HomeMy WebLinkAbout16063-z FO~'M' NO. ~
TOWN Of: $O~THOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING P E~J~AIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
County Tox Map No. 1000 Section ..... ..~....~...~.-7. ..... Block ..... ..~....t{ ......... Lot No ......~..~ ...........
Building Inspector.
and approved by the
Building Inspector
Rev. 6/30/80
Form No. 6
TOWN OF SOUTNOLD
BUILDING DEPARTMENT
TOWN t~LL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
A. This application must be filled in by typewriter OR ink and submitted to the building
inspector with the following: for new building or new use:
1. Final survey of property with accurate location of all buildings, property lihes,
streets, and unusual natural or topographic features.
2. Final Approval from Health Dept. of water supply and sewerage-disposal(s-9 form).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Sworn statement from plumber certifying that the solder used in system contains
%ess than 2/10 of 1% lead.
5. Commercial building, industrial building, multiple residences and similar buildings
and installations, a certificate of Code Compliance from architect or engineer
responsible for the building.
6.Submit Planning Board Approval of completed site plan requirements.
B. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and
'-'pre-existing" land uses:
1. Accurate survey of property showing all property lines, streets, building and
unusual natural or topographic features.
2. A properly completed application and a consent to inspect signed by the applicant.
If a Certificate of Occupancy is denied, the Building Inspector shall state the
reasons therefor in writing to the applicant.
C~. Fees
~ 1. Certificate of Occupancy - New dwelling $25.00, Additions to dwelling $25.00,
., Alterations to dwelling $25.00, Swimming pool $25.00, Accessory building $25.00,
Additions to accessory building $25.00. Businesses $50.00.
2. Certificate of Occupancy on Pre-existing Buildin~ - $100.00
3. Copy of Certificate of Occupancy - $20.00
4. Updated Certificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residential $15.00, Commercial ~15.00
Date ... ~...../.~. ~ ./.~.~ ...................
New Construction. M . Old Or Pre-existing Building ..........
'"' ..... iiiiii' ·
Location of Property...%.Cl,~....~.~..~.{ ....
House No. ~ Street Hamlet
Onwer or Owners of Property...~O~.~
County Tax Map No , ction ..... ~.~. ..... Block. .
?Icl '
Subdivision , ..
................ Filed Map ....... Lot ......................
Permit No ~0~.~.~o Date Of Permit
Applicant ·
Health Dept. Approval .............
............. Underwriters Approval . .. ..
Planning Board Approval .....
.
P. eq~est for: Temporary Certificate ........... Final Certicate ........
P S bait ted: $
THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
85 JOHN STREET. NEW YORK, NEW YORK 10038
[-- FE~3RUt~RY
THIS CERTIFIES THAT
o~y the elec~rlcal ~uipment ~ ~scrlbed below and intr~uced by t~ applicant ~med on the a~e ap~ication number in the prem~es of
H~YANN G[~T~'~, 395 TUTH~[~ ROAD~ SOUT3{OI~3,
in the followlng locari~,: ,,~ ~sement
~sexamlnedon r ~.31~.~Y O6 ~ 199b and found W be in compliance with the Na~.onal Elect~cal Code.
-- DRYERS [ FURNACE MOTORS I FUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIME CLOCKSI BELL IUNIT HEATERS MULTI-OUTLET DIMMERS
-- $ERVI~ DI~ONNECT ~. OF~1 S E R V [ C . E
~T ~P TYPE 3~3w 3~4w NOO~E~COND OF~C~ND NOOFHIt~G O~L~6 NOOFNEUTRAt5 ~U~AL
~THER APPARATUS:
SHED-~ ~
G & S CONTI~CTOR
BOX 215
SOUTHOLD, I'~', 119'71 ~$MSRA~ MANAGBR
Per_
'his certificate must not be altered in any manoer; return to the office of the Board if incorrect. Inspectors may be identified by their credentials.
COPY FOR BU%DING DEPARTMENT. THIS COPY OF CERTIFICATE MUST ~JOT BE ALTERED I. ANY MANNER.
APPEALS BOARD MEMBERS
Gerard P. Goehringer, Chairman
Serge Doyen, Jr.
James Dinizio, Jr.
Robert A. Villa
Richard C. Wilton
BOARD OF APPEALS
TOWN OF SOUTHOLD
Southold Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (516) 765-1823
Telephone (516) 765~1809
November 15, 1994
John Bertani Builder, Inc.
