HomeMy WebLinkAbout12577-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building InspeCtor
Town Hall
Southold, N.Y.
Certificate Of Occupancy
No.. Z.'1.1969 ......... Date ..... Aq~. g.~.e.r...6 ................. 19 .S.~.
THIS CERTIFIES that the building .. ,~.0.0.t~,~t~ ...................................
Location of Property . ,53965..I~eir, .ltd, ................. ~.o.u.t .hg.l.d.
House No. Street ............. ~t~r~l'e
County Tax Map No. I000 Section .... 62 ...... Block ..... ~ ......... Lot .. ~/~.~ ~.'/..2..4:.. 3.
Subdivision ............................... Filed Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore filed in this office dated
.... ~ugus:b..23 ....... 19 8.~. pursuant to whichBuilding Permit No..fl.2~77~t .............
dated August ' 30 1983 , 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 .........
For a garage &utility shed accessary
The certificate is issued to ...~:P~DR. IC · P....RICI-I .............................
(owner, lessee or tenant) .........
of the aforesaid building.
' ·
Suffolk County Department of Health Approval .............................
UNDERWRITERS CERTIFICATE NO .... 3!/A lXlGfl 7G02 ·
Building Inspector
Rev. 1/81
FO~M NO. 2
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
12577 Z
Permission is hereby granted to: '-~,~TZJ/~==~- ~'- ~'/~.//7/Z/
........ .~.az~.~...-...~..~.: ..................
~o....~--t~,~..~.~.~ ........ .~...~~...,~.~z~.~ ......................................
........... .~......,~,~.z....~..~.~..~:,~.z?~/..c...i~....~.~.~.. ..........................
at premises located at ....~.~'-~...~..~..,~.........~-~.Z./~).....~.~. ......................................................
.......................................................... .~.e~.z~z~.a,~.. =z,z...~. zz? 7 /
County Tax Map No. 1000 Section ..~..(P...~.~'~ ..... Block ..~.Z ............. LOt No.
pursuant to application dated .~,'~..¢,d~-~. ....... ..~...~. ................ , 19.~.~., and approved by the
Building Inspector.
Rev. 6/30/80
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 features.
2.Final approval of HeaJth Dept. of water supply and sewerage disposal-(S-9 form or equal).
3.Approval of electrical installation from Board of Fire Underwriters.
4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installa-
tions, a certificate of Code compliance from the Architect or Engineer responsible for the building.
5.Submit Planning Board approval of completed site plan requirements where applicable.
B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing"_
land uses:
1. Accurate survey of 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 $5.00 ~ 5-/$
2. Certificate of occupancy on pre-existing dwelling land use S/ 5.00
3. Copy of certificate of occupancy $1.00
Date. y/~.... ,/~, .~. ~-~ ........
New Building ..../,~( ....... Old or Pre-~(isting Building ...... ~/, .... V, acant Land ..~¢ ..........
Loca, on of Property~ .~-/42~/~ ~) ' ~ ~ ~-.~,J ...... ,. ~..~,, ~j~../~: /0~.. ~~/'~/,,
Owner or Owners of Property '..~.7~$~. ~..: ~'~.~-. ..............................
County Tax Map No. 1000 Section ............... Block ............... LOt ................
Subdivision ................................. Filed MapNo ........... Lot No ..............
Permit No/f~-.~.V,~...~. Date of Permi .... Applicant /~
· . ........... ,~'. ;.~,',~%J,'p?,! ..........
Health Dept. Approval ........................ Labor Dept. Approval ........................
Underwriters Approval../V ~.0.(~ (~0~ r .............
..................... Planning Board App oval .........
Request for Temporary Certificate ..................... Final Certificate .......................
z~ ~'(~
Fee Submitted $..~..~) ...................
Construction on above describe¢
building and permit meets all apl~licable codes and regulations.
..
o ?~
FIELD ~NSFECTION
1.
FOUNDATION (1st)
FOUNDATION (2nd)
ROUGH FRAME &
FLUMBING
INSULATION PER N.
STATE ENERGY
qODE
FINAL
COMMENTS
ADDITIONAL COMMENTS:
765-1802' 9
FOLLOWING
I. FOUNDATII
FOR 'POURt
2. ROUGH -
3. INSULATIOi'
4. FINAL -
AP~R~¥ED AS NOTED
NO~'IFY BUILDING DEPART~N~ Af
SPECTIONS:
q - TWO
) CONCRETE
~MING & PLUMBING
N'STRUCTION MUST
BE COMPL.E E FOR C, O.
ALL CONSTRL ~'TION SHALL MEET
THE REQUIREA~ENTS OF TF~ N.Y.
