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FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEP~RTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No Z-19199 Date JULY 9~ 1990 THIS CERTIFIES that the building Location of Property CENTP~kLAVENUE House No. County Tax Map No. 1000 Section 10 subdivision ADDITION FISHERS ISLAND~ N.Y. Street Hamlet Block I Lot 8.1 Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated MAY 11, 1987 pursuant to which Building Permit No. 16083-Z dated JUNE 16~ 1987 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 ADDITION TO EXISTING BUILDING AS APPLIED FOR. The certificate is issued to (owner) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROMAL UNDERWRITERS CERTIFICATE NO. PLUMBERS CERTIFICATION DATED GOOSE ISLAND CORP. N-136549 - JUNE 19~ 1990 N/A -- B~ild~ng ~n~p~c~or Rev. 1/81 FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No Z-19200 Date July 9, 1990 THIS CERTIFIES that the building Location of Property CEN~ A~ENUE House No. County T~x Map No. 1000 Section 10 Subdivision ACCESSORY FISHERS ISLAND, NEW YORK Street Hamlet Block 1 Lot 8.1 Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated MAY 11r 1987 pursuant to which Building Permit No. 16083-Z dated JUNE 16r 1987 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 CO~EHED LOADING RAMP AS APPLIED FOR. The certificate is issued to (owner) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HF~kLTH APPROVAL W/A U~DER~RITERS CERTIFICATE NO. N~ PLUMBERS CERTIFICATION DATED N/A GOOSE ISkkND CORP. Building InspectOr' ~ Rev. 1/81 FORM NO. 4 TOWN OF SOL'HOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No Z-19201 Date JULY 9, 1990 THIS CERTIFIES that the building. Location of Property CENTRAL AVENUE House No. County Tax Map No. 1000 Section 10 Subdivision ACCESSORY FISHERS ISLAND, N.Y. Street Hamlet Block 1 Filed Map No. Lot 8.1 Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated MAY 11~ 1987 pursuant to which Building Permit No. 16083-Z dated JUNE 16~ 1987 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 ACCESSORY OFFICE BUILDING BY DOCK AS APPLIED FOR. The certificate is issued to (owner) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL UNDERWRITERS CERTIFICATE NO. PLI~4BERS CERTIFICATION DATED GOOSE ISLAND CORP. N-136549-JUNE 19, i990 N/A '~uil~ing'I~sp&ctor' ~ Rev. 1/81 FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hail Southold, N.Y. CERTIFICAR]Z OF OCCUPANCY No Z-19202 Date JULY 9, 1990 THIS CERTIFIES that the buildin~ Location of Property CENTRAL AVENUE House No. County Tax Map No. 1000 Section 10 subdivision ADDITION FISHERS ISLAND~ NEW YORK Street Hamlet Block 1 Lot 8.1 Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated MAY 11, 1987 Building Permit No. 16083-Z dated JlRxrE 16, 1987 pursugnt to which 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 ADDITION TO EXISTING FISH MARKET AS APPLIED FOR. The certificate is issued %o (owner) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HF~kLTH APPROVAL UNDERWRITERS CERTIFICATE NO. PLUMBERS CERTIFICATION DATED GOOSE ISLAND CORP. N-136549 - JUNE 19~ 1990 N/A ' -~uild~ng Inspe~ Rev. 1/81 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDIHG PERJ~IT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N~ Permission is hereby granted to: .... ..'~..*..~...~.~ ..................................................... .~~...~.....~.,~.,.....~..~.~.,~.~ ,o.~...~t~ ......... ~..~...~.., ....................... ~ ............. ~'~.~...:,..,~J..~....'k..,._...'k,.....~...'.;.k...~ ....................................................... ~ ...0~ at premises located at ......... ~...~......~.:.......~..~...~ ........................... Coumv Tax Map No. I000 Section ......~..,~.~. .......... ~ock~.l.: ................ Lot No.....:~..a. ............. to application dated ..... ~..(~...~.~. ........................ , 19.~.~.., and approved by the pursuant Building Inspector. Fee $..,~.***.~....~.. ~. Building Inspector Rev. 6/30/80 Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY 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 limes, 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 less than 2/10 of 1% lead. r 5. Commercial building, indUs.trial 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. 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 amd 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, Swin~ning pool $25.00, Accessory building $25.00, Additions to accessory building $25.00. Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Building - $100.00 3. Copy of Certificate of Occupancy - $5.00 over 5 years - $10.00 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certifi~Bte of Occupancy - Residential $15.00, Commercial $15.00 ~ Date .... .