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HomeMy WebLinkAbout10909-z FIELD INSPECTION DATE COMMENTS b \ y FOUNDATION (1st) FOUNDATION (2nd) w �� m � 2.. ROUGH FRAME & :10 -P PLUMBING +- 3 y cn h cu INSULATION. PER N.Y. `+ - � c STATE ENERGY CODE C+ FINAL ADDITIONAL COMMENTS: 11 low) F ::A • x c� N c-F d m id FORM NO. 1 TOWITOF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examine . . . . . . . ., 19d Application Nol(�,io.5.,. . . . . . . . �/ 7 / q Approved .�. . . (. . . . . . . ., 1�. Permit NoJ.�y .. . Disapproved a/c .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . t (B ilding Inspector) APPLICATION FOR BUILDING PERMIT Date .2-94 19QQ. 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 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 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, 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 buildings for necessary ' ctions. r 1 . . . . . . . . . . . . . . . . . . . . (Sig tur of applicant, o ame, if a corporation) .555- Alvah!e• -Laney -GUt0-h09%1e. . .§41y. 11935• (Mailing address of applicant State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. . . . . . . . . . . . . . . . . . . . . . . . . . . . .01TV01 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name of owner of premises . . . .jonae •,r,, and •14ary. .E d ie be c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (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. . . . . . . . . . . . . . . . . ... . . . . Other Trade's License No. . . . . . . . . . . . . . . . . . . . . . 1. Location of land on which proposed work will be done. .ttl/-u .Al e O. one�. Outehugu.e i. Netir.•s ox j. . . . . . . .5 5• 1 . . . . . . . . . . . . . .AlvahI,� •Lane . . . . . . . . . . . . . . 0•�tchoon?e . . . . . . . . . . . . . . . . . . . . . . . House umber 4treet Ham et County Tax Map No. 1000 Section . .1090() . . . . . . . . . . Block . . .Q100. . . . . . . . . . . Lot . .029400. . . . . . . . . . Subdivision . . . . . . . . . . . . . . . (N .ame. ) . . . . . . . . Filed Map No. . . . . . . . . . . Lot . . . . . . . . . . . . . 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy . . . . . x,:i.�rr� c� ;i�fi-r c, •r+ Q b. Intended use and occupancy . . . . . .Q�StA ' . .� Q. t���Qss b �. tzJ ,Qi;orin ouT;sa de :axnituz e during the winter 3. Nature of work (check which applicable): New Building . .X.D .. . . . . Addition . . Y. . . . . . Alteration . . . . . . . . . . Repair . . . . . . . . . . . . . . Removal . . . . . , . . . . . . . . Demolition . . . . . Other Work . . . . . . . . . . . . . . . (Description) 4. Estimated Cost . . MID;, to f110M . . . . . . . . . . . . . . . . . . Fee . . . . �. d , U r� . . . . . . . . . . . . . . . . . . . . . . . . (to be paid on filing this application) 5. If dwelling,number of dwelling units . . . . . . . . . . . . . . . Number of dwelling units on each floor . . . . . . . . . . . . . . . . If garage,number of cars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I. . . . . . . . 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use . . . . . . . . . . . . . . . . . . . . . 7. Dimensions of existing structures,if any: Front . . . . . . . . . . . . . . . Rear . . . . . . : . . . . . . . Depth . . . . . . . . . . . . . . . Height . . . . . . . . . . . . . . . Number of Stones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Dimensions of same structure with alterations or additions: Front . . . . . . . . . . . . . . . . . Rear . . . . . . . . . . . . . . . . . . Depth . . . . . . . . . . . . . . . . . . . . . . Height . . . . . . . . . . . . . . . . . . . . . . Number of Stories . . . . . . . . . . . . . . . . . . . . 8. Dimensions of entire new construction: Front . . Rear . . .�.1. . . . . . . . . . Depth . /O. .6... . . . . . . . Height . . . . . Number of Stories . . . . .1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Size of lot: Front .76...67 . . . . . . . . . . . . . . Rear .$�..$2 . . . . . . . . . . . . . Depth Z/.7.,.6.7. . . . . . . . . . . . . 10. Date of Purchase . . . . . . . . . . . . . . . . Name,of Former Owner . . . . . . . . . . . . . . ... . . . . . . . . . . . . . 