HomeMy WebLinkAbout12131-zFORM NO, 4
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
Certificate Of OcCuPancy
No. Z~99~ October ~
Date ................................. 19...83
THIS CERTIFIES that the building . New dwelling
Location of Property l~t. RD. terrys Point Orient
h~dsb hal ....................... 's't/e3i .......................
County Tax Map No. 1000 Section '17 . · .Block 2 .Lot
Subdivision. J. O2fflhTA2H. g~. S/Y~_ER.N ............ Piled Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore filed in this office dated
December ~I .'7 .... , ... pursuant to which Building Permit No. '~ 2'13~ Z
................ 1982 .....................
198
dated January 3'1 3 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 one family dwelling
The certificate is issued to ROBERT & JOA~ DEVOE
..................... io¥,,'~;, '/;~'o' gr't;~;'o ......................
of the aforesaid building.
Suffolk County Department of Health Approval 12nso71~
NO N6~26~3
UNDERWRITERS CERTIFICATE .................................................
Building Inspector
Rev. 1/81
I~a~r~issioh is hereby g
(THIS PEPJ~IT MUST BE KEPT ON +HE P~k~
COMPLETION OF THE WORK AUTHORIZED
Z D~
UNTIL !ULL
approved by the
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~ d sposa -(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'5-
1and 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 cond tion of buildings.
3. Date of any housidg code or safety inspection of buildings or premises, or other pertinent informa-
tion required to p'repare a certificate.
C.- Fees:
1. Certificate of occupancy $5.00
2. Certificate of occupancy on pre-existing dwelling o~ land use ~/S-/~5.00
3. Copy of certificate of occupancy $1.00
New Building ....~. ....... Old or Pre-existing Building ............ Vacant Land .............
Mouse No. ~ Street Ham/et
Owner or Owners of Property ~ c.-~ ~
County Tax Map No. 1000 Section ....... [..~. ..... Block .... ..~ ........ Lot..O.
Subdivision
· .~.t.~C n .................... Filed Map No. .......... Lot No.
Permit No ........... Date of Permit .......... Applicant ................................, ,
Health Dept. Approval . .~.~ r~ .~.,..~-~.t ........... Labor Dept. Approva
Underwriters Approval ~ Planning Board'Approval
Request for Temporary Certificate... ~. ............... Final Certificate .......................
Fee Submitted $ .............................
Construction
on
above
described
building and permit meets all applicable codes and regulations.
Rev. 10-10-78
76.5-1802-
BUILDING DE , : . ~
INSPECTION
FOUNDATION 1ST [ ] ROUGH PLBG~
FOUNDATION 2ND [ ] INSU~TION
THE NEW YORK BOARD OF FIRE UNDERWRITERS
SURE~U oF m-ECTRIq,T~
85 JOHN STREET, NEW YORK~ NEW, ~ORK 10035
THIS CE~IFIES THAT
only th~ electdcal equipment ~ ~ri~d belo~ a~d i~$roduced by tim applicant ~r~pd on tim above application ~umber i~ the pre~nises of
~be~ De Voe, ~iva~ ~., o~f ~. 25, Or'i~,
in the yoliowlng location; ~ B~ement ~ 1st Fl. ~ 2nd FL , Section Block Lot
was examiaed o~ ~ It , ~ ~$~ and flound to be in compliance with the requirements of this Board.
45 51 45 45
DRYERS FURNACE N~,OTORS UNIT HEATERS DIMMERS
SYSTEMS
NO. OF FEET
SERVICE DISCONNECT S E R
Dicker$oI% glect. Co.
13 Tarkegtle Rd.
SheLter Island, N.Y., 11964
This certificate
AW, G
OF HI-LEG
AW, G
OF NEUTRAl
4/o
~t not be altered in any manner; return to the office of the Board if Inspectori may
HER.
FOUNDATION ( 1 s t)
COMM~NTS
FOUNDATION (2nd)
ROUGH FRAME &
FLUMBING
INSULATION PER N.