~./~..~.~..~...~. .................. New Construction .......... Old Or Pre-existing Building ..... Location of Property.iHouse ...... No.~''~'''~''Street ..... iiiiiiiii'.~.~ ............. 0nwer or Owners of Property ...... - ...... %ounty Tax Map No 1000, Section...~. ....... Block .... ~ .......... Lot''~.+'''J''''' ..... ~ubdi~ision .................................... Filed Map ............ Lot ...................... ~ermit No../.~.~.~.~..DateAI ~Of Permit.~.~f~..~..mpplicant.~~~..~. {ealth Dept. Approval...Y.¥~./~. ................ Underwriters~Ap~roval~ ...... :..~ .......... ~lanning Board mpproval~..~f~...~ ~ ~--~ ~ ~equest ~for: Temporary Certificate ........... Final Certicate....~...... Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY 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 lines, 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 less than 2/10 of 1% lead. c 5. Coramercial 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. 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 o£ 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 Building - $100.00 3. Copy of Certificate of Occupancy - $5.00 over 5 years - $10.00 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 at: ....... ........... .......... ' ....... . .... ~ ...... ~''~'L~ .................. House No./~ ~f ~ ~ ~ ~Stre~ Hamlet Onwer or Owners of Property .... ~..~.......~..~.' ............... County Tax Map No 1000, Section ...... f.~. .... Block ......... [ ...... Lot ...... .~.t../. ....... Subdivision ................................. Filed Map ............ Lot ...................... Permit No..~..~ ~o ~.'-~ ~-..Date 0f Permit ~//t.~./~. ~..Applicant~, ~. ~.. 'lanning Board Approval..~...~.~..~.....~.~... ~"'~ - ............................................... Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY 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 lines, streets, and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal(S-9 fo~m). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead. c 5. Commercial building, induRtrial 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. 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 o£ 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 Building - $100.00 3. Copy of Certificate of Occupancy - $5.00 over 5 years - $i0.00 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 / Date ....... .~.../.~..~... / .~..~.. ............ New Construct' n . Old Or PreTexisj~ing Building. House No. Street Hamlet Onwer or Owners of Property ....... County Tax Map No 1000, Section../.~. ........ Block ...... /. ........ Lot...~..,..~. ........... ~ubdivision Filed Map Lot ?ermit No./~Z~. Z..Date Of Permit~.~. ~./~. '7'' .Applican~.~-~. ~~..~'~ {ealth Dept. mpproval...~..: .............. Underwriters mpproval./V./..~..~.~.~..~..... 'lanning Board Approva . . request for: Temporary Certificate ........... Final Certicate .... FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Hall Southold, N.Y. 11971 765 - 1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted m"'---'--' to the Building Inspec- tor with the following; for new buildings or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topographic features. 2. Final approval of 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, For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of p~operty 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 New Dwelling $25.Q0, 'Accessory ,,$10.00 Business $50.00 2. Certificate of occupancy on pre-existing dwelling $ 50.00 3. Copy of certificate of occupancy $ 5,00, over 5 years $I0.00 4.Vacant Land C.O. $ 20.00 5.Updated C.O. $ 50.00 Date ...~,-I...'~.d.~,~.~.~.2 ......... NewConstruction ...... Old or Pre-existing Building ............ Vacant Land ............. Location of Property .~'¢ .~. House No. Street ~lamlet Owner or Owners of Property , County Tax Map No, 1000 Section Subdivision ................................. Filed Map No ........... Lot No .............. Permit No. Date of Permit Applicant . ~' ~f~ Health Dept. Approval ........................ Labor Dept. Approval ........................ Underwriters Approval ........................ Planning Board Approval ...................... Request for Temporary Certificate ..................... Final Certificate ....................... Fee Submitted $ ............................. Construction on above described buildin~--arrd~ermi:t r~eets all applicable codes and regulations. ADD can ~ Rev. 10-10-78 ~ '' Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This appiication'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 ail buildings, property lines, streets, and unusual natural or topographic features. 