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HomeMy WebLinkAbout13676-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. Certificate Of Occupancy No...Z.1.4.3. J.4 ......... Date ....H.a. Cc..h..2.5. .................... 198.6.. THIS CERTIFIES that the building .... 0. n..% .f.a. n3 ~.~3~..d. ¥.e.~. $.~g ...................... Location of Property ........ 1 {) ~33.. B..a .m.b.1. ~..r..B.q a..d ............... S. 9 .u.g.h.o..1 .d ........... House No, Street Hamlet County Tax Map No. ]000 Section . .~8 ........ Block . .0.~ ........... Lot ...3. ~ ............ Subdivision ............................... Filed Map No ......... Lot No ..... ~. 3 ....... conforms substantially to the Application for Building Pemfit heretofore filed in this office dated ...... l~e c....1, q ........ 19.8.5. pursuant to which Building Permit No .... .~.3.fi. 7..6.Z ........... dated ...... J. ar~ ,..1.5 .............. 19 .S.5., 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 ......... ..... One. £.amily..d~eZ.],ing ..................................................... The certificate is issued to ..... J.O. HN. K....COMMONS .................................... [owner, I~,){ of the aforesaid building. Suffolk County Department of Health Approval .... ! .4.-.S.O. 7 .8.0 ............................. UNDERWRITERS CERTIFICATE NO. ............................................. ~73940.7 . . . PLUMBERS CERTIFICATE 3//4-/86 Rev. 1/81 Building Inspector FOB. M NO, O TOWN OF SOUT~OLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y, BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Rev. 6/30/80 ~FOBM ~O, 6 TOWN OF $OUTHOLD Building Department Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY instructions A. This application must be filled in typewriter OR ink, and submitted in duplicate to the Building Inspector 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 disposol--(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 installations, a certificate of Code compliance fram 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 property 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 in- formation required to prepare a certificate. C. Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land use 3. Copy of certificate of occupancy $1.00 $5.00 De,e New Building ......... .X. ......... O~d or Pre-existing Building ............................ Vacant Land ............................ Location Of Property .~]z.9~.8...5..~.~.~..m..b..~'e..~...~.~.~.~..d..~.~.S...~..u:..~.~...~..]r~.t....~..`~..Y.: ....................................... , ......... Owner Or Owners Of Property ....J.~.hn..~....C.~.mmc~.~.,...~...~.T.~.~.d..Y.~..e..~...~.~.~.~....~m~.t;.~.~.~.~ Map of Terry Waters ~+ 13 ,, 1085 Subdivision ................................................................... No ............. Block No ............. House r~o ............. 13676 Z .... 1/15/85. , . Heidtmann & Son, Inc.. Permit No ..................... uate gr I~ermit .................... ,~,pplicont .................................................................. Health Dept. Approval ...(..~...z..~....(~...-.....~..C) ............. Labor Dept. Approval ................................................ q%qHoq ' Plonnin Underwriters Approvol ~. ..........................................g Boord Approvol ........................................ ~equest For Temporary Certificote ........................................ Finol Certificote .......................................... NoYo Fee Submitted $ .................................... Construction on above described buildina ~and permit meets all applicable Cl;~des and regulations. Sworn to before me this (stamp or seal) THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY ~ 85 JOHN STREET, NEW YORK, NEW YORK 1OO58 Date Ma:~'ch 'J.?~)~f~g.. ApplieationNo. onfit~3~0797/~5 ~.,~ ~..,.,~ ~.