STATE ENERGY
G,ODE
FINAL
ADDITIONAL COMMENTS:
HENRY E. RAYNOR, Jr., Chairman
.lAMES WALL
BENNETT ORLOWSKI, Jr.
GEORGE RITCHIE LATH~M¥1, Jr.
WILLIAM F. MULLEN, Jr.
Southold, N.Y. 11971
TELEPHONE
765-1938
January 17, 1983
Mr. Victor Lessard
Building Administrator
Southold Town Hall
Southold, New York 11971
Re: Stern Access Road
Dear Mr. Lessard:
It was the concensus of our board at our regular meeting
January 10, 1983 that a building permit be issued for lot #3
on the filed subdivision map of Jonathan D. Stern, located at
Orient, and that no CO is to be issued until the right-of-way
to said lot has been approved by the Planning Board.
If you have any questions, please feel free to contact
our office.
Very truly yours,
HENRY E. RAYNOR, JR., CHAIRMAN
SOUTHOLD TOWN PLANNING BOARD
B E. Long, Secretary
cc: Joanne Devoe
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION ZST [ ] ROUGH PLBG.
FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING
REMARKS: /,
FINAL
April 9,1983
Southold Town Building Dept.
Permit ~12131Z
Re: Dow Styrofoam Brand roof insulation system
Dear Sirs:
Dow Styrofoam Brand Insulation has shown its insulating
qualities for fourteen years. It has been an accepted product of
exceptional value and approved for use by BOCA, ICBO,SBCC,HUD/FHA
UMB.
Section A404-~_~rf the State Building Construction Code states:
"c- Foam plastic shall be permitted as an integral component
within a wall, roof or floor/ceiling assembly, approved for the
intended use."
In our letter from Dow Chemical, dated March 22,1983, Dow
Chemical confirms our belief that ventilation of our Dow Styrofoam
cathedral ceiling system with soffit and ridge vents would negate
the insulation value of the Styrofoam and should not be required.
Therefore: Robert and Joanne DeVoe release the Building Depart-
ment of Southold Town from responsibility in the Dow Chemical
cathedral ceiling system in our new house in Orient.
Sincerely,
DOW CHEMICAL U.S.A.
March 22, 1983
GRANVILLE RESEARCH CENTER
P.O. BOX 515
GRANVILLE, OHIO 43023
JoAnne Devoe
RR3 Town Harbor Lane
Southold, New York 11971
Re: New Construction Orient
This letter confirms our telephone conversation in which I stated that
the following cathedral ceiling system should not require ridge or
soffit ventilation:
(Outside)
shingles
felt
plywood
STYROFOAM* Brand Insulation
plywood
foil faced fiberglass batt
drywall
(Inside)
The foil facing on the fiberglass batt (if installed properly) will
serve as a vapor barrier and therefore minimize the potential for
condensation within the fiberglass insulation. Soffit and ridge vents,
if used, would negate the insulation value of the STYROFOAM.
Kathy Wolfgram
Technical Representative
STYROFOAM Brand Insulation
(6!4) 587-4348
*STYROFOAM Brand Insulation - Trademark of The Dow Chemical Company
AN OPERATING UNIT OF THE DOW CHEMICAL COMPANY
State Building
Consh~Oflon Code
APPLICABLE TO
One- and TwO-Family Dwellings
(INCLUDING FACTORY MANUFACTURED HOMES]
P~tnted Januar'/ J, 1982
STAT[: OF NEW YORK
Hugh L. Care'y, Governor
Richard A. Berman. CommiSSioner
'~ and the base to whmh they are ap-
shall be filled w~th noncombustible
so that no dimension of such con-
t vertically or 20 feet horizontally.
)ists with ceihngs attached directly to
~d for the full depth of the joists at all
pported wails and partitions having a
Ig, and under all partitions separating
airs shall be firestopped so as not to
d bottom of the stairs with concealed
lion.
eaves shall be firestopped at the ends
at intervals of not more than 20 feet.