1380 Oakwood Drive
Southold, NY 11971
Re: Appl. No. 4274 - Mary Ann Grefe a/k/a Mary Ann Mastroianni
Dear John and Linde:
Please find enclosed a copy of the determination rendered by the
Board of Appeals at our November 2, 1994 Regular Meeting and filed
today with the Town Clerk's Office concerning the above applica-
tion.
A copy of this deternu'nation has also been furnished to the Southold
Town Buli~ling Department pertaining to your pending building permit
application request. However, it wi]] be necessary for you (or the
owner) to contact the Building Department (765-1802) to he sure your
application request is returned to their re-activation rack.
Also, due to the proximity of this project within 500 feet of a
waterway, State or County Road, we have transmitted copies of the
variance file to the Suffolk County Department of Planning for their
deterndnation as required under the County's Administrative Code.
Once that agency has finalized its review and forwarded its comments
to our office, we will transmit a copy of the same to you.
you have any questions, please feel free to call.
Very truly yours,
Linde Kowalski
lk
Enclosure
Copies of Decision to:
______-~B nilding Department
~Suffolk County Department of Planning
APPEALS BOARD MEMBERS
Gerard P. Goehringer, Chairman
Serge Doyen, Jr.
James Dinizio, Jr.
Robert A. Villa
Richard C. Wilton
BOARD OF APPEALS
TOWN OF SOUTHOLD
ACTION OF THE BOARD
Southold Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (516) 765-1823
Telephone (516) 765-1809
DATE OF ACTION: November 2~ 1994 APPL. #4274.
APPLICANT: MARY ANN GREFE (John Bertani Builder, as agent)
LOCATION OF PROPERTY: 395 Tuttkill Road
Southold, NY.
COUNTY TAX MAP DISTRICT 1000 SECTION 55 BLOCK 4 LOT 3.
BASIS OF APPEAL: Notice of Disapproval issued by the Buildiug Inspector
dated 9[13/94. "Accessory buildings shall be located in the required rear
yard."
PROVISIONS APPEALED FROM: Article III, Section 100-30A.4 (re[. 100-33)
RELIEF REQUESTED: 16'6" x 20' accessory storage (barn) building located
in the southerly side yard with a setback of at least three (3') feet from
the southerly side property line (along land referred to as Lot 26). The
shed is located near the pool and fence enclosure and will not protrude
into the front yard area, as more particularly shown on survey dated
3/28/88 submitted with the application.
MOTION MADE' BY: Serge J. Doyen, Jr., Member
SECONDED BY: James Dinizio, Jr., Member
ACTION/RESOLUTION ADOPTED: Granted side yard location of au 16'4" x
20' accessory barn building for sto{'age purl)oses~ as exists near pool area~
with a setback at three feet from the southerly property line as shown on
3/28/88 survey~ SUBJECT TO THE FOLLOWING CONDITIONS: (1) Be
used for accessory storage purposes incidental to the owner's residency in
the main building; (2) Only utilities shall be electric, as proposed.
REASONS/FINDINGS: House was built in 1970 with a 25 ft. rear yard
setback, which today is nonconforming. Size of property is also
nonconforming, aithough lot is known as Lot #25 on the Subdivision Map of
Yennecott Park. Rear yard area is very limited due to shape and character
of lot. These circumstances have existed for 24 years and lend to
difficulties in conforming with a rear yard location. No alternative is
available.
VOTE OF THE BOARD: Ayes: Serge J. Doyen, Member
James Dirdzio, Jr., Member
Richard A. Wilton, Member
Gerard P. Goehringer, Chairman-Member
Absent: Robert A. Villa (out-of-state).
OUNDATIO.U ( 1 s t)
OUNDATIO;~ ( 2nd )
OUGH FRAME &
FLUMBING
~:.~SULATION PER N. Y.
STATE ENERGY
CODE
FI ,AL
ADDITIONAL CONMENTS:
Town H&tl, 53095 M&in Road
P. O. Box 1179
Southold, New York 11971
Fax (516) 765-1823
Telephone (516) 765-1802
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
January 17, 1995
John Bertani Builder,
1380 Oakwood Drive
Southold, N.Y. 11971
Inc.
To Whom This May Concern:
We are unable to complete your Certificate of Occupancy
because of the following reasons:
An application for Certificate of Occupancy is
not on file. (Enclosed)
XX
No Underwriters Certificate on file.
The check is (outdated/not on file.)$25.00
No Health Department Approval on file.