~ N 739407 o~y the e~ec~r~ca~ eq~ip~e~ ~ ~scribed be~o~ a~d introduced by the appllca~t ~amed on ~he abo~e application n~mber in the premises of in ~he~ollowing location; ~ Basement ~ ls$ Fl. ~ 2nd FI. Sec~io~ Bloc~ Lot was examined on ~'C~ ~ ~ ~ ~ ~ ~ and found to 5e in co~npliance with the requiren~ents of this Board. FIXTURE OUTLETS RECEPTACLES SWITCHES FIXTURES RANGES OVENS EXHAUST FANS FLUORESCENT VAPOR 25 39 33 DRYERS FURNACE 25 FUTUEE APPLIANCE FEEDERS TIME CLOCKS UNIT HEATERS MULTI-OUTLET SYSTEMS NO. OF FEET DIMMERS SERVICE DISCONNECT OTHER APPARATUS: Smoke Detector--1 S E R V I C E OF HI-tED NO' OF~iEUTRALS OF NEUTRAL Electric lio. $578-E GENEI~AL MANAGER This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspector, s may be identified by BUILDING DE ~ COPY ~ ; ALTERED IN ANY MANNER. TOWN OFFICE bF P.O: BOX SOUTHOLD, N.iy, (please · 7654 802 TOWN OF $OUTHOLD OFFICE OF BUILDING INSPECTOR P.O. BOX 728 TOWN HALL SOUTHOLD, N.Y. 11971 CERTIFICATION TBL. 765-1802 Building Permit No. Owner Copq~r~ ~ ~ (please print) (please print) I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. Sworn to before me this ~/~ day of Notary Public, (plumber ' s sig~.~; ~ Notary Public County ~ ~. 5~%sO~% ~o ,-lC, $°e°~ Fi ELDPINS~'R~CT ION COMMENT~3 FOUNDRTIOH (?st) FOUNDATION (2nd) ROUGH FRAME & PLUMBING INSULATION PER N. STATE ENERGY C,ODE FINAL COMMENTS: Phone (516) 734-7484 Night (516) 765-1128 GLENN F. HEIDTMANN & SON, INC. BUILDER COX LANE, CUTCHOGUE, NEW YORK 11935 To Town of Southold, Building Department Main Road, Southold, N.Y. Mr. E. Hinderman Date: MAIL ADDRESS P.O. BOX 932 CUTCHOGUE, N.Y. 11935 BLDG, DEPT. TOWN OF SOUTHOLD Decembe= 18~ 1986 Gentlemen: We are /ob John K. Commons (X) Enclosing ( ) Forwarding under separate cover ( ) Handing you Rambler Road Southold, N.Y. New Residence Copies 1 Dwg. No. Title Permit No. 10-82-(1174 1 N.Y.S. Department of Environmental Conservation Amendment to permit - Extension of Expiration Date Which are for Comments ( ) Approval and distribution ( ) Your information (X) Record Please initial and return copy By Date Very truly yours, GLENN F. HEIDTMANN & SON INC. NEW YORK STATE DEPARTMEHT OF ENVIRONMENTAL CONSERVATION PEP~IT ISSUED TO John K. Co~on$ ADDRESS OF PERMEI~EE 111 Orandvfew Lane, Smithtown, NY 11787 ~ PEI~IT NO, 10-82-017/+ UNDER THE ENVIRONMENTAL CONSERVATION LAW ARTICLE tS, (Protecllon of Water) [] ARi'ICLE 2S, (Tidal Wetlands) ARTICLE 24, (Freshwater Wetlands) ARTICLE 36, (Construction in Flood Hazard Areas) LOCATION OP PROIECT (Section of stream, tidal wetlaed, da~ building) Rambler Roa__d~ B~at Basin adjacent to ~o8 Neck ~ DESCRIPTION DP PROJECT Con~truet one~f~mil.y dwelling a minimum of 75' from Tidal Wetland Boundary ~nd in~tall a sanitar% ~stem a minimum of 100r from Tidal Wetland Boundary. TOWN Sout_ _ol__ L.PERMIT EXPIRATION DATE pri____l, 30,~ 1983 __ COMMUNITY NAME (City, Town, Village) _ Bayview COUNTY Suffolk 1. fha pere~iltee shall file in the office of the appropriate Regional 'ermit Administrator, a notice of intentioo to commeuce work at least ,ia ~ours In advance of the lime of commencement and shall also notify him )totally In writing of the completion of the wozk. 2. The p~rmltled work shall be subject to inspection by an authorized epresentative of the Department of Environmental Conservation who may ~rder Ihe work suspended if the public interest so requires. 3. As a condition of the issuance of this permit, the applicant has aco opted expressly, by the execution ot the application, the fuU {esal respon- ibility for all damages, direct or indirect, of whatever nature, and by whom- ,var suffered, arising out of the project described herein and has agreed {o ndernflify and save harmless the State from suits, actions, damages and osts of every name and description resulting from the said project. 4. Any material dredRed In the prosecution of the work herein permitted hall be removed evenly~ without leaving large refuse piles, ridges across {he ,ed ot the waterway or flood plain or deep holes that may have a tendency to ause injury to naviRable channels or to the banks of the waterway. S. Any material to be deposited or dumped under this permit, either in 7:. That If future operations ~y the State of New York require ae alteration GENERAL CONDITIONS 8. That the State of New York shall tn no case be liable for any damage or lniury to the structure or work here~o authorized which may be caused by or result from future operations undertaken by the State for the conservation or bnprovement of navtgatlon~ or for olher purposes, and no claim or right to compensation shall accrue from any such damage. 9. That if the display of lights and signals on any work hereby authorized is not otherwise provided for by law, such lights and sisnals as may be pre- scribed by the United States Coast Guard shall be installed and maintained by a~d at. the expense of the ~wner, 10. All work carried out under this permit shall be performed in accor~ dance with established engineering practice and In a workmanlike manner. 