HomeMy WebLinkAbout12133-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
Certificate Of Occupancy
No. ~.1.85~,0 .......... Date ....d.u. qe...2.9. ..................... 198.4.,
THIS CERTIFIES that the building ....... .fi.a.d. J:..t.~.o.n. ...............................
Location of Property ....7.5..~o. 9.d.c. 1..i .f.f..D.~ .iy.e. ................... ~.a.t.t.i. ~..u.c.k. ........
House No. Street Ham/et
County Tax Map No. 1000 Section .. 1. 0 ? ....... Block ...Q ? .......... tot ...0. 2. .8 ...........
Subdivision ............................... Fi]ed Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore fried in this office dated
· ...N. qv.....2.3. ......... , 1~.2. . pursuant to which Building Permit No. 1.2. ! .3.3.Z. ..............
dated .. ~ p.v.... 2 3 .................. 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 .........
for an addition with enclosed pool.
The certificate is issued to .... .J.a.m.e.s., .B....&...Cy.n. ~..h.~.a..g.....K.a.m..ip.s.k.~ ...................
(owner, levee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval ......... I~/. ~ ..............................
UNDERWRITERS CERTIFICATE NO ................. #. 6 .4 B.7.5 1 .........................
Z.B.A.
Appeal #3060 Decision
rendered Jan. 13, 1983
Building Inspector
Rev. 1/81
Perh~ission is hereby
(THIS PEP-J~IT MUST BE KEpT
12133 Z ..: .....
granted to:
tO ~.~ ..~.;..J ............................. ~ ...................... ..
..;:;..~ ......... ; ................. ~ .......... ; ..................... ; ............. ~.,.....?,~,
4 ~,u~ Tax Map No. 1000 Section
~ p~pant to application dat~
B tl lng Ihspector. : :
~EP, MI~ INCLUDES APPROVAL J
- ~,~ TO REMOVE EXCES~ FILL
F~OM ABOVE PREMISES BY J
. sDI~JG LOT _ ~
E~SPO0~ CON~ i RUC~ION .~
{LAR CONST~UC-rlON ,
Nd; ', .......................
!pproved by the
FORM NO. 6
TOWN OF SOUTHOLD
Building Department
Town Hall
.~outhold, N.Y, 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This application must be filled in typewriter OR ink, and submitte~p~c=t= 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, propertv 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.Su bm it Plan ning Board approval of comp leted site p lan requ i~ements where applicable.
B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing"
land uses:
1, Accurate surve of peoperty showing ~Jl property lings, streets, buildings,and un, usual natural or
topographic features. -- ~ ~ ~ ~
2. Sworn statement of owner or pC'evious owner as to ¢'se. occuCancy 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: ~
C,
1. Certificate of occupancy k~ $5.00j
/
2. Certificate of occupancy on pr'emxfst~ing dwelling ! land use --?re-E× ±s t in~; C, O, $15.
O0
3, Copy of certificate of occupancy $1.00
Vacanf. ]Land C.O. $ 5.00
~_~.. ~ Date .... ~/~. ~/..~.¢ ...........
New Building ............. Old or Pre-existing Building ..... ~ .... Vacant Land .............
Locationof Property .. ~.~...~. O.Q ~7.el ~L" ~' ~'-~ ¢' '~ j ["~"-' ........... ~ '~ ["r~ ~ ~
House IVo. Street Hamlet
Owner or Owners of Property J.~/~.~','-.~.'.~.'. ,~'; .~.~.~'.''~'~.'ta~..J.- -~'~¥'/'/~J'/~"~'~'~'
County Tax Map No. 1000 Section ... !..qT. ...... B ock ..... ..... Lot...& .......
Subdw~s~on ................................. Fded Map o ...........Lot No.., ............
Health Dept, Approval ........................ labor Dept. Approval ........................
~ d' App
Underwriters Approval .................... Planning Boar royal ......................