4, and 5 construction, the space in at-
e floor or roof construction and a sus-
estopped so that no area of such con-
:er than 3000 square feet.
tIM AND DECORATIVE
Is for acoustical correction, surface in-
eatment on the surfaces of walls and
materials, shall conform with all re-
~ section.
~ shall be of materials that will not, in.
~, amounts of smoke or objectionab!e
,r Finish Materials
nish materials shall be classified in ac-
:e flame-spread ratings determined by
~ity with generally accepted standards,
Surface flame-
spread rating
0 to 25
26 to 75
76 to 200
201 to 500
iling finish materials in required eh-
,^ or B.
~iling finish ma',erials in any location
I exit shall be class A, B~ or C.
A 404
A 404.1
(648.1)
A 404-2
(648.2)
Fire-Safety Requirements
PLASTIC MATERIALS
General Requirements
a--Plastic materials Shall be classified in accordance with their
burning characteristics as determined by tests conducted in con-
formity with generall,~ accepted standards.
b--P~astic materials shall be identified by permanent legible
markings on each piece in conformity with generally accepted
standards.
c--The requirements of this section are limited to construction
regulated by this Code and shall not regulate plastic materials as
permitted in Part 5 of this Code.
d--Plastic materials which give off smoke or gas denser or more
toxid than given of[ by untreated wood of paper under compar-
able exposure to heat or flame, or which burn faster than 2V2 in-
ches per minute as determined by tests conducted.in conformity
with generally accepted standards, shall not be permitted.
e--Plastic materials may be used as a roof over an unenclosed
structure located at grade level, provided such reel does not ex-
ceed 10 feet in height and 1000 square feet in area.
f--Plastics for light transmission from artificial lighting equip-
ment are not required to conform to the flame-spread ratings for
interior finish.
g--One-story accessory structures located at grade level not ex-
ceeding 500 square feet in area and 10 feet in height, located out-
side of fire limits may be constructed of p~astlc materials provided
the distance separation is at least 10 feet.
Foam Plastic
a--Foam plastic insulation, except as set forth in paragraphs b
and c of this section, shall have a surface flame spread rating no
greater than 75 and a smoke density rating no greater than 450
and shall be permitted as follows:
Within the cavity of a concrete or masonry wall
On the interior surface of concrete or masonry walls pro-
vided the foam plastic insulation is protected by a thermal
barrier.
Within kombustible wall, ~oof or floor/ceiling assemblies,
that are not required to have a fire resistance rating, provid-
ed the foam plastic insulation is protected on the interior
side by a thermal barrier.
As nonstructural sheathing for combustible exterior wails
provided the wall cavity is insulated with noncombustible
material cove{ed by a thermal barrier on the interior side.
b--Foam plastic shall be permitted as a component of an ap-
proved built-up roof.
c--Foam plastic shall be permitted as ah integral component
~ within a wall, roof o~' floor/ceiling assembly, approved for the
tended use.
7.14/Do
STYROFOAM Brand Insulation
Cathedral Ceilings
Installing STYROFOAM brand in-
sulation is an effective way to
increase the thermal efficiency of
cathedral ceilings where space be-
tween the ceiling and roof is limited.
Whether the foam *s installed under
or over the roof deck is optional as
Figures 14 and 15 show.
Figure 14 -- Installation
Under Roof Deck
Sloped Ceiling
Fibrous batt
between rafters
Vapor Retarder
Rafter
Plywood
Shingles
Drywall
STYROFOAM TG
Brand Insulation
Figure 15 ~ Installation
Over Roof Deck
Exposed Beam Ceiling
; -* STYROFOAM TG
Plywood~/, Brand Insulation
· ~,, ~.i/'?
Wood
Nailer
Shingles
Multi-Family Structures
STYROFOAM brand iesulatio~ is
lightweight and easy to cut. It goes
up quickly and easily, helping to
save labor, time and expense in
multi-family structures. What's more,
!t delivers dependable, long lasting
~nsulation performance. The use of
STYROFOAM provides an energy
efficient package that enhances the
initial value of the multi-family struc-
ture and helps maintain its resale
value.
