HomeMy WebLinkAbout11746-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
Certificate Of Occupancy
No. Z11480 Date February 15 ., 19.8.3
THIS CERTIFIES that the building ................................................
3750 Youngs Avenue
House No. Street Ham/et
County Tax Map No. 1000 Section ...0.5.5. ...... Block ....0.2. ......... Lot ...0.1.6. ...........
Subdivision... $ ........................... Filed Map No. X .Lot No. X
conforms substantially to the Application for Building Permit heretofore filed in th/s office dated
.... M..ay..2.'/ .......... , 198..2. pursuant to which Building Permit No .... 1. 17.4.6...Z ..........
dated .... J..u .n.e.. 1. .7 ................ 198. .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 .........
a 9De-family dwelling (altered and restored).*
The certificate is issued to WARREN & ELLEN HUFE
(owner, lessee-m.
of the aforesaid building.
Suffolk County Department of Health Approval . .1.2.-.5..0.-.9.5. ,...1/.2.8../.8.3.,.. ~.o.b.~ :..A....V. ~.l.l.a. ,. F.g.
UNDERWRITERS CERTIFICATE NO ......... .N. 588061
-.~ Building Inspector
*The Zoning Board of Appeals, #3009, on July 29, 1982,
granted Warren & Ellen Hufe approval to retain former
non-conforming one-family dwelling use subject to the
condition that no further additions be made without
the Board's written consent.
BUILDING
HALL
$OuTHOLD, N~. Y.
BUILDING PERMIT
(THIS PEP, MIT MUST BE KEPT oN ;fTH,E PJ~,E~MI
COMPLETION OF THE WORK AUTHORIZED)
1:[746 Z Date
Permission is hereby granted t~o;.
~...~..~./.. :~ .... ~,- ...~ ..........
....... .............
........ ~.--.~..~,~.~.~..
to.../..~;~..,~:. ~./...,e:.~...q..Z......~7..c~. c~,':,~.~.~,~...
at premises located ot..~...~..~.
County Tax Map No. 1000 Section ....(*~,~ .~.,..~;. ..... BIo(Jk ~.~....,.i... Lot No..C~./.,~ ...........
~ursuant to ~ppffC~fion d~t~ .. .:,.~ .??...~..,; ....... , '1 ond ~pprov~ by the
~uildlnO Insp,ctor. '
Rev, 6/3~/80 // ~ ~ ~-~. ~~'.~
FORM NO. 6
TOWN OF SOUTHOLD
Building Depa,~,,,ent
Town Hall
$outhold, N.Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
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 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.
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(Z) ;.~.-_ _- =/Vacant Land ............
Location of Property ........ /,... . ............ $ I/.., _..
House No. Street Hamlet
Owner or Owners of Property ...~.0,..Y.v'.~.-~ ~.....'~..~;~,J r...O~...~ ~J~_.....~r-~.~.~,O...~,T~.~.., ........
County Tax Map No. 1000 Section . .0. ~..~ ......... Block :~- Lot . .l~...J.~.
Subdivision ................................. Filed Map No ........ Lot No ..............
Permit No ........... 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 permit-meets all at~pLi,cable_.co~es and regulations.
FORM NO. 6
TOWN OF SOUTHOLD
Ruilding Department
Town Hall
$outhold, ~'~.'/.
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
This application must be filled in typewriter OR ink, and submitted in duplicate to the Building Inspec.
to: with ~ne following; for new buildings or new uss:
1. Final surzey of property with accurate location of all buildings, property lines, streets, and unus~.~;
nalura[ or tooograohic features.
2. Fina~ a~roval of Heaith Dept. of water supply and sewerage disDosal--(S-9 form or equal),
3. Acprovai of e~ectr~caJ installation from Board of Fire Unde~rJtars.
4. Commercial buildln~s, Industrial buildings, Multiple Residences and similar build[ng~ and installa-
tions, a certificate of Code complianc~ from th~ Architect or Engineer responsible for the building.