Request for Temporary Certificate ..................... Final Certificate ..................
Fee Submitted $....~,* .O..~. ...................
Construction on above described building and p~ermit meets all appliCab[e codes,and regulations.
Applicant ... ~.. ~/~~.~ ..............
Rev. 10-10-78
looo~[3 THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRI~I~
--~ ~i~.~t~. ~{J'(--~ ].~ 85 JOHN STREET, NEW YORK, N~W ~ORK 10038
THIS CERTIFIES THAT
only the e~ectrical equipment as described below and interlaced by the applicant named on the above appt~at~r~ ~m~er ~n the preo~ses of
inthefollow~,tg ~catlon~ ~ Basement ~ lst Fl. ~ 2ad Fl. Section Block Lot
was exanttaed on and found to be in co,nplla~ce with the requirements of this Board.
DRYERS
~oto~s;
E · -v I ' c
AW, G
OF HI-LEG
Joseph Hololob
~ox 1307
765-t802
BUILDING DEPT
// INSPECTION
FOUNDATION 1ST [ ] ROUGH i PLBG.
FOUNDATION 2ND [ ], INSULAtiON
[ ] FRAMING [] FINAL
REMARKS: ~/~//~ ~ ~//'-'--
DATE
~INSPECTOR
BUILDING,, DE~. ~) ~.
,
INSPECT '
[ ] FOUNDATION 1ST ~ ] RouGH: ,~L G.,~
[ ] FOUNDATION 2ND[ 1 INSULA~T~0N --i,
REMARKS: , : ,~,,,, .,,
'DATE,
iNsPECFoR
TOWN OF $OUTHOLD
OFFICE OF BUILDING INSPECTOR
P.O. BOX 728
TOWN HALL
SOUTHOLD, N.Y. 11971
January 5, 1983
TEL. 765-1802
Board of Appeals
Town of Southold
Main Road
Southold, N.Y. 11971
Re: Cynthia Kaminsky
rear yard reduction, variance
Gentlemen:
First of all, I would like to apologize for any disruption
.caused at your past meeting regarding lot coverage on the prem-
ises owned by above applicant.
When Mrs. Kaminsky made her application for the building
permit, I checked the lot coverage and i recall the figures
showed that all of the buildings, including the proposed con-
struction, were within the 20% allowed. The only explanation
I can give is that my calculator did not function properly.
When Mr. Buckley spoke to me on December 8, 1982, I found
I had made the error and this time I used the information, as
to size of garage (17' x 23') from the property file card in the
assessors office, putting the lot coverage over 20% by 90 sq.
feet.
The following day of your last mee6ing, Mrs. Kaminsky came
into the office to have this matter s~r~ightened out. Naturally
she could not understand what had happened since I had checked
out the lot coverage in her presence when she made the appli-
cation for permit.
Since her application did not give the size of the accessory
garage on the plot plan, I assumed that the 17' x 23' garage
listed on the property file card was 6he size of the building,
however, Mrs. Kaminsky had constructed a 24' x 24' accessory
garage building that did not appear on the property file card.
In view of what has happened, I wou&d like to request that
the' disapproval notice issued on Novembe.r 23, 1982 be accepted
as amended to include insufficient lot area with proposed addi-
tion. Total lot coverage permitted is 3~75 sq. feet. Total
lot coverage as proposed is 3650 sq. feet, for a total of 275
Board of Appeals
1/5/83 Page 2
square feet over. If acceptable, I can ~ake the change from
90 square feet to 275 square feet.
Edward F. Hindermann
Building & Housing Inspector
FORM NO. 3
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N.Y.
NOTICE OF DISAPPROVAL
File No ................................
.. ~... .T: .~, . . . z.~. . ~. . /.~. -:.~. . : .....
· .~.~, ~,,~-.~..~../u. ~ ......
for pemit to constmc~. ~. ~...~.. ~.(~. ~t1,~ ...... at
Location of Property ~ ~o~7 7 ~, ... .