One-Hour Fire Rated Walls
Versatile STYROFOAM brand insula-
tion can also be used in stud wall
constructions requiring a on~-hour
fire endurance rating. Two wall sys-
tems have now met the req u~rements
of ASTM E 119-79 and are described
below:
1. Nominal 2" x 4"wood studs on 1~"
centers
~/a" Type X gypsum board attached to
the interior s~de of the studs wiih 5d
drywall nails on 7" centers (perimeter
and field)
Rq3 2.1 pcf mineral hber (rock wool)
botts in the stud cavities s~de of the
studs
STYROFOAM TG brand Insulating
sheathing nailed to the exterior side of
the studs
Tested exterior s~d~ngs ~nclude.
1/2" nominal lapped hardboard sid-
ing, attached with one 10d na~l per
stud intersection
a/4,, shiplapped redwood s~d~ng, at-
tached w~th one 10d nail per stud
intersection
Y2" plywood panel siding, attached
with 8d naris, 6" cc (perimeter) and
12" cc (field)
2. Nominal 2" x 4" wood studs on 16"
centers
5/a"Type X gypsum board attached to
the ~ntenor s~de of the studs w~th 5d
drywall nods on 7" centers (perimeter
and field)
R-11 krafbfaced fiberglass botts in the
stud cowries
W' plywood sheathing, attached with
6d nails, 6" cc (perimeter), and 12" CC
(field)
1' STYROFOAM RS brand insulahng
sheathing attached with 5d roofing
nails 12" cc (perimeter and held)
This assembly passed without an exte-
rior s~dmg, hence, any exterior finish
may be used w~th it,
NOTE: 3/4" and 1" STYROFOAM TG and
1" STYROFOAM RS brand insulations
were tested; subshtutions of other
thicknesses may be made at the d~s-
crebon ol the build~ng official with
unsdiction.
76S,1802
BUILDING
DEPT,
INSPECT
ROUGH PLBG. ·
FOUNDATION 2ND [ ] INSULATION
FRAMING [ ] FINAL
HENRY E. RAYNOR, Jr., Chairman
lAMES WALL
BENNETT ORLOWSKI, Jr.
GEORGE RITCHIE LATHAM, Jr.
WILLIAM F. MULLEN, Jr.
Southold, N.Y. 11971
January 17, 1983
TELEPHONE
765-193g
Mr. Victor Lessard
Building Administrator
Southold Town Hall
Southold, New York 11971
Re: Stern Access Road
Dear Mr. Lessard:
It was the concensus of our board at our regular meeting
January 10, 1983 that a building permit be issued for lot ~3
on the filed subdivision map of Jonathan D. Stern, located at
Orient, and that no CO is to be issued until the right-of-way
to said lot has been approved by the Planning Board.
If you have any questions, please feel free to contact
our office.
Very truly yours,
HENRY E. RAYNOR, JR., CHAIRMAN
SOUTHOLD TOWN PLANNING BOARD
B E. Long, Secretary
cc: Joanne Devoe
Memorandum from....
BUILDING INSPECTORS OFFICE
TOWN OF SOI~THOLD
TOWN H^LL, SotrrHOLD, N. Y. 11971
765-1802
FORM NO. 3
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N.Y.
NOTICE OF DISAPPROVAL
~ o r p~i t to co n~t~,c~ . . ~. .~. . ~ . . . ~.~?. ~.~ ~. /. ~ . . ~. . .~.~ ~. C.~. ..................... at
............................ 'S't;~i .................... h3~/~
County Tax Map No. 1000 Section ...O.f. ~'. ...... Block ...(~...~.. ....... Lot ...(~.?f.'..c~.~'.'...
Subdivision .... Filed Map No ' Lot No ~
is returned herewith and disapproved on the following grounds. ~.~..c~.~&..~?.~.. ,C~..../fff(¢.~...
· '~...~..~....~.~..~./.~..~. .... ~..,~,~.¢~...~.~ .......................
Building Inspector
RV 1/80
Memorandum from....