STATE cONsT~.UCTION & ENERGY'
CODES. NOT~ RESPONSIBLE FOP-,,
DESIGN OR cOIJlsTRUCTION ERRORS,
D
HENRY E. RAYNOR, Jr., Chairman
3AMES WALL
BENNETT ORLOWSKI, Jr.
GEORGE RITCHIE LATHAM, .Ir.
WILL[AM F. MULLEN, .ir.
Southold, N.Y. 11971
TELEPHONE
765-1938
August 26, 1983
Mr. Frederic P. Rich
P.O. Box 1045
Southold, New York
11971
Re: Colonial Village
Site Plan
Dear Mr. Rich:
The following action was taken by the $outhold Town
Planning Board, Monday, August 22, 1983.
RESOLVED that the Southold Town Planning Board approve
the site plan "Colonial Village at Southold" for the con-
struction of a storage building.
Would you please supply our office with the application
fee of $25, payable to the Southold Town Clerk.
Thank you.
Very truly yours~
HENRY E. RAYNOR, JR., CHAIRMAN
SOUTHOLD TOWN PLANNING BOARD
ce:
By Susan E. Long, Secretary
Building Department/
FRNDF~RIC P. RICH
MAIN ROAD - SOUTHOLD. NEW YORI< ! 1971
(616) 766-84~6
August 2, 1983
Robert Tasker, Esq.
Town Counsel
425 Main Street
Greenport, New York
11944
Dear Bob:
With £urther re£erenoe to my letter o£ July 29, I think the
problem stated stems entirely £rom the £act that Colonial
Village is regarded the same as a subdivision which it is not.
A subdivision (which probably includes condominiums) under
RPL335 embraces property divided into sites "£or sale to the
public" where, RPL335 also provides (sect 2) £or the approval
o£ a site map by the Pla~ining Board ( because the lots are to
be sold to the public).
Altho eight sepera:te apartments were built on the land I own
at 52965 Main Road, Southold, this is not a condominium where
apartments will be o££ered for sale but I continue to own each
apartment. Since each apartment was not on a public highway,
under Town Law 280a entitled "Permits for buildings not on
improved mapped streets", I had to have the Town Board declare
it an "Open Developmen~ Area" be£ore any buildings could be
built. In doing this, the Town Board was not required to
approve a site plan but merely declared the entire area at
52965 Main Road an "Open Development Area" where buildings.
could be erected along the rights o£ way shown on the map £iled
with my application.
I think i£ -this £und~aental concept is understood it will be
realized there is not now legal requirements £or the ~proval
o£ a site plan by the Planning Board as would b~ true ~£ a
subdivision.
Regards.
Yours very truly,
FPR:mfh ~g~
CC: -.Dan Smith, Contractor
Miss Susan Long, Southeld P. B.
Mr. Ed Hinderman, Southold Bldg. Insp.
AV~, 0 3 Er~
I~OllERT W. TASKER
OFFIC~~RNEY
425 MAIN ST.
GREENPORT, L.I., NEW YORK 11944
August 2, 1983
TELEPHONE
(516) 47%1400
Frederic P. Rich, Esq.
52965 Main Road
Southold, New York 11971
Dear Fred:
Receipt is acknowledged of your ,letter to me dated July 29, 1983,
concerning the construction of a utility building at Colonial Village.
You have indicated that the Building
permit for this building until a site
approved by the Planning Board.
Inspector will not issue a building
plan has been submitted to and
According to the zoning map, Colonial Village is located in a B-1 General
Business District. Section 100-70 of the Zoning Code provides that all
permitted uses in the B-I District are subject to site pla~ approval by the
Planning Board in accordance wi.th Article XIII. Section 100-130 of Article
XIII, provides that "in all cases where this ch,~pter requires approval of
site development plans by the Planning Board, no building permit shall be
issued by the Building Inspector except upon authorization of and in
conformity with the plans approved by the ,Planning' Board." It is,
therefore, apparent to me that under the abo~/e cited provision of the
Zoning Code, that a site plan must be approved by the Planning Board
before the Building Inspector is authorized to issue a building permit.
In your letter and memorandum, you have referred to the fact that
Colonial Village is ~ "Open .Development Area"~and have referred me to
the case of Recggs Homes, Inc. v Dickerson. I do not believe the question
of whether or not Colonial Viflage 'is ~i3' open development area or whether
280A approval is :required has anything to do' with the question at hand,
namely, the requirement for a site plan approval by the Planning Board.
I note, however, that there is no requirement in the Zoning Code that the
Planning Board hold a Public Hearing for an, application for a site plan,
approval.