~ouso IVO.
~ ~amlet
co~.~ ~ ~ ~o. ~000 ~o~ ... ~ T. .... ~oc~ .. ~ ~. . ~o~ . .~ ..........
Subdivis[o~ ~ Filed Map No. ~ . Lot No. ~ .......
.... ............................
~ ~~, BuildMg Inspector
Memorandum from....
BUILDING INSPI~CTORS Oln~IC~
TOWN OF SOUTHOLD
TOWN H,~L~, SOfT,oLD, N. Y. 11971
765-1802
APPEALS BOARD
MEMBERS
GERARD P. GOEHRINGEH, CHAIRMAN
CHARLES GRIGONIS, JR,
SERGE DOYEN, JR,
ROBERT J. DOUGLASS
JOSEPH H. SAWICKI
Southold Town Board of Appeals
MAIN ROAD- STATE ROAD 25 SOUTHOLD, L.I., N.Y. 119'71
TELEPHONE (516) 765-1809
January 26, 1983
Mrs. Cynthia Kaminsky
75 Woodcliff Drive
Mattituck, NY 11952
Re: Appeal No. 3060
Decision Rendered January 13, 1983
Dear Sir or Madam:
Attached herewith is a copy of the formal findings and deter-
mination recently rendered and filed this date with the Office of
the Town Clerk concerning your application.
In the event your application has been approved, please be sure
to return to the Building Department for approval of any new construc-
tion in writing, or for other documents as may be applicable.
If you have any questions, please do not hesitate to call either
our office (765-1809) or that of the building inspector (765-1802).
Yours very truly,
Enclosure
Copy of Decision to
Building Department
GERARD P. GOEHRINGER
~ Lind~ F: IKowalski
Secretary
Southold Town oard of'A pe s
MAIN RrlAD- ~TATE ~IDAD 25 ~IDUTHE)LD, L.I., N.Y. 11971
TELEPHONE (516) 765-1809
Appeal No. 3060
Application Dated November 30,
TO: Mrs. Cvnthia Kaminskv
75 woodcliff Drive
Mattituck, NY 11952
ACTION OF THE ZONING BOARD. OF APPEALS
1982
[Appellant(s)]
At a Meeting of the Zoning Board of Appeals held on Januarv 13, 1983
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
[ ] Request for Special Exception under the Zoning Ordinance
Article , Section
IX] Request for Variance to the Zoning Ordinance
Article III , Section 100-3~
Upon application of CYNTHIA KAMINSKY, 75 Woodcliff Drive, Mattituck,
NY for a Variance to the Zoning Ordinance, Article III, Section 100-34 for
permission to construct addition (enclosed pool) with reducion in the rear-
yard (sideyard) setback at 75 Woodcliff Drive, Mattituck, NY; County Tax
........................................
The board finds and determines as follows:
By this appeal, applicant seeks permission to construct a 33' by
42' addition (including an 18' by 36' swimminqpool) in line with the
southerly line of the existing dwelling and with a setback from the
westerly property line at 15'8". Existing On the premises is a one-story
one-:family dwelling with attached garage and accessory 24' by 24' storage
building in the northwest corner of the premises. The premises in ques-
tion is a corner lot as defined by Section 100-34 of the zoning code and
contains an area of 16,875 square feet.
In reviewing this matter, the board finds that the proposed
addition would create excessive lot coverage by a total of 275 square
feet over the permitted 3,375 square feet, and applicant was adviBed
of same at the original public hearing held on December 22, 1982. On
December 29, 1982, the applicant filed an application for a variance
due to the excessive lot coverage, which is determined as noted in
Appeal No. 3068, same date hereof.
It is the opinion of the board that the proposed addition could
be turned lengthwise to the house which would allow more of a setback
from the rear property line, or the appli~aRt could, reduce the size of
the pool area to an 16' by 32', and therefore a maximum reduction at
20 feet from the rear (west) property line should be vielded.