No final inspection has been made.
No Plumber Solder Certificate on file.
(All permits involving plumbing being
issued after April 1, 1984).
BUILDING PERMIT # 22325-Z (GREFE- ACCY BARN)
Please contact our office on this matter. Thank you for
cooperation.
SOUTHOLD TOWN BUILDING DEPT.
FORE{ NO. 3,
TOI, IN OF SOUTNOLD
BUILDING DEPARTI~NT
SOUTHOLH,
NOTICE OF DISAPPROVAL
To
1994
OATE: . .S.e~.t.e.m.b.e& .1.3., ......... ... . .
SOUTliOLD, NEW YORK 11971
PLEASE TAKE NOTICE that your application dated AUGUST 22,
. ROUFIS
RV 1/80
is returned herewith and disapproved on the following grounds ...................... ... ... . .
STORAGE SH~D IS IN VIOLATION OF ARTICLE III SEC. 100-33 OF TOWN OF SOUTHOLD
CODE. ACCESSORIES SHALL BE LOCATED IN ~ REQUIRED REAR YARD.
ACTIOH REQUIREO RY ~H~ ZONING BOARU OF .A~.PEAL~.
~c~ FOR EXISTING ACCESSORY STORAGE SHED
for permit .......................... at
395 TUTHILL ROAD S~..I~..OLD ..I.~..W YO,.R~.
Location of Proper~y .................. · ...............
House No. Street Hamlet
County Tax Map No. 1000 - Section .... ~ ..... BLOCK ... ~ ...... LOT .2...~. ......
Subdivision ................... . . ........ .. Filed Map No. .........Lot No .... ....
FORM
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N.Y.
NOTICE OF DISAPPROV~iZ j
, . . Date .... 'J ?../..
~o .4¥.,.~~, ~/~//~~. ~'~/~: ................ ~
................... r ....... ~ ~' :~-~ ·
. ' .............. t .............. ]. · . r.,,~.~}. ~.. ~.'.~. at
County Tax Map No I000 Section ~.~. Block ' ~- ~
iS retu~ed herewith and disapproved on the following grounds ~ ~~f~
RV 1/80
i
VICTOR LESSARD
PRINCIPAL BUILDING INSPECTOR
(516) 765-1802
FAX (516) 765-1823
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
OFFICE OF BUILDING INSPECTOR
TOWN OF SOUTHOLD
December 4, 1989
Mary Ann Grefe
385 Tuthill Road
Southold, NY 11971
Re:
Swimming Pool & Storage Building
S.C.T.M. ~ 1000- 55- 04- 03
Building Permit 9 16063Z
Dear Ms. Grefe:
Please be advised that B.P. ~ 16036Z has expired and a
Certificate Of Occupancy was not issued for the building.
In addition, we can find no record of a building permit for
the swimming pool.
According to Article XXVIII, Chapter 100-281 and Chapter
100-284 of the Code of the Town of Southold, you must have a
building permit for construction of a swimming pool and a
Certificate of Occupancy before use.
In order to avoid legal action you must resolve the
violations immediately.
Thank you for your cooperation.
(Cert.)
Very truly yours,
Southold Town Bldg Dept
Vincent Wieczorek
Ordinance Inspector
BOARD OF HEALTH
3 SETS OF PLANS .~.,~.''.
'FoRm No, SURVEY :
TOWN OF SOUTHOLD CHECK
BUILDING DEPARTMENT SEPTIC FORM ............. :
TOWN HALL NOTIFY
$OUTHOLD, N.Y. 11971 CALL ..... i ~ 5~'- ..........
TEL.: 765-1802
MAIL TO:
Examined...~,W~. L~..., 19~.'/.
Approved . .~g'P~....I.~.., 19~?. Permit No. ]../.f.O..~..~..?-
Disapproved a/c .....................................
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
......... .7
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3
sets of plans, accurate plot plan to scale. Fee according to schedule.
b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets
or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli-
cation.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such permit
shall be kept on the premises available for inspection throughout the work.
e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy
shall have been granted by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described.
The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to
admit authorized inspectom on premises and in building for necessary inspections. / ~. , . ~
.. A c.o. . : .... ':..
(Signature/df applic~rtt, o$ name, ~'a corporation)
[Mailing address of applicant)
State whether applicant is_pwner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises . ¥.. ./~./~. · ·
he tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
(Name and title of corporate officer) ·
ALL CONTRACTOR'S MUST BE SUFFOLK COUNTY LICENSED
Builder's License N~: . ~".q":. · · ~ · · .~ -
Plumber's License No .........................