Y(~Urs very truly,
ROBERT W. TASKER
RWT: aa
cc: Dan Smith, Contractor
Miss Susan Long, Southold Town Planning Board
Mr. Ed Hindermann, Southold Building Inspector
LAW OFIelCES
FREDERIC P. R~cH
Robert Tasker, Esq.
Town Counsel
425 Main Street
Greenport, New York
11944
fi~966 MAIN ROAD - SOUTHOLD, NEW YORK 11971
(616) 765-BztB6
July 29, 1983
Dear Bob:
I have made application to the Building Qepartment to construct
a 20 x 24 separate garage and utility building to store our
equipment at Colonial Village, away from the garages where it
is now stored, where the tenants' cars are garaged, which, I
think, is highly desirable in case of fire.
The Building Department has okayed the building plans prepared
by Dan Smith, but will not grant a permit without first sub-
mitting the matter to the Planning Board for public hearing on
the site plan. My only objection to this is that I am advised
by the Secretary of the Planning Board, that this procedure en-
tails delay of two months. Colonial Village is not a subdivi-
sion, but was declared an "Open Development Area~--~y the Town
Board under Sect. 280A of the Town Law in 1966. Under the Reggs
case, discussed in the enclosed memo, there is nothing for the
Planning Board to decide. The Building Department has okayed the
building plans and has indicated there is no question of suitable
access. The garagee also complies with all provisions of the Zon-
ing Law as to setbacks, etc.
Now that I have sufficient funds to construct the new garage, I
am most anxious to have it done as soon as possible as I am
greatly concerned about the fire hazard mentioned above.
If you agree with me, Ed Hindermann says he will issue a permit
right away, if you advise him in writing it is not necessary for
him to submit the application to the Planning Board before a
permit can be issued.
The next meeting of the Planning Board is August 22. Since there
is nothing for them to look into, could it not be arranged, in any
event, to have them then pass on the matter and authorize a permit
at that time, without further delay, if you should decide a hearing
before the Planning Board is necessary.
Best personal regards.
Yours very truly,
FPR:fae
CC: Dan Smith, contractor ~
Miss Susan Long, Southold P. B.
Mr. Ed Hindermann, Southold Bldg. Insp.
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
In re the Application of
Frederic P. Rich to construct
a garage and utility building
on the premises at 52965 Main
Road, Southold, N.Y. 11971
MEMO OF LAW IN
OF APPLICATION
SUPPORT
An application has been made by Frederic P. Rich to con-
struct a separate garage and utility building at the rear part
of property owned by him located at 52965 Main Road, Southold,
New York, known as Colonial Village.
Although there has been built eight apartment houses on
this property, all of it (extending on the North along the Long
Island Railroad tracks and behind the Fire House, to Boisseau
Avenue) is owned by Frederic P. Rich, as individual owner of the
entire property, which in no sense has been subdivided in any
manner.
In short, the application is simply an application for a
permit to build a garage by a property owner at the back of his
property abutting the Long Island Railroad, with no other property
owner being in any way affected.
Despite the foregoing, the Building Department will not is-
sue a permit until the site plan has been approved by the Planning
Board, and has referred the matter to it to conduct a public hearing
pursuant to the authority vested in the Planning Board by Section
276 of the Town Law to approve plats.
The trouble with this procedure is that the application of
Frederic P. Rich is not, repeat, not an application kovhave a plot
plan approved, but simply a request for a permit to build a
garage on his property. The fact that there happens to be eight
apartment buildings already built on tke property is entirely
immaterial to the present application. These were authorized by
a 1966 Resolution of the Town Board when it declared the property
to be an "Open Development Area" under Section 280-A of the Town
Law, after referring the Plot Plan annexed to the then petition
of Frederic P. Rich (showing the eight apartments to be built)
to the Planning Board. A copy of the Resolution of the Town Board
dated March 22, 1966 is annexed.
Later a Zoning Variance was also sought and obtained ap-
proving the square foot area on which these apartments were built
under an Ordinance subsequently enacted specifying the square foot
area required for a multiple residence.
All these matters are matters already properly passed on
and are, in no way involved in the present application which (as
already stated) is merely an application of a property owner to
build a garage at the back of his property where the courts have
held that the only public question involved is that of proper ac-
cess by emergency and fire apparatus under the same Section 280A
of the Town Law under which the apartment buildings were originally
authorized in 1966.
This question certainly requires no public hearing to
determine and the Building Department raises no question on this
point. In fact, it is common knowledge that the Fire Departments
from all over the East End for years have used the roadways at
-2-
Colonial Village to disperse their 5pparatus after the Annual
Parade and Drill held annually by the Southold Fire Department.