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 less than 2/10 of 1% lead. : 5. Commercial building, indus~trial building, multiple residences mhd similar buildings and instaliations, a certificate of Code Compliance from~architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. 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 o£ 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 Building - $100.00 3. Copy of Certificate of Occupancy - $5.00 over 5 years - $10.00 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 ; j Date .~./~....~../.~....~. New Construction...~. ...... Old Or Pre-existing Building ....... House No.~__~Street '~' Hamlet 0nwer or Owners of Property .... ~~...__. .~ .................. ou.y No .00, ....... ...... Subdivision ...................................· Filed Map ............ Lot .................... .. ~erm±t No.~ ~.~.~.Z..Date,,lOf Permit ~./~/l..~...Applicant.~~.~~..~. tealth Dept. Approval .... /.y,.~. ............... Underwriters Approval ........................ ~lanning Boar d mpp roval..~,..~ ~../~./~. ,equest for: .Temp°rary Certificate ........... Final Certicate...~.. ..... THE NEW YORK BOARD OF FIRE UNDERWRITERS ),0()00 ]. 3 BUREAU OF ELECTRICITY O~te ~pplicatio. No. onfile 6q214790/90 '~ 136%&:) T~IS CERTIFtE~ THAT DRYERS MOTORS FEEOERS TtME CLOCI(S MULTI-OUTLET DIMMERS SERVICE DISCONNECT S E R V I C OTHER APPARATUS: olecl:ci,cal ~qtdp~ent in ~he I; [S['I~,R$ 'f SL.XlI~D ,, ~¥, NO OF CC COND PER ~' AWG, OF CC COND, NO. OF HI-LEG E This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by their credentlals. COPY FOR BU LDING DEPARTMENT, THIS COPY OF CERTIFICATE MUST NOT BE HENRY P. SMITH, Presiden( JOHN M. BREDEMEYER, Vice-Pres. PHILLIP J, GOUBEAUD ALBERT KRUPSKI, JR, ELLEN M. LARSEN BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 TELEPHONE (516) 765-!.892 May 19, 1987 Mr. Robert A. Greene Alternate Regional Permit Administrator New York State Dept. of Environmental Conservation Bldg. 40, SUNY - Room 219 Stony Brook, New York 11794 Dear Mr. Greene: Transmitted'herewith is Wetland Application No. 542 submitted by Reynolds duPont, Jr., President, Goose Island Corporation. We would like to coordinate with you in our role as Lead Agency regarding this application. May we have your comments on same by June 8, 1987. HPS:ip Attachments Very truly yours, Henry P. Smith, President Board of Town Trustees cc: Commissioner Henry G. Williams, D.E.C., Albany Southold Town Building Dept. BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 TELEPHONE (516) 765-1892 APPLICATION IS HEREBY MADE TO THE TOWN TRUSTEES OF THE TOWN OF SOUTHOLD, SUFFOLK COUNTY, NEW YORK FOR THE ISSUANCE OF A PERMIT PURSUANT TO THE LAWS, ORDINANCES AND REGULATIONS GOVERNING THE COASTAL AND INTERIOR WETLANDS, FLOOD PLAINS AND DRAINAGE AREAS OF THE TOWN OF SOUTNOLD, AND THE ISSUANCE OF PERMITS PURSUANT APPLICATION NOo___~ DATE OF APPLICATION TAX MAP NO. C~O . (.~ ~ ° ~ (~1~__, ~ J LOCAT ION OF PROPERTY FOR WHICH PERMIT WANTED HOME ADDRESS OF PERMI T APPLICANT IF O [ FFERENT CREEK, PHONE NO · FROM AFORESAID LOCATION BAY OR HARBOR FRONTING PROPERTY HEIGHT ABOVE HIGH WATER YARDS TO BE EXCAVATED ~ yARDS TO BE FILLED UA WIDTH OF GANALi CREEK OR BAY FRONTING PROPERTy A//t DISTANCE TO TN~ NEAREST CMANNEL__~ ...... FT. DISTANCE PROJECT EXTENDS BEYOND SIMILAR PROJECTS IS THIS FOR PRIVATE OR BUSINESS USE? ,~ AREA MANNER IN WHIC~ MATERIAL WILL BE REMOVED OR DEPOSITED 'T IN THE AREA INTENDED USE OF PROPERTY DESCRIBE ANY KNOWN PRIOR OPERATIONS CONDUCTED ON THE PREMISE AND WHETHER AN~ PRIOR LICENSE OR PERMITS HAVE BEEN ISSUED TO ERRECT STRUCTURES OR TO DREDGE OR DEPOSIT FILL ON SAID PREMISES AND WHETHER ANY PERMITS ORJ LICENSES WERE EVER SUSPENDED OR REVOKED BY A GOVERNMENTAl DESCRIBE FULLYi THE REHABILITATION AND PROPOSED CONDITION OF THE PREMISES AFTER:THE WORK IS COMPLETED INCLUDE AN ADDITIONAL SURVEy OF THE PROJECT ~I~E IF NECESSARY_JV__~. WRITTEN CONSEN~ OF THE OWNER OF 'THE PROPERTY, I F NOT THE SAME AS THE APP ARE THERE ANY PROHIBIT THIS :OVENANTS OR RESTRICTIONS IN YOUR DEED THAT WOULD PROJECT? ~O BOARD OF TOWM TRUSTEES -' - TOWN OF SOUTHOLD SHORT ENV~RON~AEMTAl AS~ESS~SNT FORM proiect {nformatton (To be completed by Applicant or Project L, Jc~T ut~-~:rt. ~ FtsHe~.s Z~Lae,,l) 7. Amount of la~d affected. Inmar]¥ ~izt acres Ultimately ~//q acres ~ WIll oposed actton comply w~th exl5tmg zonmg or other existtag [aHd u~e restrtcbons~ ~ Residential ~ Industrial ~ommerclal ~ Agriculture ~ Parkland/open space ~ Other c~. /5'144% ~ PART II Environmental ~ssessment (To be completed by Agency) A. Does act on exceed any Type threshold in 6 NYCRR, Part 617,12~ if yes, coordinate the rew~w process and use the FULL/LONG FORM EAF. [] Yes [~] No O, Will acuon recewe coordinated review as provided for Unlisted Actions in 6 NYCRR, Part 617.7t If No, a negative declaratmn may be superceded by anot C. Could action esul n .