5. Submi~ 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 utes:
1. Accurate suP/ay 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. '/
C. Fees:
1. Certificate of occupancy SS.C0
2. CertificaTe of occupancy on pre-exlsdng dwelling or land use
3, Copy of certificate of occupancy SI,O0
$5.00
Oate..5/..J.~/~ "~5...
/Vacant Land
New Building ............. Old or Pre-existing Building(X) .. .... = ...........
Locat,on of Property .... %q'h~..-.Y~. ~.,.~rJ~.:. ................. , ...... ~1~...
/You.ce No. $~reer Ham/et
Owner or Owners of Property . ~V.~.r~.~ q~..~.tl~ ~...1~.~.~.~.
County Tax Map No 1000 Section ........... Block ....... Lot ....
SubcivJsion ................................. Filed Map'No ..: .... Lot No
Fer~,t.,o..I. t~.~.~,ate of Perm,~ 4//~. ~.~-p~',,c;n~ .Z~.... ~' · ....... · ......
Health Dept Approval , Labor Dept Approval ...........
Under,vri[ers Approval .............. . .......... ~ Board Approval ..
-
Request for Temporary Certificate ..................... Final Certificate ...........
Construction on above described 5uildinq and perm,s'meets all aPp~abl~odes and regulations.
~ ~. ' ~,'0 ~' ~ ~_ ~ C.O.~II~.~
,,~ . /~,~ ..~. '-~ .~ ~.
..-,, ....:/.~..' >r,.~.- -- ~',. ~ ~
THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
~ 85 JOHN STREET, NEW YORK. NEW YORK 10038
THIS CERTIFIES THAT
w~ exami~d on ~ ~1 ~ and found to be in compliance with the require,nents of this Board.
FIXTUR[ FIXTURES
OUTLETS SWITCHES FLUORESCENT
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS
RANGES OVENS DISH WASHERS EXHAUST FANS
TIME CLOCKS UNIT HEATERS MULTI-OUTLET DI/V~MERS
SYSTEMS
NO. OF FEET
NO. OF;EUTRALSl
NEUTRAL
2/0
~l ~ox 1~ l~tn Street;
N.Y. 11962,
Ltc.4783~
This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
F~LD r~S~E~T~ON
FOUNDATION (1st)
FOUNDATION
2.
(2nd)
ROUGH FRAME &
PLUMBING
INSULATION PER N. Y.
STATE ENERGY
q~DE
FINAL
ADDITIONAL COMMENT2
PROVED AS NOTED ~
765-1802 9 AM TO 4 PM FOR THE
FOLLOWING IN ~OECTIONS:
1. FOUNgATION - TWO RL~QUIRED
FOR PgURED CONCRE!E
2. ROUGH - F~MING & PLUMBING
3. 1NSULATfON
4. FINAL - CO~TRUCTION MUST
BE COMPLETE FOR C.O.
ALL CONSTRUCTION 5HA~ ME~
THE REqUIREME~S OF THE N.Y.
~AtE CONSTRUCTION & EN~
CODES. NOT RES~NSlBLE ~
~SIGN OR CON~CTION E~
FORM NO. 3
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N.Y.
NOTICE OF DISAPPROVAL
File No ................................ Date ............
...................................... 22~ / ~
PLEASE TAKE NOTICE that your application dated .......................... 19 .....
for permit to~ltit~c~. ............. .~. ........................................ at
Location of Property/:t .................. ~r~'~O'~ ..... '~ ........... ~ ....
OU~ NO.. V~ Stroat Hamlet
County Tax Map NO. 1000 Section ........ 7..'~... Block ....... ~,- .... Lot ... (..~.~ ......
Subdivision ................. Filed Map No ................. Lot No ..................
~...,,,gg.~. .... ~...,,-,,,,......4,~....~ .... .,w~......~.'..., ..............
.... .....
Building Inspector
RV 1l~
FORM NO. 3
TOWN OF SOUTttOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N.Y.