In the case of Reggs Homes, Inc. v Dickerson 179 N.Y.
S2d 771 (1958); affd by the Appellate Division of this Department,
186 N.Y. S2d 215, 8 AoD.2d640, it was held an owner was entitled
to a building permit as a matter of
of the Town Law, the only matter of
Justice L. Barton Hill as follows:
right under Section 280 A
interest being stated by ~r.
"[2] A building permit can be validly denied under
this section only when the facts will support a find-
ing by the administrative body that the conditions
set forth in subdivision 5, supra, cannot be met; viz.,
fire apparatus and other emergency vehicles cannot
safely and with reasonable certainty travel to and
from the proposed structure."
The section referred to in the quoted portion of the decision
is Section 280 A of the Town Law.
The Building Department has indicated its approval of the
building plans under the Building Code, raises no question con-
cerning its suitability; is in agreement that the garage is not in
a "front yard" and that it is 3 feet removed from the boundary, as
required by the Zoning Ordinance, but still insists the site "'
klan be approved by the Planning Board, after public hearings,
which means a delay of at least two months before a permit can be
issued.
The Building Department has treated the matter as
if it was necessary to obtain the approval of the Planning Board
under Section 276 of the Town Law, which is the section authorizing
the Planning Board to "approve plots showing---sites---within that
part of the Town outside the limits of any incorporated city or
village."
-3-
The ruling of the Court in the Reggs case is equally ap-
plicable to the present case when the court held:
"Here there is no application for the approval
of a plat under Sections 276, 277, Town Law; this
approval was already given in 1946. The only ap-
plication made by plaintiff is for a building per-
mit which is governed by Sec. 280-a, Town Law."
In the present matter, all of the determinations necessary
for the issuance of a permit are within the prov~nce of the Build-
ing Department and there is no need to refer the matter for public
hearing before the Planning Board.
Yours very truly,
Frederic P. Rich
Atty pro se
0 & P.O. Address:
52965 Main Road,
Southold, N. Y. 11971
Telephone 765-3436.
-4-
WHEREAS, Frederick Rich
has made application to the Town Board for the establishment of an OPEN
DEVELOPMENT AREA pursuant to the provisions bf Section 280-A of the
TOWN LAW, and
WHEREAS, the Town Board has heretofore referred the matter to the
Plaqning Board for its advice and recommendation, and
WHEREAS, the Planning Board has recommended that the application
of .............. ~.~ .~.~ .~. ,%.C.k.. I~, i¢~h ............................................ be g~'anted,
NOW, THEREFORE, BE IT RESOLVED: that the Town Board of the
Town of Southold does hereby establish an OPEN DEVELOPMENT AREA
over the property of .................. ,F.r..e..d..e.,r..i...c..k.....P"'~'.q.h.. ........... .... as shown
forth on the map attached to the application.
By Order of the Southold Town Board.
Dated: March 22, 1966.
Alber~ W. Richmond
Town Clerk
THE NEW YORK BOARD OF FliRE UNDERWRITERS
85 JOHN STEEET, NEW YORK NE~ ~ORK 1003~
THIS CEffTIFIE8 THAT
only the electrical equipment ~ ~scribed bel~ and iRt~duc~ by tl~ applicant ~d on the above application nu tuber irt the premises of
in tbe ~ollowing location; ~ Basemen~ ~ 1st FI, ~ 2nd FL ~e Section HIock Lot
was examined on and found to be in compllar~ce with the requirements of this Board.
FIXTURE FIXTURES OVENS DISH WASHERS EXHAUST FANS
OUTLETS SWITCHES INCANDESCENT FLUORESCENT
5 3 5
DRYERS
O~HER APPARATUS:
S E C
NO Oi~ERCC~,CON D,
Peter [k~ovic
Road
~ou~hold, N.Y. ll~Jql
This certificate must not be altered in any manner; return to the off;ce
~: 'i~ ~OPY ~lO DEPARTMENT. THkc
F the Board
A W. G NO, OF NEUTRALS A, W G
OF HI-LEG OF NEUTRAL
GENERAL MANAGER
Per il
me), be identified by their crede~tidls.
MANNER.
FORM NO, 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL,: 765-1803
Examined . ......