Electrician's License No .......................
Other Trade's License No ......................
1. Location of land on which proposed work will be done] .................................................
7'-- '
............. . ............... 77Z-/.cO.& ......................
House Number Street Hamlet
County Tax Map No. I000 Section '~$'~- Block .~. Lot --~
Subdivision ......... ?~'/,) .~.C ......... O7~..~. ~. .~..~ ............ Filed Map No. ......................... .5-[ .~.7- Lot o~
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ...~.T.-.-.-.~'~ ~.'~,-..'.~-~/~A~. T. .......................................
b. Intended use and occupancy . ~_,~.~.t~ ~_~.. d?.,..~.~)D/9.~...~.(.J..~...~..I.Tf~..~. ~.__.,. ~ .............
3. Nature of work (check which applicable): New Building ... ' ..... Addition ·. · i ...... Alteration ..........
Repair . ~ ............ Removal .............. Demolition ............ i · Other Work ...............
.~..~. ~ . .t~2' ' i (Description)
4. Estimated Cost ............................. Fee .....................................
(to be p~id on filing this application)
5. If dwelling, number of dwelling units ............... Number of dwelling units ion each floor ................
If garage, number of cars
6. If business, commercial or mixed occupancy, specify nature and extent of each typel of use .....................
7. Dimensions of existing structures, if any: Front ............... Rear ........ ...... Depth ...............
Height Number of Stories ' ' '~' ......
Dimensionsof same structure with alterations or additions: Fro)ut /: ~ .. ~ear ....~.~.. ~ .........
·
Depth ...... ,; ............... Height ... ~,~ ......... Number o, rios ........ ) .......
8. Dimensions of entire new construction: Front · ')/,'r · . Rear .... /.6...
2- '
Height Number of Stories
9. Size of lot: Front ...................... Rear ...................... Diepth ......................
:10. Date of Purchase .......................... .~.ameo~Fo,~.f.,O.w,~¢o Former.Ow er i ..........................
1 1. Zone or use district in which premises are situated. ,..%.t'.~.. ~. [... .......................
12. Does proposed construction violate any zoning law, ordinance or regulation: ./~/.19.
13. Will lot be regraded ....... ,,., ..... a .... ,* ......... Willex_cessfillberemmtedfrompremises:_b ~Ye~s No
14. Name of Owner of premises lr//;.~.Y?g/~ .(.y~F~.~...._. Address . ~ .~-~..~..~/.~.'~..e_~;,.. Phone No. ?.~.'~.. ~.~.,~...~..
Name of Architect .................... ....... Address ................ [.. Phone No ................
Name of Contractor .......................... Address .... : ........... i.. Phone No. k~e ............
15. Is this property located within 300 feet of a tidal wetland? *YesI ..... No ..~...
· If yes, Southold Town Trustees Permit may_ be required.
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existir
*roperty lines. Give street and block number or descri!c
nterior or corner lot.
;TATE OF NEW YORK,
,'OUNTY OF ............ S.S
and. indibate all set-back dimensions from
and show ~tmet names and indic,ate whether
., ................................................ being duly sworn, deposds and says that he is the applicant
(Name of individual signing contract)
hove named.
te is the .
(Contractor agent corporate officer otc )
,f said owner or owners, and is duly authorized to perform or have performed the said work and to make and: file tkis
pplication; that all statements ¢ontained~ in this application are true to the best of his knowledge and belief;and that the
~ork will be perforined in the manner set forth in the application filed therewith.
~worn to before me this.
.............. /..~. ...... day of......~ r,*4~ ......... , 19 ~.?
lotaryPublic, ........ ~,g~N~...~.-..~)/-~/.~.....County," ~ ,: /, ~
.....
.............
~ ~,tlO. ~, ¢~'.Y~ ( / // (Signature of applicant)
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTtlOLD, N.Y. 11971
TEL.: 765-1802
Examined ................ , 19...
Approved .......... ~ ......19... Permit No ............
BOARD OF HEAL. TIt ........
'1 SETS OF PLANS ........
SURVEY .................
ClIECK .....
sEpTet';oR:, -
CALL
(Building Inspector)
APPLICATION FOR BUILDING'PERMIT
INSTRUCTIONS
a. Tkis application must be completely filled in by typewriter or in ink and submitted to the Building inspector, with,
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 sti'eet
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 penni
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 Occupanc5
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 anc~ in building for necessary in.~5~ections.