*,NY adverse e facts on. to. or arising from the following: [Answers may be handwritten, if legible) drainage or flooding pr~blemsf Explain briefly: C3, Vegetanon or fauna, movement of fish or w~ldrife species, significant habitats, or threatened ot endangered speciesf Explain briefly: C4. A commumty's existing plans or goads as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain brmfly. C5. Growth, subsequent dev~elopmen, or related activities likely to be induced by the proposed action~ Explain briefly. Ct. A change in use of e~ther quann y or type of energy? Exp ain briefly PART Determination pf Sign f cance (To be completed by Agency] INSTRUCTIONS: For ~ach adverse effect identified above, determine whether it is substantial, large, important or otherwis significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurrin[ (c) durauon; (d) lrreverslb hty; (e} geograph c s~ope; and (f) magnitude. If necessary, add attachments or reference supportin materials. Ensure that explanations contain sufficient detail to show that all relevant 3dverse impacts have been identifie~ and adequately addressed, [] Check this box if y~u have identified one or more potentially large or significant adverse impacts which MAY occur. The, proceed directly to~ the FULL/LONG FORM EAF and/or prepare a positive declaration. [] Check tbis box if y~u have determined, based on the information and analysis above and any supporting documentatior that fhe proposed action WILL NOT resuJt in any significant adverse environmental impacts AND provide here, and o~ a~tachments as nec ~ssary, the reasons supportng this determination: COUNTY OF SUFFOLK ) STATE OF NEW YORK )SS: AND SAyS THAT HE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS, AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS KNOWLEDGE AND BELIEF, THAT THE WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE TOWN BOARD OF THE TOWN OF SOUTHOLD. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT, IF GRANTED, Zn completing this application I hereby authorize the Trustees. agent or representative to enter onto my property to inspect the premises in conjunction with review of th~is,~p~licat~n: I hA URE OF AP [IYANT NOTARY pUBLIC EXAMINED APPROVED "WETLANDS" PERMIT (CHAPTER 97) APPROVED "BOAT,DOCKS, WHARVES" PERMIT (CHAPTER 32) DISAPPROVED "~ETLANOS PERMIT" (CHAPTER 97) DISAPPROVED "BOATS,DOCKS, WHARVES" PERMIT (CHAPTER 32) CONDITIONS, IF ANY EXAMINING BODY SIGNATURE OF EHAIRMAN COMPUTATION OF FEES :\vvroved 2/27/85 hew¥or~ $1ale Depa~menl Of£n¥ironmental Conse~atJon R~gulatory Affairs Unit Bldg. &0, SUA~, Pa. 2!9 S:onv Brook, N. y. 11794 (516) 75i-7900 Goose Island Corp. P.OoBox 365 Fishers Island,NY ~6390 Attn: Reynolds duPont dr.,President Dear Mr. duPont: December 8, 1986 In conformance with the requiremanns of the State Uniform Procedures Act (Article 70, ECL) and its implementing Regulations (6A~CRR, Part 621) we are enclosing your permit. Please read all conditions carefully. If you are unable to comply with any condinions, please contact us at the above address. Also enclosed is a peri--it sign which is lo be conspicuously posted at the project size and protected from the Weather. Very truly yours, DeDuty Regional Permit 10-86-1624 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION PERMIT Under the Environmental Conservation Law 12/8/86 EXPIRATION DATE(s) 12/31/88 j Arhcie 15, Title 3; 6N¥CRR 327, 328, 329: Aquatic Pesticides Article 15, Title 5: Protection of Water _~ Article 15, Title 15: Water Supply I Article 15, Title 15: _~ Water Transpor~ j--J Article 15, Title 15: J Lgng Island Wells J Article 15, Title 27: ,__ Wild, Scenic and Recreational Rivers J~---J Article 24: Freshwater Wetlands N--New, R--Renewal, M--Modification. C--Construct (*only), O--Operate (*only) 6NYCRR 608: Water Quality Certification Article 17, Titles 7, 8: SPDES Article 19: Air Pollution Control* Article 23, Title 27: Mined Land Reclamation Article 25: · Tidal Wetlands N Article 27, Title 7; 6NYCBR 300: · Solid Waste Management* Article 27. Title 9; 6NYCRR 373: Hazardous Waste Management Article 34: Coastal Erosion Management Article 36: Floodplain Management Articles 1, 3, 17, 19, 27, 37; 6NYCRR 380: Radiation Control Goose Island Corp., Attn. Reynolds duPont Jr., President P.O.Box 365, Fishers Island, NY 06390 N/A zc~x~x~;s~x~ma~yax~xm~x~x~m~ LOCATION OF PROJECT: West Harbor south of Central Fishers Island Suffolk Southold Construct replacement pile and timber pier and install 6 mooring p~lam. A~] shall be in accordance with NYSDEC approved plans (attached), GENERAL CONDITIONS By acceplance of this permit, lhe permittee agrees that the permit is centlnsent u~on strict compli- ance with Ihe ECL, all applicable regulations and the conditions specilled herein or attached hereto. J'~ ~'li lSSUANL~ DATL PI R~IT A~INIS~RATOR j aog~ess Bldg. 40, S~, Rm. 219 J 12/8/86 Alfred T. Kellar I Stony Brook, ~ 11794 3 Page] *t, m the opinion of the Department of Enwronmenta[ Conservation 14 waters or flood flows or e~dan§er the health, safety or we[fare of modd~cahon of the watercourse hereby authorized shall not be corn- That the State of New York shall in no case be hable for any damage Any material dredged In the prosecution of the work herein permitted shall be removed evenly, without leawng large refuse p~les, ridges across the bed of a waterway or floodplain or deep ho[es that may have a tendency to cause damage to nawgable channels or to the bank~ of There shall be no unreasonable ~nterference w~th nawgat~on by the wo~'k herein authorized If upon the expiration or revocation of th~s permit, the proJect hereby authorized has not been completed, the appbcant shall, w~thout expense any porhon of the uncompleted structure or fdl and restore the s~te to Ks former condition. No cla*m shall be made against the State of I[ granted under Article 56. th~s permit does not s~gndy m any way that the project will be free from flooding If granted under 6 NYCRR Part 608, the NYS Department of Enwron- mental Co,servation hereby cert~hes that the subject prolect w.l[ not Sections 301, 302, 303, 306 and 307 of the Clean Water Act of 1977 (PL 95~217} prowded that all of the conditions hsted hereto are met, w~th the approved plans submitted by the applicant or h~s agent as part of the permit appbcat~on. Such approved plans were prepared by SPECIAL CONDITIONS 1. Existing capstones along 73' of revetment directiy seaward of Mobil Station to be relocated to the toe of existing seawall. 2. Place 10-50 lb. stones in voids between existing cement seawall and rock revetment for entire distance of seawall. Supplementary Special Conditions (A) through (J) attached. Page 2 of :3 New York State Department of Environmental Conservation NOTICE The Department of Environmental Conservation (DEC) has issued permit(s) pu-rsuant to the Environmental Conservation Law for work being conducted on this site. For further informa- tion regarding the nature and extent of work approved and any Departmental conditions on it, contact the Regional Permit Administrator listed below. Please refer to the permit number shown when contacting the DEC. Regional Permit Administrator NOTE: This notice is not a permit NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION UNIFORM PROCEDURES ACT 467694 ,~ck 4 Mone~Or~er E] Memorandum from... · BUILDING INSPECTOR'S OFFICE TOWN OF $OUTHOLD TOWN HALL, $OUTHOLD, N. Y. 11971 765-1802 May 14, 1987 I)ear Mr. Le Boeuf: ] am returning your applications~ please have them notarized where you signed on the back of the application. I am returning your check #0269 please send a check for $300. Thank you. Also list any contractors license num- ber who will be working on the job. Yours truly, Secretary July 17, 1987 BLDG. DEPT. TOWN OF SOUTHOLD Town of Southhold Office of Building Inspector Attn; Mr Victor Lessard Town Hall P.O. Box 1179 Southold. NY 11971 Dear Mr Lessard, Enclosed are the two building permits you issued us, all work has been completed. As per our conversation on July 17, 1987 we are opening the resturant,~ as you have given us a verbal temporary CO. Would you please follow up with a written temporary CO, so we could have it for our records. Our Board of Directors have met with the Planning Board today and the agreed with you that we procede with a site plan. We are doing a site plan and enclosed is a preliminary site plan done for this meeting, we will procede as rapidly as possible to get the site plan approved. We noticed on our permit for our Deck, that page 2 was missing, so enclosed is page two of our application which must have been misplaced. We thank you very~much for all the time and consideration you have given us in this project. Sincerely yours Paul Vartanian Vice-President Goose Island ¢orp /~z b T OUNDATIO~! ( 1 st I OUNDATION (2nd) OUGH FRAME & FLUMBING ~NSULATION PER N. STATE ENERGY CODE FI ,AL . ADDITIO~;A'L COMMENTS: ~ FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL · ?,°OUTHOLD, N.Y. 11971 . TEL.: 765-1802 Approved..-~d4441k.. t.~.., 19~..'/. Permit No./..