
Other Trade's License No ...............................................
Subdivision
Location of and on which proposed work will be done. Map No.: ........................................Lot No...a ........ ~..
Street and Number ............ .~./..~...S~ ........ ~~.....~....~ ...................... MunicipalitY/ '
State existing use and occupancy of premises and intended use and occupancy of proposed construction:
o. Exisiting use ond eccuponcy ........... ff...?....~../.. .¢..~':.,~....~.. ...................................................................................
b. Intended use and occupancy ..£ ¢ .s../'..~ ..~ .~.? ....(=~.....~.., ...~.. ....... ..~....~..~ ~ ............ ' .....................
County Tax Map No. Dist. 1000 Section 7(~) Block (' Lot /~ _
C~9.
10.
11.
12,
13.
3. Nature of work (check which applicc
Repair .................. Removal ...........
5. If dwelling, number of dweliling unit:
If garage, number of cars '"i ..............
6, If business, commercial, orI mixed
7. Dimensions of existing struc[ures, if c
Heigh~ ...... /..'~ ........... Number of
Dimensions of same structure with
Depth ............ Z~..~. ............. jHeight
8, Dimensions of entire new construct~
He'ight ..... ~.. ........... Number of Stc
Si,e of lot: Front ............... i.¢.~. ....
Date of Purchase '
Does proposed construction yiolate
Will lot be regraded . ........... ~ ...........
Name of Owner of premises
Name of Architect ............. .............
Name of Contractor
Locate clearly and distinctly Oil buildi
property lines. Give street and block nur
whether interior or corner lot.
hie): New Building.. ................. Addition ................ :.~ Alteration .................
...... Demolition .................... Other Work
(Description)
.......................... Fee /._,~'-, 0 0
(to be paid on filing this application)
............................ Number of dwelling units on each floor ............................
~ccupancy, specify nature and extent of each type of use ............................
~y: Front .......... ~.....~. ......... Rear .............. ~. ............... Depth
Dries .............. / ........................................................... · ....................................
'orations or additions: Front ........... .~......~,. ............... Rear ........ ...~z..~., ...........
...... /...~i..~ .......... Number of Stor~es ............... ./ ..............
~: Front ......... ~.... ~9~. .................. Rear ......... ~.~ ..o~.. .......... Depth ....... ../...~. ...........
les .............. ../.. .......................................................................................... , .........
.......................... Rear .............. .~.~.. ................... Depth ...... .~../~...(-'Z .........
.......................... Name of Former Owner ........................................................
Zone or use district in which premise are situated ....... .~.....~'.~.~. ...........................................................
zoning
· Will excess fill be removed from premises: ( ) Yes. ( ) No
........ ; ......................... Address ..v~,.. ............... ~ ........ Phone No .......................
PLOT DIAGRAM
3gs, whether existing or proposed, and indicate all set-back dimensio?s from
~ber or description 'according to deed, and show street names and ~ndicate
STATE OF NEW ~'(~1(.,. ~ ils S
COI, JN_Ty OF .~..,,.iJ'
........ . ,.
J (Name of individual signing cc
above named.
He is the '
of said owner or owners, and is duly autl
this application; that all stateme6ts contai
tha~ the work will be performed in[the mani
Sworn to befgre me this
.....
.....
Term Expl
................... being
racf)
duly sworn, deposes end sbys that he is the applicon
perform or have performed tl)e'-~id work and to make and file
ned in this application are true to the/best/of his knowledge and belief; and
~er set forth in the application filed th~re~_h.
................................... :: .............
~ ~ / (Si~a~ ~ *ppl~ont)
Tfl ANN NEVI~E
.10, ~te ~ Hew
~50, Suffol~ Cou~
*es Uar~ 3~,