NOTICE OF DISAPPROVAL
File No ................................ Date ............... . .~...~. ~.~....~, 19 .~. ~-,.~,
To ..t. ll/E~ &/A~'1~kl ~ o~ .~..~LL~
......... ~L~ A~
PLEASE TAKE NOTICE that your application dated ................. /.~.~..~.. ??., 19 .~...7-v-.
~9oo
Location ofProperty [43~?io] ......... ~'(P'tl~'t~' g h V£ ff6tJT/l~t.~.~
..... '$'t~i " ) ...................... ~amlat
County Tax Map No. 1000 Section ...... ~.~... Block ........ ~ .... ~t . ~ ..........
Subdivision -- ' Filed Map No ................. Lot No ..................
is returned herewith and disapproved on the following g~ounds .
~ od.~ ~ ~ ~ ~ . .USr. . .eM.5 . . ~ ~. ~.{ . .~. /~cwt T ~ ~.a~ ~. . :. r~. . .o .... _7 ~. .~.t.t~ . .tYfT. . . ~.C. . . .
~. . . .A ~a.~ ~ ...... A ~. . ~. . .l~.v. 1/. ~. . ~ ............................
Building Inspector
FIV 1/80
Southold T wn Board of Appeals
MAIN R~AD- ~TATE ~l-lAD 25 SE}UTHI~LD, L.I., N.Y. 11~71
TELEPHONE {516) 765-1809
APPEALS BOARD
MEMBERS
GERARD P. GOEHRINGER, CHAIRMAN
CHARLES GRIGONIS. JR.
SERGE DOYEN, JR.
ROBERT J. DOUGLASS
JOSEPH N. $AWICHI
August 2, 1982
Rudolph H. Bruer, Esq.
Main Road
Southold, NY 11971
Re: Appe$1 No. 3009
Warren E. and Ellen Hufe ;
Dear Sir or Madam:
This letter is to confirm that the following action was
taken at a Regular Meeting of the Southold Town Board of Appeals
held on Thursday, July 29, 1982:
RESOLVED, that Appeal No. 3009, application for WARREN E.
and ELLEN HUFE for permission to retain former nonconforming
one-family dwelling use in this "B-l" District, be and hereby
IS APPROVED SUBJECT TO THE FOLLOWING CONDITION:
No further additions to this dwelling structure without the
express written prior consent of this board.
This resolution was unanimously adopted.
An official determination and findings will be filed with
the office of the Town Clerk as soon as possible and simultane-
ously forwarded to you for your records. -
If you have any questions, please do not hesitate to call
our office. If you wish to start construction as early as pos-
sible, please return to or call the Building Department for
issuance of your building permit at 765-1802.
Yours very truly,
GERARD P. GOEHRINGER
CHAIPu%t~N
By Linda Kowalski, Secretary
cc: Building. Department
,/
TO N OF SOUTHOLD
OFFICE OF BUILDING INSPECTOR
P.O. BOX 728
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL. 765-1802
June 2, ~982
Mr. A. W. Albertson
Main Road
Southold, NY 11971
Dear Sir:
As to our telephone conversation of June 1st, pertaining
to the building behind Tryac. You state that the owner wishes
to return the building to a residence and in fact a party was
living there last winter (legal or otherwise). I would have
to conlude that the building is in a condition that would indi-
cate that it was habitable. Because it is in a commercially
zoned area I would suggest the owner file with the Zoning Board
of Appeals, for a Variance. This would seem to be the way to
go and no parties would be put in a compromising position.
I trust I have been of some assistance.
Sincerely yours,
Victor Lessard
Administrator
VL:ec
TOWN OF SOUTHOLD ~.~,-~a
~IJILDING DEPARTMENT
TOWN CLERK'S OFFICE
S4XJI~Ot.D, N. Y.
Examined ......................................... 19 ........
Application No. ...........................
Approved ......................................... 19 ........ Permit No .....................................
Disapproved o/c ............................................................................................
................................................................................
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
........ ........ i .........