~..0..~.~..~.. Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT BLDG. TOWI~ OF SOUTHOLD Received ........... ,19... Date ,eq...~.¥.., i! ........ 19 ~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 bnildings 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 ~ 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. ·..G..o.o..s.~..., .%..s. )~.~. 8..., .c:o. ?.p. .............. (Signature of applicant, or name, if a corporation) . ,(D..Q,, .~. ~). g.,, c.(q ........................... State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. : ......................................................................... Name of owner of premises . .~..O.~.S. ~... ~.~..~. ! .O?..C(... , .(.~. ?..~... ........................................ (as on the tax roll or latest deed) If applicant is a corl201ration, sigooture of duly authorized officer. (Name and ~tle of corporate officer) Builder's License No..].3...Z~.} ~-. 7..~.~. ......... Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... 1. Location of land on which proposed work will be done .................................................. ............................... C.e..M:.~. (.. ~v.~. .............. ./5'.~c..~....~..~h.~.c/ ............. House Number Street Hamlet County Tax Map No. I000 Section c.3 I O Block ]. d)O Lot. Subdivision ................ (iq'a~'~ ~) ................ Filed Map No:,,,: .'-"T.~ ." .~..., . ~,¢· ..... Lot ............... 2. State existing use and OCCupancy of pre;nises and intended use and occupancy 9}'yfopoked construction: a. Existing use and occupancy . . .¢.t?..c4! ( . . ..~.? . .S.~.~O.~ ........... :. :'... t'. ...................... b. Intended use and occupancy ........................................ ... 2 ........................ 3. 'Nature of work (check which applicable): New Building ..... ' .... Addition........,.~ Alteration .......... Repair .............. RemoVal .............. Demolition .............. Other Work ............... (Description) 4 Estimated Cost ~ I~p. 0- 6 .~ Fee (to be paid on filing this application) 5. If dwelling, number of dwelling u'nits ............... Number of dwelling units on each floor ................ If garage, number of cars ..... i .................................................................. 6. If business, commercial or mixedi'occupancy, specify nature and extent of each type of use ................... 7 Dimensions of existing structured, if any: Front .3..6.~ Rear ~ (q..~ Depth /.(~ Height ........ /fq.I..g... Number of Stories .... ~ ................................. Dimensions of same structure with alterations or additions: Front . Cl 6 t Rear ~.b. t Depth 14,~ Height ~. ~ ~ Number of Stories 8. Dimensions of entire new constm, etlon: Front ............... Rear ............... Depth ............... Height ............... Number of Stories ........................................................ 9. Size oflot: Front ..&&.o.,~...' ........... Rear..~,(~.~g, .............. ~epth ,t~a! . 10. Date of Purchase .I.~..%0.¢. ~..~. ,. . Name of Former Owner J5.9.~..-t. i 11. Zone or use district in which prem}ses are situated ..................................................... 12. Does proposed construction viol~,te any zoning law, ordinance or regulation: ,. ~.P ..................... 13. Will lot be regraded ...... ~. O ................ Will excess fill be removed from premises: Yes ' ' 14. Name of Owner of premises .~O,'qq~...~..s. c~ ~.d. c'.Or~.. Address .~p.¢..~. g..../7-2/7 ...... Phone No.~. x7. 6>4r.-.7¢".~.4~. . Name of Architect '. ................ Address ................... Phone No ................ Name of Contractor .... ~ ................. Address ................... Phone No. 15. Is this property located within 1100 feet of a tidal wetland? * Yes ..... No ..... · If yes, Southold Town Trustees Permit may be required. PLOT DIAGRAM Locate clearly and distinctly ali buildings, whether existing or proposed, and~indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW~~:(3~IC~ s t S S CO][JNTY OF...~. '_-vt i' · ~..~ ~ ' (Name of individual si~ning contract) above named. I ~i ~ * (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 cohtalned in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this I ....... ' ..... ...... day::of.. .......... FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL ~OUTHOLD, N.Y. 11971 TEL.: 765-1803 U×amined....~.Z4,~V~.I. ~.., 195.7 Approved · ,~.,¢e*~. l.(&., 19~.~. Permit No./ Disapproved a/e ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT ~eceived ........... ,19... Date ~..~.Y...).1. ......... 