BUILDING INSPECTORS OFFICE
TOWN OF SOUTHOLD
TOWN HALL, SOm'HOLr~, N. Y. 11971
765-1802
NEW YORK STATE DEPARTMENT O~: ENVIRONN{ENTAL CONSERVATION
PERMIT
PERMIT NO.
0-82-0896
UNDER THE ENVIRONMENTAL CONSERVATION LAW
[] ARTICLE 15, (Protection of Water) [] ARTICLE 25, (Tidal Wetlands)
ARTICLE 24, (Freshwater Wetlands) [] ARTICLI~ 36, (Construction in Flood Hazard Areas)
PEP~IT ISSUED TO
Robert and Joanne Devoe
ADDRESS OF PERMITTEE
640 Soundview Avenue Peconic, NY 11958
LOCATION OF PROJECT (Section of stream, tidal wetland, dam, building) Northside of Right of way off Bi rds Eye Road
.Dna Island Sound, Orient. Town of Southold. Suffolk County
Ci~nstruct single dwelling (60'x44') plus attached decking and associated septic system at
minimum of 100' landward of mean high water.
COMMUNITY NAME (City, Town, Village) TOWN
Orient Snuthol d
COUNTYSuffolk F,A COMMUNITY NO. DAM NO,
GENERAL CONDITIONS
t. The permittee shall file in the office oi the appropriate Re§ional
Permit Administrator, a eotice of intention to commence work at least 48
PERMIT EXPIRATION DATE
10/31/83
8. That 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 or
9. That if the display of lights and signals on any work hereby authorized
is not otherwise provided for by law, such lights and signals as may be pre-
scribed by the United States Coast Guard shall be installed and maintained
by and at the e~pense of the owner.
10. All wo.rk carried out under OHs permit shall be performed in accor-
dance with established engineering practice and in a workmanlike manner.
11. If granted under Articles 24 or 25, the Department reserves the right
to reconsider this approval at any time and after due notice and hearing to
95-~0-4 (9/75)
(SEE REVERSE SIDE)
SFECIAL CONDITIONS
1. All excavated material will be suitably contained at the work
site so as to prevent its eroding, leaching, or otherwise entering
into adjacent waterways.
2. There shall be n? disturbance to vegetation or topography within
50' landward of the tidal wetland boundary.
See additional alttached conditions A through J.
PERk~IT ISSUE DATE PERMT~DMINISTRATOR J~ - f~ ~ ADDRESS NYS Dept. of Envir Conserv.
11/10/82 J Danle! J. Larki~~,,)J Bldg. 40 SUNY Stony Brook, NY 11794
NYSDEC Law Enforcement - R~gion I
US~CE
FORM NO. 1
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-180:a
Examin ..... ~. .., 19(. ?
Approved ................. 19... Permit No
Disapproved a/c :f-~/~-,.~.; .,~"'..~...
~ff--~, /tT.x~ /7 /~.~ (Building Inspector)
~//~ APPLICATION FOB BU[LDING PERM T
~..fff, ~/.. ~f~.~.~t.f ff~o'2~ ~( ~ INSTRUCTIONS
Application No../~./c~...
Date ' "~'..C .~..
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.
i 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.
~ ~.' 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.
rhe applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to
admit authorized inspectors on premises and in building for necessary inspections.
(Signature of applicant, or name, i~ a c;;~;;a~io'n)
:.
dr (Mailing address of applicant) ~q7 I
State, whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
...... .............................................................................
Name of owner of premises . {'C~.~..q'...~3...~......~D.~.e..C.~.....~..6..~.0..~m. ...................................
e-~s .'. (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.. ~ ~.O..~..¢~. ..............
Plumber's License No. ~..O..~ 7'. ..................
Electrician's License No. ~..q.~. ,~... ~..~
Other Trade's License No ......................
Location of land on which proposed work will be done..~.~¢~ ..... - O&~,~ct -' ................. f~ ...~.
House Number Street Hamlet
County Tax Map No. 1000 Section ........ ['] ........ Block ...... ~ .......... Lot.. J.°..a-.. ...........