Approved Z ..... , Permit
Disapproved a/c ......................... ...... i /
/~ zz.. rpov..~ APPLICATION FOR BUILDING PERMIT
/ ~..~..~ Date.. ,~C-~....~...~...,
INSTRUCTIONS
Application No, /'.~,'~,~.(,.~..
a. This application must be completely filled in by typewriter or in ink and submitted 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 issued 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, as herein described·
The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, a, cd regulations, and to
admit authorized inspectors on premises and in building for necessary ins. l~tions. // P
(Signature of applicant, or name, if a corporation)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises ~. ~.~'/~].~ .... .~.,...~./.~..H ...........................................
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
(Name and title of corporate officer) /
Budder s Lmense No ..............
Plumber's License No ..... ~ ..........
Electrician's License No.~ ...........
/
Other Trade s License No ......................
1. Location of land on which proposed work will be done ..................................................
· .,r.2.~. ~,.r. ............ ~I~/IV .... T~D.. ...................... ,X.O..oT.H.o.4 g... N~ .F... ~t.~. z~ .......
House Number Street Hamlet
~q. 2
County Tax Map No. 1000 Section ...... ~.~. ......... Block .... ] ............. Lot...,7.~.,..,~. ...........
~ . .£o. lo.,~ t ¢. l .... ff .l.l.4 e ~............. Filed Map No~]O.~. ~q~b.. d?.lr$1&)t ...............
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existinguseandoccupancy. ~.cJt r,~ r ~P~.~...~/~..~' , - .
· /' .............. T .... ~.¢,~'~'J;,?.~'*~ ~'~'~v'~'~> l~ ......................
b. Intended use and occupancy. ~:~[ ~ ~. ~ ¢./. ~ ~ r ~ ¢ ~. ~. ~ ~ ~;2;P~:~~ ..................
3. Nature of work (check which applicable): New Building . .fi( ...... Addition .......... Alteration ..........
Repair .............. Removal .............. Demolition Other Work ..........
-'" (Description)
4. Estimated Cost ....... ~,. ........................... Fee ...................................
(to be paid on filing this application)
5. If dwelling, number of dwelling,units... ~...]~ ......... Number of dwelling units on each floor..2~:~. · ..........
If garage, number of cars .... ~.~. .....
' ' ' 1 ' ' fly. ~.atl,t d f h typ '
6. ]f business, commerma or m~xed occupancy, spec re an extent o eac e of use .....................
7. Dimensions of existing structures, if any: Front.. /~..~. . Rear ............ Depth ...............
lteight ............... Number of Stories ........................................................
Dimensions of same structure ~ith alterations or additions: Front ................. Rear ..................
Depth ................... i · · Height ............ ? ......... Number of Stories ............ t .........
8. Dimensions of entire new constrUction: Front ...... ,~O. ..... Rear ...3.0..t ........ Depth .~.~t ..........
Heighi ............ :.. Nun~ber of Stories .. O.~. ~. ...................................
9. o~ze of lot. Front .... ~t. ~.~ i . ·.
............ Rear..{" ' ' . ................... Depth ..... , ..............
10. Date of Purchase .. I.q.S.~ i ................. Name of Former Owner .. ~'a ~.e]/.~.
11. Zone or use district in which prbmises are situated .....................................................
12. Does proposed construction wolate any zoning law, ordinance or regulation: .. ~}.0 ..........................
13. Will lot be regraded ...... ~ .................. Will excess fill be removed from premises:/bt/~ ,Yes No
14. Name of Owner of premises .~.e.d..t~! ~...~..~.t.~.~l. .... Address ,~$~]$$'fi)tdl.~..Y',',~.d .... Phone No..7.~5~.'.$.~..~.~...
Name of Architect .. ! ................. Address .... ~q~ol:r~.q/~ ~ ~... Phone No ................
Name of Contractor ~.~.e.]..7~..,~.,~l.~ ......... Address/~..e~.o~l~..~.?'. ...... Phone No. 75..,~..-;S.~..~. .~....
PLOT DIAGRAM
Locate clearly and distinctly ali buildings, whether existing or proposed, and. indicate all set-back dimensions from
property lines. Give street and block
interior or corner lot.
number or description according to deed, and show street names and indicate whether
STATE OF NEV2/YORK~ . S S
COUNTY OF,,.,,g'V/.fiO[ ~. ....... i '
................. ~7.d~.l.~. [...~...~..~..~..~ .......... being duly sworn, deposes and says that he is the applicant
(Name of inaividual signing contract)
above named.
He is the ........................................................................................
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this
application; that all statements contained in this application are true to the best of his knowledge and belief; and that the
work will be performed in the manner set forth in the application filed therewith.
Sworn to before me this
.......... · '~. · ~..// ..... day of .~ ..... ,19~..-~..
Notary. Public ...... County ~
~1~?~1~~ : (Signature of applicant)