In considering this appeal, the board determines %hat the
circumstances are uniaue; that bv allowin~ ehe variance as indicated
no substantial detriment to adgoinin~ properties will be created; that
the difficulty cannot be obviated bv a me~hod feasible to appellant
other than a variance; that the relief requested will be in harmonv
with and promote the general purposes of zoning; and in view of the
manner in which the difficultv arose and in ~consideration of all the
above factors, the interest of justice will .be served by allowing the
variance, as indicated below.
(CONTINUED ON PAGE TWO)
DATED: Januarv 25, 1983. CHAIRMAN,. SOUTHOLD TOWN ZONING BOARD
OF APPEALS.
Porto ZB4 (.rev. 12/81)
Paqe 2 - Appeal No. 3060
Matter of Cvnthia Kaminskv
Decision Rendered January 13,
1983
On motion bv Mr. Goehrinqer, seconded by Mr. Douqlass, it was
RESOLVED, that Appeal No. 3060, apDlication o~ CYNTHIA KAMINSK~
for permission to construct addition (inaround swimminqpool) be and
herebv is GRANTED SUBJECT TO THE FOLLOWING CONDITIONi ~
That the pool addition shall not be set back dloser than 20 feet
from the rear yard property line (west DroDertv linet.
Location of Property: 75 Woodcliff Drive, Mattituck, NY;
County Tax MaD Parcel ID No. 1000-107-07-028. :
Vote of the Board: Aves: Messrs. Goehrinqer, Doyen, Grigonis,
Douqlass and Sawicki. This resolution was unanimously adopted.
A ?ROV_F. JZ '
RECEIVED AND FILED BY
lkm ,,~OU ~_.C:LD TO:CN CLEPJf
t/ To'wn Clerk Town o~ S~thold
APPEALS BOARD
MEMBERS
GERARD P, GOEHRINGER, CHAIRMAN
CHARLES GRIGONIS, JR,
SERGE DOYEN, JR.
ROBERT J, DOUGLASS
JOSEPH H. SAWlCKI
Southold Town Board of Appeals
MAIN ROAD- STATE ROAD 25 SK1UTHOLD, L.I., N.Y. 119'71
TELEPHONE (516) 765-1809
January 26, 1983
Mrs. Cynthia Kaminsky
75 Woodcliff Drive
Mattituck, NY 11952
Re: Appeal No. 3068
Decision Rendered January 13, 1983
Dear Sir or Madam:
Attached herewith is a copy of the formal findings and deter-
mination recently rendered and filed this date with the Office of
the Town Clerk concerning your application.
In the event your application has been approved, please be sure
to return to %he Building Department for approval of any new construc-
tion in writing, or for other documents as may be applicable.
If you have any questions, please do not hesitate to call either
our office 765-1809) or that of the building inspector (765-1802).
Yours veery truly,
Enclosure
Copy of Decision to
Building Department
GERARD P. GOEHRINGER
IRMAN · ./ .
VB~Lind~ F. Kowalski
Secretary
$outhold Town Board of Appeals
ACTION OF THE ZONING BOARD OF APPEALS
Appeal No. 3068
Application Oated December 29, 1982
TO: Mrs. Cynthia Kaminskv
75 Woodcliff Drive
Mattituck, NY 11952
[Appellant (s) ]
At a Meeting of the Zoning Board of Appeals held on January 13. 1983
the above appeal was considered, and the~aetion indicated below was taken
on your [ ] Request for Variance Due to Lack of Access to Property
New York Town Law, Section 280-a
[ ] Request for Special Exception under the Zoning Ordinance
Article , Section
Request for Variance qo the Zoning Ordinance
Article III , Section 100-31
The public hearinq on this application was also held on January 13, 1983.