-- (Signatur9 of applicant, or name, if a corporation)
.... . ...... .
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, generai 'contractor, electrician, plumber or builder.
Name of owner of premises ........
(as o e a 1 orlatest deed)
If ap~ is a corporati~B~, signature of,duly authorized officer.'
· (Name and title of corporate officer)
PI b ' L' N "
um er S lcense 0 ......................... :
Electrician's License No. . ......
Other Trade's License No. ~
1. Location of land on which proposed work will be done ................................. ; ................
House Number Street Hamlet
County Tax Map No. lOOOSection ~...'..~i( ........ Block ..... .¢. .... i.j... Lot ..... ~ ............
St,bdivision..~C~.~. ~ ...... '. Filed Map No. ~. Lot ~
(~ame~ ....... ' ......................
/
2. State existing use and occupancy of premises and intended use and occupancy of proppsed construction:
a. Existing Use and occupancy ............ ~.. . .... ~ . . ',.
b. Intended use and occupancy c~ %~h% ~ O C
· 3. Nature of work (check which;applicableS. New Building . ~ '
~ " ........ Addition .......... Alteration , ,, 0,0 ,,
Repair .............. RemovaI . r~ ...... -
· ' ............ ~"anonnon .... ; ......... Other Work .... ,,,,,
4. Estimated Cost c~'~f-drg (Description)
i ........................ Fee ....................................
, (to be paid on filing this application)
5. If dwelling, number o f dwellitig units .............. Number of dwe its on each floor ...............
· If garage, number of cars ...l.. . .. lli~gun
6. If business, commercial or m ed occu,nncv ~nr.r'irw · ' ' ' .......
· 'ex u'res .-----~, -.- .... j nature and extent of each type of use ....
7. Dnnensionso! istingstruct ,if any: Front .... ' .......
Height ............ ~u,moer of Stories ......~ .......... ' .......... ' pth ..............
· . ~,,:_, : .......... Rear .... De
Dimensions of shine structure vith altera on or addition Front .....
Depth ~ ' ,, ~ ................. Rear ...........
8. '"' ' ................ ~ · · . lncight . . . ~. ,~ ',; ....... '. · NumberofStories ........... i~...
wm'mnsions of entire new construction: Front / .9' Rear . ./1~.' ~ ~' . . . Depth . fl..oq..~.. '
Height ............... Number of Stories ... ...... c:~ .... ' ..... ·
9. Size oflot: Front ......... ,i ........ k . Rear.. ' .... ; .... ~,'''.' ..................
10. Dateofmurchase ... ' ................. ,eptn ........... '.ii
11. me of Fenner Owner ................ ..
Zone or use dmtrict in which premises are situated ..... .
· lng I ; " " ...........................................
12 Does proposed Construction violate any zen aw, rdmance or regulation: ..............
I,~ Will lot be regraded ...... ;i .................. Will excess fill be removed from premises: Yes Nc
fp ,
· NaJne of Owner o remises , .: .................. Address ................... Phone No ............ ~...
Name of Architect ......... ! ........ ' Address .... Phone No.
Name of Contractor : .... ' ......................... . ....
· ' ....... ]3~3'0 ............ Address ................... Phone No .............
15. Y.s this property within feet of a tidal wetland? *Yes ........ No ..... '"
· If yes, Southold ,Town Trustees Permit may be required ~ ''
'·'. i PLOT DIAGRAM
Locate clearly and distinctly ali buildings, '~heth&r 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
inter/or or corner lot.
iTATE OF NEWtS~RK, ff .~ .
........ ~ t' ~'~" ..... being duly sworn, deposes and says that he is the applicant
tl'~ame el individual signing contract)
bore named. . · ,
said owner or owners, and is duly hutl{orized to perform or have performed the said work and to make and file this
~plication; that all statements contain~ed in this application are true to the best of his knowledge and belief; and that the
ork will be performed in tile manner s~t forth in tile application filed therewith.
.'.'om to,before me this
............. ~ .... '...day of'>
Notary Public, State 6f ~.
NO. 5?8125850; Suffol
T~r~?,, ~qfir~a Octob~ri3'
County ,o '
',aw York ........ / ..... r,--. ~,. ~;--.,~ ~,,~ ~.~. ..............
¢ Cou.~ty
,19.~,-. (Signature of applicant)