11. Zone or use district in which premises are situated . . . .'. . . . . . . . . . . . . . : . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. Does proposed construction violate any zoning law, ordinance or regulation: . 110 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13. Will lot be regraded . . . .na . . . . : . . . . . . . . . . . . . . . . Will excess fill be removed from premises: Yes No 14. Name of Owner of premises . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . .Phone No. . . . . . . . . . . . . . . . Name of Architect . . . . . . . . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . Phone No. . . . . . . . . . . . . . . . Name of Contractor . . . . . . . . . . . . . . . . . . . . . . . . . . Address ... . . . . . . . .. . . . . . . . . . Phone No. . . . . . . . . . . . . . . . PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and.indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. SEE KffAGI*AF_wTS STATE OF NEW YORK, COUNTY OF 4�.Ul;' 'C. . . . . . . . S' . . . . . . . . . . . . . . . . . . . . . . . . . . being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. Heis the . . . . . . . . . . . . .OVAO ' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (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 heforme this �Y . (�a . . . . . . . . . . . . . . day.o , 19 1 . D Notary Public, . . . �i L�. . County -: ALLAN C.•DICKERSQN . . . . Z4gnaiure . . . . . . . . . . . . . NOTARY PUBLIC, STATE OF NEW YORK of applicant) QUALIFIED IN SUFFOLK CO., NO. 52-602 5 COMMISSION EXPIRES MARCH 30, 191y 4 . ki N Zelins "odfo�ftd rro 247'67 hedges N le ` er et Val'&I AN iv cON 0 6 �,=- b• pipe set -1 ( o 14.fo 1 -Lv, • 234 s4•ft � •�W 2 1 g3 N� A reo f a .,Se o Q,S �i®��� C� B ��r►�G {,�OL GOZC YOUNG & YOUNG 400 OSTRANDER. AVENUE, RIV�RHEAD, NEW YORK d t'� pw`� ` p A` � 5'( ALDEN W. YOUNG HOWARD W.YOUNG. 1• EYOR `� LAND v ���1i� `�' 0 PROFESSIONALSURVEYOR. N.Y.S. LIC NO, 12845 N.Y.S. LICVNO. 45E93 RG�C� G ME``� SURVEY FOR: F,NPG��pLE0G`po o '(1��N�RG ✓ONAS E. HIGBEE B MARY E. HIGBEE R S FO ,ENE GpN RE 1�. Npi 5(�v AT GUARANTEED TO: GpoES. �R�pN , CUTCHOGUE TOWN OF SOUTHOL D SUFFOLK CO., N.Y. 6Y OZuv4�Ci e. SCALE: /�� =30, DATE:✓UNEE I.6, 1977 NO. 77-232 101 r2 It WOM fIWIAL —1� 6 RAILING SEAT Gov DECK ba Cl t £�f i i:'• �y,'"f �.~: ...,�.y,Rf - ..'f- f f/ y`,,x R�`-ft. �`. r fl Yr � 1�'(,'�•+' Y'C`•���f,r1�14�����'9"'''�ry�. +m �_r i4�•- i,--.�,- .e,-_.1.�. A:�T f+ .,s, e..,:?�• ' '+ •' � �p. 'i �• �"q,�. ._ �_1 •..,y�s�ii.._ __max\,': - �� r r,"v4 .. vr� l' //,1�' t� •5/f °l �. ..1. t f + `.- ��F�•'s STEP Plan jilt � z w000 RAILING . ,.r:� �`",: I/'i 1 .>,�'�'xr'�'� .�' ';'•tit. ',L. ;� � `i .�t�u_' �� �,`.'.•;:•. `' � •t,'; !/r .✓1,`I,'�-..�. '' = *d,. .: ,S •i: :....b' .,fit ' .., ;� I.....- .- s �; .. i off`•�� ^� t ' ��.�•�x Eta 4 •�`-� f•�'+`:,?�;`'- 'y,/.�;_�I ' >. .� ��y FORM NO. 3 TOWN OF $DUTH,QL BUILDING t4PAPi TO WN HALL SOUTHOLD, N. Y. BUILDING PERMIT; (THIS PERMIT MUST BE KEPT ON THE PiZENIIS�S UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) NY 10909 Z Date ....... ............... Permission is hereby granted to: ................. ............ 44450.... .. ................ .................................. at premises located aW=.-S..... .... -4rrW,'1741C•.... ...................................'.............................. ...........I......... ................. ......... ........................... ....................................... ...... .......... ............... ........................................ i County Tax Map No. 1000 Section .............. Block . .......... ,Lot No. ........................ pursuant to application dated ...... 19.A and, approved by the ap-)— 4....... ................ Building/Inspector. Fee $ s. . ... .......... Building nsp' ector Rev. 6/30/80 al FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Hall Southold, N.Y. 1 197 i 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 topograohic 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. 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 5.0 2. Certificate of occupancy on pre-existing dwelling or land use $5.00 3. Copy of certificate of occupancy $1.00 Date . . New Building . . . . . . . . . . . . . Old o/r� Pre-existing Building(X) . _. .