INSTRUCTIONS
a. 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 os
areas, and giving a detailed descript?on of layout ofpropert~ 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
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, os 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 buildings for necessary inspections.
(S'g a re of applicant, o~/nam~., if a corporation)
.............. .............................
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
........................................................... .....................................................................................................................
Name of owner of premises ...... .~.ll~.~.~.~.~....~......J~......~....J~..~..~...~.. .........................................................................
If applicant is a corporate, signature of duly authorized officer.
(Name and title of corporate officer)
Builder's License No ..... ~...~...~ ..............................
Plumber's License No. .
Electrician's License No .............................................
Other Trode's License No ...............................................
Location of land on which ,,roposed work will be done. Map No.: ............ ..~'. ........................ Lot No......~.. .................
Street and Number ........ ~.('.Q~.....~.,Q.C,L.c~ .............................................................. ~ ..........
Municipali~
State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Exisitinguseo.do¢cupan ....! ...... ..................................................................
3. Nature of work (check which applicable): New Building'. ................. Addition .................. Alteration .........
Repair .. '~.-. .......... Removal .................. Demolitiar .................... Other Work ................................................ . ....
(Description)
4. ~s.mated co, t ....]....o..~.~...~...O.. ............................ F. ..........................................................................................
(to be paid on filing this al~lication)
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 of existing structures, if any: Front ............................ Rear ................................De~th ....................
Height ........................ Number of Stories .................................................................................................................
Dimensions of same structure with alterations or additions: Fro~t .................................... Rear ............................
Depth ................................Height ............................ Number of Stories ................................
8. Dimensions of entire new construction: Front .................................... Rear ............................ Dq3th ........................
Height .................... Number of Stories ....................................................................................................................
9. Size of lot: Front ........................................................ Rear .......................................... Depth ................................
10. Dote of Purchase ........................................................Nome of Former Owner ........................................................
! 1. Zone or use district in which premises ore situated .....................................................................................................
12. Does proposed construction violate any zoning law, ordinance or regulation: ...~....~.. ...........................................
13. Will lot be regraded ....~..~... .............. Will excess fill be removed from pmmim: ( ) Yes ( ~/)~ No
14. Name of Owner of premises .................................................... Addm~ ................................ Phone I~. .....................
Name of Architect .............................................................. Addres~ ................................Phone No. .....................
No,-,,~ of Co,tractor .~.A~.t.~....(.',.-.....ff~.~..b.~...'%. ^~,'~ ..6.¢.X..4..~."'¢.....~~ ~ .'.'.'.'~.~.-..~.'.~.'¢
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-bock dirner~ons 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 YORK,.. I c c
COUNTY OF ~.~f.'~..,~..~,~...,.....,~.f'~"~
............... ~..~,../3 .......... J~.....~,,,4 ...................................... being duly sworn, deposes and soys that he is the apphcan,
(Nome of individual signing contract)
above named.
He is the .................................................................................................................................................................................
(Contn~ctor,. agent, corporate officer, etc.)
of said owner or owners, and is duly authorized to per~orm or have performed the said work and to make and file
this application; that atl statements contained in this ap~Uc, ation are true to the best of his kncnde~ and belief; and
that the work will be performed in the manner set forth ih the application flied theeewith.
Sworn to before me this
..... ~.-. ..........~. ~/-:..;=.;.-;::,-., -._d~y of_ .... /'~~.... , , ]~-~' .....
· (Signature of al~ltcant)
LINDA F. KOWALSKI
NOTARY PUBLIC State of New Yo~
No. 52-452477!
I~ualU/e~ in Suffolk ~ounty
FORM NO. 1
TOWN OF SOU'[J;IOLD
BUILDING DEPA~ENT
TOWN HALL
SOUTHOLD, N.Y, 11971
~e~.,e..c../. 7.., 1.~.~ TEL.: 7~.~
^p;rove~7~.. ~.Z.... l~/. Perm,t No.. ~
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
Application No. ff~./Z . .~.. ........
a. 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
or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli-
cation.