19 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 issnance 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 inspectors on premises and in building for necessary inspections. ...G. 9.o. ?...~.~./a .~....qo[~.P. ................. (Signature of applicant, or name, if a corporation) ....¢. p....a..~.¢.... 5fi. ........................ .... (ma±ling address of applicant) State whether applicant is owner, lessee, agent, architect, en~neer, general contractor, electrician, plumber or builder. Nameofownerofpremises . ..~.~9.~.~....~.&.Lat.a,~.. ('O.0.~... ........................................ (as on the tax roll or latest deed) If ap21icant is a corp~f~atio~n, signattkre of duly,a,u, thorized officer. i ........ I' (Name and t;ltle of corporate officer) Builder's License No..J.~ .: ~.~.~. :.1.4..~. ......... Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... I. Location of land on which proposed work will be done .................................................. ............... ~ r~ 4. ~.~. ! ...... .~. . .e. ....................... F.,.~. be~.~. . .~ l.o.~, c,/ ............. House Num bet Street Hamlet County Tax Map No. I000 Section ..... ~).l {). ....... Block .,:~..~:.~.~'i .3 ......... Lot. <~-.O. ~.. Subdivision ................... File~Map No.,; Lot ............... (h'a;~) ! ' ' " ............ 2. State existing use and occupancy of premises and intended use a~d occ~pa~ncy' of l~roposed construction: a. Existing use and occupancy ...~..~.~L.%~ ..... ~L~5. .~ ~-z .~.ta k b. Intended use and occupancy ..... . ............................................................... 3. Nature of work (check which applicable): New Building ~'~ Addition Alteration Repair Remo~,al Demolition Other Work ~ ~ (Description) 4. Estimated Cost ............. ........................ Fee ........... . .......................... ., ,~,, .... i , ., :, , , , ~ (to be prod on filing, this application) 5, If dwe¢ing, riumber 6f itxO~liifig~lihi~s ?~.;; :':.} ~.,.,4 ;. (:: ?::,~ Num.'b~f)0'~'dwMling'units:;n~ e~¢t{~f~i~': ¢ '. )!'i~ If garagel humber of cars ..... .......................................... , .... , .................... 6, If business, commercial or mixed occupancy, specify nature and extent of each type of use ..................... 7, Dimensions of existing structure~, if any: Front ............... Rear ........... ,... Depth .............. Height ............... Num~ber of Stories ....................................................... Dimensions of same structure wkh alterations or additions: Front ............... :. Rear ................. Depth , Height Number of Stories 8, r)imensions of entire new constrUction: Front .... ~. [ ......... Rear .... g/ .... Depth 8' t [!eight ....... .~.{ ......Number of Stories ......... l ....... 9, Size oflot: Front .. ~3.O,0 .... Rear...~.~,.g.~ o / .......... Depth . J .g. ................. 10, Date of Purchase . l'~.OC. Sc, .~$ ................. Name of Former Owner &%'.-/. ¢Y..o. 4¢/....~.~.tp.4 .f~..¢.... 1 I. Zone or use district in wl~ich pr~mises are situated .................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ../E.O ........................... 13. Will lot be regraded ........ i ................... Will excess fill be removed from premises: Yes 14. Name of Owner of premises ~0o~s ¢ 27..s'/o.~Cl (.~w. Address 8. py,. ?(~...g.-.t,~,.~.~..2~lqCPhone No~..//~ 7.'~5~..-.~oc~.. Name of Architect ......... ~'. ................ Address ................... Phone No ................ Name of Contractor ' Address Phone No 15. Is this property located,:withinli00 feet of a tidal wetland? * Yes ..... No ..... · If yes, Southold Town Tr¢stees Permit may be required. I PLOT DIAGRAM Locate clearly and distinctly al! buildings, whether existing or proposed, and, indicate all set-back dimensions from property hues. G~ve street and block number or description according to deed, and show street names and indicate whether interior or corner lot. SZATE OF NEW 9. r, t . i COUIVrYDn. .OF'. ' ~ (Name of individual si~ning contract) above named. He is the ., ............................... ~ (Contractor, agent corporate officer, etc.) of said owner or owners, ~d is ~uly authorized to perform or have perfo~ed the said work and to m~e and file this application that all statements centred ~ this ~application a~e true to the best of his knowledge and belief; and that the work will be perfomed in the m~her set forth ~ tM application filed therewith. Sworn to before me this ~ quallfiod in Su~ulk Counly~ ~rnJ Expires hiarch FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examine~.. 1.f*~. t ./~.., 19.8.7 Approved . '. ~.../.{q., 19~'. ·~. Permit No..] .~9~O. ~ .~ .