Upon application of CYNTHIA KAMINSKY, 75 Woodcliff Drive, Mattituck,
NY for a Variance to the Zoninq Ordinance, Article III, Section 100-31 for
Permission to construct enclosed pool and deck areas, which will exceed the
maximum permitted 20% lot coverage requirement of the zoninq code. Loca-
tion of Property: 75 Woodcliff Drive, Mattituck, NY; County Tax MaD
Parcel ID No. 1000-107-07-028.
The board finds and determines as follows:
By this appeal, applicant seeks permission to construct a 33' by
42' addition (including the 18' by 36' swimmingpool) in line with the
southerly line of the existinq dwellinq tO be set back from the rear
property line at 15'8" and exceedin~ the maximum permitted lot coveraqe
bv 275 square feet. Existinq on the premises in question is a one-story
one-family frame dwellinq with attached Gar~qe and accessory 24' b¥ 24'
storaqe buildinQ at the northwest corner of the premises. The premises
in Question is a corner lot as defined by Section 100-34 of the zOninq
code and contains an area of 16,875 square ~eet. The total lot coverage
permitted by the zoninq code is 20% of the ~ot area, or 3,375 square
feet. The total lot coverage proposed is 3,650 sGuare feet.
It is the opinion of the board that the lot coveraqe as proposed
is not excessive, approximately 8% of a v~riance from the zonin~
requirements. For the record, it is notedl that a decision has been
rendered simultaneously herewith under ADP~ No. 3060 qrantinq a
variance for a 20' setback from the rear property line for this same
~roposed construction.
In considerinq this appeal, the board determines that the
variance request is not substantial in rel~t~ion to the reGuirements
of the zoning code; that the circumstances, a~e unique; that by allow-
inq the variance no substantial detriment to adjoininq properties will
be created; that the difficulty cannot be obviated by a method fea-
sible for appellant other than a variance; that the relief requested
will be in harmony with and promote the qeneral purposes of zoning;
and in view of the manner in which the difficulty arose and in
consideration of all the above factors, the interest of ~ustice will
be served b¥ allowinq the variance, as indicated below.
On motion bv Mr. Goehrinqer, seconded b~v Mr. Griqonis, it was
%$TED: January 25, 1983. CHAIRMAN,~ SOUTHOLD TOWN ZONING BOARD
OF APPEALS
Paqe 2 - Appeal No. 3068
Matter of CYNTHIA KAMINSKY
Decision Rendered January 13, 1983
RESOLVED, that Appeal No. 3068, application of CYNTHIA KA~INSKY
for approval of excessive lot coveraqe at eight perceSt for the con-
struction of a pool and deck areas, be and herebv IS APPROVED, PROVIDED
THAT THE SET BACK FROM THE REAR PROPERTY LINE (WEST L~NE) IS NOT LESS
THAN 20 FEET,
Location of Propertv: 75 Woodcliff Drive, Mattituck, NY; Count¥
Tax Map Parcel ID No. 1000-107-07-028.
Vote of the Board: Aves: Messrs. Goehrinqer, Doven, Gri~onis,
Douqlass and Sawicki. This resolution was unanimousl, adopted.
Oh~lrman Boa.~'d of Apper,!~
RECEIVED AND FILED BY
n~ SOUTHOLD TO%VN CLERK
DATE
d/Tdwn Cie[k, ,,town
FIJjLD ~.NSPECTION COMMENTS
FOUNDATION (2nd)
ROUGH FRAME &
PLUMBING
INSULATION PER N.
STATE ENERGY
qODE
FINAL
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1803
Examined./~ . .~....~..~..., 19 .~.~'.~
Approved :'X. ..... ,
........ ......
~¢~ /~/~5 , APPLICATION FOR BUILDING PER~IT
Application No..."~..(~: f. ..........
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 throu~out 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, and regulations, and to
admit authorized inspectors on premises and in building for necessary inspections. __ ,
· .~. ~/&-~e~.. ~. ;.;/'i ......