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 is,me 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
shall have been granted by the Building Inspector.
.APPLICATION IS HEREBY MADE to the Building Depa~huent for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described.
The applicant agrees to comply with all applicable laws, ordinances, building code, housin$ code, and regulations, and to
admit authorized inspectors on premises and in buildings for necessar~s~, ctions.~
... ........
(Signature of applicant, or. name, if a corporation)
(Mailing address of applcant) ~ ~ X
State whether appli.cant is o. wner, levee, agent, architect, enl~eer, gene~l contractor, electrician, plumber or builder.
........ ..Q~~ ........................................................ i ................. ~....
Name of owner of premises ...~-~..~..F..~.. } ..........................................................
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
(Name and title of corporate officer)
Builder's License No.....~....~..~. ..............
Plumber's License No .........................
Electrician's License No .......................
......................
1. Location of land on which proposed work will be done .... ~!..-rv~.. I- .0. .......
.e~ ..... :g~..~ .......................................... ..~...~../.~ .....
House Number Street Hamlet
· c;unty Tax Map NO. 1000 SeCtion .... O..~....~...' .... Block....~"....; ........ Lot ......
Subdivision ........... X ........................ Filed Map No ............... Lot ...............
(Name)
2. State existing use and occupancy of premises, and intended use and occupancy, of proposed construction: ' -- .
.......
.b. Intended--,,and Occupancy .....
3. Nature ofwork~eck which applicable): New Building .......... Addition .......... Alteration ...~.. ....
Repair .... ---v.. ....... Removal .............. Demohtion .............. Other Work ...............
._.=,/ /..<__,>~ (D~scription)
4. Estimated Cost ..... ~..c~...c~....' ..................... Fee..~.../.~ .............................
(to be paid on filiag this application)
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 n~tRro ~md extent of each tyl~,.of use ....................
7. Dimensions of existing structures, if any: Front. ~.. 1.~..~ .... Rear .... ].1~-~."~... Depth...~., .~/.~...
Height ............... Number of Stories.. ~ ................... ~ ....................... ~ ........
Dimensions.o/,, m ruc=e with,ite ,tions or addi,ons: Front ... ....... Rear .... .......
Depth .... _~'~/Q ,'t'~. ,.~; .......... Height ....... ~.-~ ......... Number_0f,~tories... ~ ..... ,e, ........
Dimensionl'bf~nstire new construction: Front .... ~ ..... Rear .... /. ~ z.- ..... Depth ...//.~ .......
8.
Height ..... ~.' ........ Number of Stories ..... .t... ...............................................
9. Size of lot: Front ........... Rear ...................... Depth., .....................
10. Date of Purchase .... ~. i .C~-.' i [ 11 .............. Name of Former Owner ....~.k~-,.tC .................
I I. Zone 6r use district in which premises are situated .......................... . ...........................
12. Does proposed construction violate any zoning law, ordinance or regulation: ...~...C) ..........................
13. Will lot be regraded ............................ ~ Will excess fill be removed from premises: Yes
14. Name of Owner of premises .................... Address ................... Phone No.' ..-~ fi-.-.l(~.~...'~-
Name of Architect ......................... Address .................... Phone No.
N meo Contra tor.
................ Ad&'e~ ....
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, ami, indic~e all set-b~k ~ from
property lines. Give street and block number or description according to deed, and show s~et nm~s and/ndicate wimther
interior or corner lot.
STATE OF NE~ YORK.//~/;f)¢ ~ ~
COU~
............ being duly sworn, d~poses and says that he is tl~ ai~iicant
(Name of individual signing i[ontract)
above named.
/k,~_ (Contractor, ~nt, corporate officer, etc.)
of said owner or owners, and is duly au~hm, i~o-p~ or have perforated the said work and to m~ke and ~e this
application; that all statements contained in this application are Line to tho best of his lmowiml~ ~d [~li~f; and that the
work will be performed in the manner set forth in the appligation ~ed therewith.
Sworn to before me this
l!