~. ~ " Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. Thi%application must be completely filled in by Wpewrlter or in ink and submitted to the Building Inspector, with 3 sets df 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 pemfit 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 deseribed. The applicant agrees to comply with all applicable laws, ordinances, building cod~,hhousing code, and regulations, and to. admit authorized inspectors on premises and in building for necessaryjospqctions. / .2 ^ . - ............. (glgnatuEe of applicant, or name, if a corporation) · .p.....o...,, ......................... '- iq. -~ ~)a~cJ N~ o,bSqo . . . · ~LS.. :eA. .... : ............ :. .... ¢: ........ (raail:mg address or app~J, cant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. .,..o..N ,m.e.¢. .................................................................................... Name of owner of premises .G. CO-5 C....~L& ~qmd. , . .C.o.~.~ ............................................... (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. t3.z~h$.v.~. ........... Plumber's LicenseNo ......................... 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. 1000 Section .... O./. O ....... ~ LTO© . ...... Lot ~.OO [ · . Block,<,,_;: .... : .................... Subdivision ................................ Fded Map'N~ .... -.~,.. ....... Lot ............... 2. State existing use and occupancy of premises and intended use and occupancy of proposed constructio}l: a. Existing use and occupancy ~'~Wc~t[ ~ab 3~-rx,~/~n ,- ' b. Intended use and occupancy .................................... ': ............................... 3. i~lature of work (check which applicable): New Building .......... Addition ..... Alteration .......... Repair .............. Removal .............. Demolition .............. Other Work ............... (Description) 4. Estimated ........................ Fee ...................................... (to be paid on filing this application) 5. If dwelling, n~mber of dwelling units ..... .A{.o. ....... Number of dwelling units on each floor ................ If garage, number of cars ...... : .......................................... 6. If business, commercial or mixed bccupancy, specify nature and extent of each type of use ~-q~.~..~.~. ......... 7. Dimensions of existing structures,! if any: Front ~.~.~....c~..%q~..JRear .............. Depth ............... Height .............. Number of Stories ........................................................ Dimensions of same structure with alterations or additions: Front ................. Rear .................. Depth . Height Number of Stories 8. Dimensions of entire new construction: Front~. er0.cl.o~..~,ag. Rear ............... Depth ........ Height ...... - ......... NumBer of Stories ........................................................ 9. Size of lot: Front . .'~'~'~'~'~'~'~'~'~. (3.~ .~.~.'¢..el3 ....... Rear ...................... Depth ...................... 10. Date of Purchase . .tT:.O.<f ga, ................ Name of Former Owner 11. Zone or use district in which premises are situated ..................................................... 12. Does proposed construction vlol~te any zoning law, ordinance or regulation: . ~.o. ............................ 13. Will lot be regraded ....... ;. i..~. ............... Will ex~s,s fill be removed from premises: Yes 14. Name of Owner of premises~t~= _~k~.~.~...~. .... Adal~ss .~..*~..~;{~..t~. ~.}/... Phone No."~2dll ........ Name of Architect .......... !. r .............. Address ....... .-Z'. .......... Phone No...'-22. ............ Name of Contractor '--' Address ~ Phone No 15, Is this property located Withinl;00 feet of a tidal wetland? * Yes ..... No .J~.. · If yes, Southold Town TruStees Permit may be required. ~ i j PLOT DIAGRAM ~ L6cate clearly and distinctly all .! buildings, whether existing or proposed, and, indicate all set-back dimensions from property lines. Give street and block dumber or description according to deed, and show street names and indicate whether interior or corner lot. STATEOFNEW~.~..~.~.VN,..~...~[..~N.~. ''Y-' S.S . COUNTY OF ......... . : i1'1~ ....V? ..................... being duly sworn, deposes and says that he is the appliqant (Name of individual" ' s~nmg contract) above named. ; He is the . ~ .~.~.t.i1474..'.'~. ....... : ..................................................................... (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 cqnta/ned in this application are true to the best of his knowledge and belief; and that the work will be performed in the maimer set forth in the application filed therewith. Sworn to before me this ............... ..... Notary Public, .-~¢~...~..'...~....0>~.. ........ t 7 0 0 0