~Signature of applicant, or nmne~/if a o p at'on)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, en~neer, general contractor, electrician, plumber or builder.
(as on the tag: roll or latest deed) 0
If applicant is a corporation, signatgre of duly authorized officer.
(Name and title of corporate officer)
Builder's License No....~...4..~
Plumber's License No .........................
Electrician's License No .......................
Other Trade's License No ......................
1. Location of land on which'proposed work will be done ..................................................
..... %-. ............... 1,d.o o~. e.t_~ e~'.'~, r~.~.~.~ ....... JYl ~.-r.T. ~ T.U.~ ~<,. N.'.¥.,.. !.~ .~...S..=...
House Number Street Hamlet
County Tax Map No. 1000 Section ..... l.o.r{. ........ Block ........ 0.7 ....... Lot ...... 0.o~ ~ .......
Subdivision ~ . .............
..................................... Filed Map No. Lot
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of pr0posed construction:
a. Existing use and occupancy ..................... - . . ,,,,,.~..,,,~, ....................
.,nten duse , o o ,an .................
3. Nature of work (check which applicable): New Building .......... Addition ..... Alteration ..........
Repair .............. RemoVal .............. Demolition .............. Other Work ...............
(Description)
4. Estimated Cost .... ff..31~,t O. oD ..................... Fee ......................................
i (to be paid on filing this application)
5. If dwelling, number of dwelling tinits ........ /. ...... 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 type of Iasc h' .7~....~
7. Dimensions of existing structure~, if any' Front . .~q. ~ Rear /~ ~. ~ ~pt . ..
................... :~... D
Height a~, !.~.t ........ Number of Stories ........... ~ ........... ~. ..... ............... .~ ......
Dimensions of sam.e structure wi~h alterations or additions: Front .. ~; ~ '~.' . Rear ~ ~,' ~..'
Depth ..... ~.~.. ¥ ......... . . Height ~,..~. ..... t ......... Number of Stol%s ..... ~ ............
8. Dimensions of entire new constrUctiol~: Front ..... .B ~ ...... Rear ...... .,B,,~5..t.... Depth .... ~..~ .......
Height .......... Number of Stories ...... ~ ........................ ,,~ .........
10. Date of Purchase . .,~,. i' .I..q,6 .~ .......... Name of Fornlqr Ow.n? ./'~.. ~ .....
11. Zone or use district in which premises are situated ......... ~ ....... ' .......... ' .........
12. Does proposed construction violhte any zoning law, ordinance or regulation: .... ~ ........................
13. Will lot be regraded ..... D'~...~.. ~ ~ ...... ~ .... Will excess fill~be rem~ed fro~ gremises: Yes No
N~e of Architect ~ ~ ~ ........... Address ~/~~hone No. ~.q ~ ~6~...
Nme of Contractor . ~ ~.~ .... Address ................... Phone No ................
PLOT DIAG~M
Locate clearly ~d distinctly ~I ibufld~gs, whether existing or proposed, ~d~ indicate ~1 set-back d~ensions from
property lines. Give street ~d block ~umber or description accord~g to deed, and show street rimes and indicate whether
interior or corner lot.
STATE OF NEW ~ORK,
COUNTY OF {~ .S.S
(Name of individual sign!ng co ract)
above named.
being duly sworn, deposes and says that he is the applicant
Sworn to before me this
.c~.~ ~ 19~..e~
....................... day oi ................ ,
Notary Public ............. County
VERONI¢~ F, ~DONff
~OrARY Puauc, ~ rATE OF NEW YOR~
NO, a2 ~68t~8
QUALIFIED IN ~UFFOLK COU~ ~ ~
COMMISSION EXPIRES MARCH 80, 1~ ~ ~
He is the i
~ (Contractor, agent, corporate officer, etc.)
of said owner or owners, and is dul~ 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.
l
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