__ _- 'Vacant Lannd' . . . . . . . . . . , . Location of Property . .6 .Vr .4 . . . f1L j/R fI S. .y ,A,AID. . . . . . . �U.TG.N0.6U. . . . . lv.�:-. . . . . . . . . . House No, Srreer Hamlet Owner or Owners of Property County Tax Map No.,1000 Section . . - l Q.�. . . . . . Block . . . . . . . . . Lot . . . . . . . . . . Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Filed Map No. . . . . . . . . . .Lot No. . . . . . . . . . - . . - Permit No. A!-!:/.0 t . . Date of Permit .40-:T-.(�O.Applicant .K, 11.1C 3-Ek . . . . . . . . . . . . . . . . . . . . . Health Dept. Approval . . . . . . . . . . . . . . . . . . . . . . . .Labor Dept. Approval . . . . . . . . . . . . . . . . . . . . . ... . Underwriters Approval . . . . . . . . . . . . . . . . . . . . . . . .Planning Board Approval . . . . . , , ./, Request for Temporary Certificate . . . . . . . . . . . . . . . . . . . . .Final Certificate . . . . . . . ;. . . . . . . . . - Fee Submitted $ .i. . 00 Construction on above described building and ermit meets 11 a l cablesodes and regulations. � ' ViApplicant . . . . . . . . . . .. . . . . . . . . . . . . . . . . aa�.io-ioaa 'Ao FOuf TEL. 76sa 802 TOW OF SOUTHOLD OFFICE OF BUILDING INSPECTOR P.O BOX 728 •', i_ TOWN HALL O. �.. SOUTHOLD, N.Y. 11971 �0.�'� -L'� Applicant C t" LAI — Dear This is to advise you that the jotl under Building Permit No . Oqo issued� to v� pi` �` on le o for �AcC R __ _s completed and a final jnspection -as "as( 4 o V 5 / been done . In order to complete this file it is necessary that a Cerci_`ica to of Occupancy be issued . Please fill out enclosed form s the ( ) , return same to ti,e above office with a check for $5 , 00 payable to the TowInalicaten of Southold . Please and arrange whom the CertifQcate of Occupancy is to be mailed g_ with this office for an inspection date . Thank you for your prompt attention . Very truly yours , Victor Lessard Administrator VL : ec Enclosures ronces 671 nder 8 F 247-61 t hsd9a �, �'oots� \A fla9Spo torrs. �c tro Cn �a 1 ,YY •i { ZClio t' mON aa . v e ` p,re set q � N 234 sG f t ze Z 7- ; 21 f,Of v 0 2�g.93 0 N Are Q,as Z f W'lp�� , R �p�itt f CIO", Y �"j S,r �sfXn";C ✓yt _ f rI r.yt th6a, r *V �JAC, YOUNG & YOUNG r�Cor'e 400 OSTRANDER AVENUE, RIVERHEAD, NEW YORK • .a p ,, Yy , Iti " y r�hh•4�`G l h��j'�j ALDEN W. YOUNG HOWARD W.YOUNG PROFESSIONAL ENGINEER AND LAND SURVEYOR LAND SURVEYOR. N.Y.S. LIC. NO. 12845 N.Y.S. LIC. NO. 4VS93 6• ���A� �,.t= `�;� �'� �;- », �� SURVEY FOR: ✓ONAS E. HIGBEE B MARY E. HIGBEE o �ppfS OR CO AT CUTCHOGUE GUARANTEED TO: TOWN OF SOUTHOLD t SUFFOLK CO., N.Y. SCALE: f 11 =30 r DATE:✓UNE 16, 1977 NO. 77-232 10° roll WOOD FIIJI-AL ---1,� fD QAILING , ,, ,�. SiIItJGLCS SEAT RP WOOD DECK "YYIth, r.t�F ''��� a�i. 1 ra.6 .•��s.?c., Yrw;'•-: «fJ xrkY','.rd" •�.�a=-,.tt k�•. �.+� ,�.� �, w ti " �J �E%%. STEP Plan 3'e� Ow-coltokTivE 'FASCIA �,4 . p �T �\, W000 RAtuN6 CORM (40. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examine l . . . .l. . . . . . .. 19 4 Application No./OIF091 . . . . . . . Approved . . �. . . . . . . . /.0. d .4 / 19 . . Permit No. . . . . . Disapproved a/c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (B ilding Inspector) APPLICATION FOR BUILDING PERMIT Date . . . , etember 29.119g�. 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 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 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, 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 buildings for necessary • pections. . . . . . . . . . . . . . . . . . . (Sig at of applicant r name, if a corporation) .5.55. AaXV Lb!;9. .bane.,. .Cutrhogue.,. .11Y. 11935• (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. . . . . . . . . . . . . . . . . . . . . .Owner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name of owner of premises . . . .J.Qna9- .N. . anal .Nary. .E. . Ili.ghee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . (Name and title of corpo�rratteeJofficer) Builder's License No. . . "oL. '/.'.