Subdivision .'~lV:O ~.~'~ .~. ...... qO.~.~..[~. ......... Filed Map No ............... Lot ...............
(Name)
State existing use and occupancy of premises and intended use and occUpahcy of proposed construction:
a. Existing use and occupancy .~/~.e~ ~t .'~,.~. ~ .'~.~. 4
3. Natu're of work (check which applicable): New Building ..... .../... Addition .......... Alteration ..........
Repair Removal Demolition Other Work
/ JT~ (Description)
4. Estimated Cost ~'.k~,~'tOt~D · .......... Fee~.. ~.O~ .~-~... ..............
(to be paid on filing this application)
. ,
5. If dwelling, number of dwelling upits ............... Number of dwelling units on each floor ................
If garage, number of ears i~;~, .........................................................
6. If business, commercial or ~xed occupancy, specify nature and extent of each type of use ...'7' .................
7 Dimensions of existing stmcturesi if any: Front '--* Rear ~ Depth
Height -- Number of Stories ~ . ...............
Dimensions of same structure with alterations or additions: Front -- Rear
Depth ~ : Height ~ Number of Stories .'77.
8. Dimensions of entire new construletion: Front ............... Rear ............... Depth ...............
Height ............... Number of Stories ~ .... : ............................................
9. Size of lot Front ~l~ ~ i Rear 3.S' D~nth 3 -~. ~
10. c . .a,\..q .\.~'..~ ................. Name of Former Owner . .~q.,.t-,e/yr.. ~..c.b.~.[.~$. ........
Date of Pur rase [ ~ ~- ................................ :' .........................
11. Zone or use district in ~hich premises are situated .C~.*~ {~q~-~.'~ 1~ I ........
12. Does proposed construction violate any zoning law, ordinance or regulation: . .~.~. .........................
13. Will lot be regraded ...,,~.... .... '.c' · · · :, ........ Will excess fill be removed from premises: Yes (~
14. Name of Owner of premises W'~r.~..~',r~. ,~,.'~.e-N.o.*?.... Address ~,l~.'Tq~. ~¢bor./-;~.. Phone No.~.t,~': ~..qt .~. ~ ....
Name of Architect ........... : ................. Address ........... Phone No ................
Name
of Contractor.
.... ~..*--.qP.~, ...... Address::: :gJ~: ........... Phone No ................
PLOT DIAGRAM
Locate clearly and distinctly all ~uildings, whether existing or proposed, and. indicate all set-back dimensions from
property lines. Give street and block n~mber or description accordir~g to deed, and show street names and indicate whether
interior or corner lot.
STATE OF NEV~ORJ~, ,~ ?~:
~2~i~e of individual signing contract). ',
above named..
being duly sworn, deposes and s. ays that he is the applicant
~{e is the; .................. ,' . . . ......................
~f said owner or owners, and is duly [anth~to perform or have performed the said work and to make and file this
tpplication; that all statements contained in this application"are true to the best of his knowledge and belief; and that the
} york will be performed in the manner ~et forth in th'e application filed therewith
~worn to before me this .' · ' .
........... ~.~..(e/~ .... day o ,-m,-~,.-m-( ......, 19 ~ - i
~lot~a~}ublic, ...~..~, ........ ,-.,.~... County , .,
0
0
Z
d
40
C~'~ o~.
SUFFOLK COUNTY DEPART~LENT OF HEALTH SERVICES
FOR APPR0VAL 0F CONSTRUCTION 0NLY
The water supply and ~ewage
systen~ [or this residence will con-
5~rn~ to the standard o[ the Suffo~
Department o[ ltealth
0
x 0
.. ~
'x
dOANNE
p/
· Tr
' is used
ti coPPer tubing
stem; p~pmg s~nCm '~e
o~ typeS K or L on~Y~
L
soF
P"~LD P'cP.Lz, L-_: t., ,,_ ~ ~. _i~ &(~ ~
FOP._,._'.
E/~.3Ti, T___ LF_.¥A"T-I
__ t-..¥A ~ iOIX2