-•. . . . I . . . . . . . . . Plumber's License No. . . . . . . . . . . . . . . . . . . . . . . . . Electrician's License No. . . . . . . . . . . . . . . . . . . . . . . Other Trade's License No. . . . . . . . . . . . . . . . . . . . . . 1. Location of land on which proposed work will be done. .W/S. .AlvahAs .Lane i •Cutehoguo t •New York• • • • • . . . .5.55. ttixzk. . . . . . . . . . . . . . Alvah!s. .Lane. . . . . . . . . . . . . . . . .Cutchcgue. . . . . . . . . . . . . . . . . . . . . . House Number Street Hamlet County Tax Map No. 1000 Section . 10900. . . . . . . . . . . Block . . 0200. . . . . . . . . . . Lot . .02900.0 . . . . . . . . . . Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Filed Map No. . . . . . . . . . . . . . . Lot . . . . . . . . . . . . . . . (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy . . . . Brivat.e. .Resi delate• • • • • • • • • • . • • • • • • • . . . . . . . . . . . . . . . . . . . . . . . . • • • b. Intended use and occupancy . . . 7=pisuX'e-;use;_w/p©ssiblat qtAktt'Drio 01zt.aide. furniture during`the Arlt V I .;a 3. Nature of work (check which applicable): New Building . . . . . . Addition . . . . . . . . . . Alteration . . . . . . . . . . Repaip oval . . . . . . . . . . . . . . Demolition . . . Y . . . . . . . Other Work . . . r Rem . . . . . . . . . . . . . . . (Description) 4. Estimated Cost . . . . . . . . . . . . . . I . . . . . . . Fee . . . . l�r� �. . . . . . . . . . . . . . . . . . . . . . . � • � a f)OO+ (to be paid on filing 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 nature and extent of each type of use . . . . . . . . . . . . . . . . . . . . . 7. Dimensions of existing structures,if any: Front . . . . . . . . . . . . . . . Rear . . . . . . . . . . . . . . Depth . . . . . . . . . . . . . . . Height . . . . . . . . . . . . . . . Number of Stories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dimensions of same structure with alterations or additions: Front . . . . . . . . . . . . . . . . . Rear . . . . . . . . . . . . . . . . . . Depth . . . . . . . . . . . . . . . . . . . Height . . . . . . . . . . . . . . . . . . . . . . Number of Stories . . . . . . . . . . . . . . .A . . . . . . 8. Dimensions of entire new construction: Front . .. . . . . . . . . . . . Rear . .6. . . . . . . . . . . . Depth . . . . . . . . Height . ./1. . . . . . Number of Stories . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .'I. . . . . . . . . . . . 9. Size of lot: Front . . ..�1 . 7 . . . . . . . . . . . . Rear . .$6 e $?.. . . . . . . . . . . . Depth s (s. �/ . . . . . . . . . . . 10. Date of Purchase . . . . . . '. . . . . . . . . . . . . . . . . . . Name of Former Owner . . . . : . . . . . . . . . . . . . . . . . . . . . . . . 11'. .Zone or use district in which premises are situated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. Does proposed construction violate any zoning law, ordinance or regulation: . N 0. . . . . . . . . . . . . . . . . . . . . . . . .13. Will . 14. Name ofOwner o . . . .N o. . * ' ' ' ' ' ' ' ' • • • Will excess fill be removed from premises: Yes regraded . . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . Phone No. . . . . . . . . . . . . . . . Nameof Architect . . . . . . . . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . Phone No. . . . . . . . . . . . . . . . Name of Contractor . . . . . . . . I. . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . Phone No. . . . . . . . . . . . . . . . PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and.indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. S£E A-r(Ac-o EN7-$ STATE OF NEW YORK, S.S COUNTY OF .Suff.01k. . . . . . . . . , , Mary. E, ,Higbee, , , , , , , , , , , , , , , , , , , , , , , , , being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. ti Heis the . . . . . . . . . . . . .owner. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (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 mannIft.h. the application filed therewith. e re me th's Sworn to. A o . . . . . . .. 19 , . . . . . . y . . . . . . County NotaryPublic .�� . QUALIFIED IN BL�TATE OF NEW ALLAN T NOTARY PUBLIC, STATE OF NEW YORN . . . . . . . . . . :. . . . . . . . . . . . . . . . . . . . . . . . N CO.,NO.52.8022?2�g�S (Signature of applicant) COMMISSION ERPiAES MARCH 80, 1S_L y A