11. If 8ranted under Articles 24 or 25, the Department reserves the right to reconsider this approval at any time and after due notice and hearing to continue, rescind or modify this permit tn such a manner as may be found to be jusl and equitable. If upon the expiration or revocation of this permit, the modification of the wetland hereby authorized has not been completed, the applicant shall, without expense lo the State, and to such extent and in such time and manner as Ihe Department of Enviromnen{al Conservation roay requlre~ remove all or any portion of the uncompleted structure or fill and restore the site to its former condillon. No claim shall be made against the State of New York on account of any such removal or alteration. 12. This permit shall not be construed as conve¥1n~ to the a~pitcaot right to trespass upon the lands or Interfere with the riparian rights of others to perform the permitted work or as authorizing the impairment oi any rishts~ party to the permit, 13. The permlt~ee Is responsible for obtaining any other permits, prowls, Jands~ easements and rights.of.way which may be required for this project. 14. If sranted under Article :~6, this permit Is granted solely on the basis of lhe requirements of Article 36 of the Environmental ConservaHon Law and Part S00 of 6 NYCRR (Construction In Hood Plain Areas having Special Flood Hazards - Building Permits) and in no way signifies that the project will he free from flooding. 15. By acceptance of this permit the permlttee agrees that tim permit is continRent upon strict compliance with the special conditions on the reverse side. (SEE REVERSE NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Building 40, SUNY--Room 219 Stony Brook~ NY 11794 (516) 751-7900 Permit No. AMENDMENT TO PERMIT EXTENSION OF EXPIRATION DATE Your recent request to extend the above permit has been reviewed pursuant to 6NYCRR, Part 621. It has beea determined t!,~t there has not bee~ a meterial eha~ge i~ environmental c~ditions, relevant technology or applicable law or regul- .~ions since the issuance of the existin~ p~rmtt~ therefore, This letter is an amendment to the original permit and as such, shall be attached thereto~ and e copy poated at ~ job site. All other terms and conditions remain as written in the original permit, Very truly yours, Daniel J.~'~arkin Regional P~r~ Admin~strator DJL:cz PERMIT SIGN NO ~ 10-82-0174 ~as been issued t~: ~o,~ address: _. 111 Gramdview Lane, Smithtm¢~, NY 11787 ,, ~nim~ of I00~ from ~ ~da! We~tand Bounde~. under the E~vir0nmenta[ C~nservation Article 15, (Protection of Water} Article 24, JFreshwater Wetlands] Article 25, (Tidal Wet~andsJ Article 36, (Construct[on in FJood ~ew Y~r~ S~mte Depmment ~f Environmental Conservation Hazsrd Areas) '~,/~ P~er~t' Ad=inistrator April 14, 1982 Dste issued 9s.~.l (~/Ts) April 30, 1983 Formerly EA-93 P~one (516) 734-7484 Night (516) 765-1128 GLENN F. HEIDTMANN & SON, INC. BUILDER December 3, 1984 COX LANE, CUTCHOGUE NEW YORK 11935 Town of Southold Main Road Southold, New York 11971 Re: John K. Commons New Residence Rambler Road - Bayview Southold, MAIL ADDRESS P.O. BOX 932 CUTCHOGUE~ N.Y. 11935 Energy Code Resistence Ail roof area to reveive 6" insulation R 19 factor All exterior walls to receive 4" insulation R 11 factor Ail basement area to receive 4" insulation R 11 factor All exterior window openings to be Perma-shield windows manufactured by Anderson Corp. All exterior door openings to be hollow metal insulated manufactured by Benchmark Corp. All exterior sliding ooor openings to be Perma-shield manufsctured by Anderson Corp. Glenn F. Heidtmann & Son, Inc. TOWN OF SOUTHOLD OFFICE OF BUILDING INSPECTOR P.O. BOX 728 TOWN HALL SOUTHOLD, N.Y. 11971 ~:~. TEL. 765-1802 To Whom This May Concern, We are unable to complete your Certificate of Occupancy because,of the following reasons. /5/ /-/ /? An application for Certificate of Occupancy is not on file. No Underwriters Certificate on file. The check is(outdated/not on file.) No Health Dept. Approval on file.-- Final Survey° No final inspection has been made. Please contact our office on this matter. Thank you for your cooperation. Building Permit # I A k ~ ~ Building Depto ***/~/ No Plumber solder Certificate on file. ( all permits involving plumbing being issued after April 1,1984 Disapproval Issued Application Recetve~ ~19 FORM NO. 10 APPLICATION FOIl DEVELOPMENT PERMIT In the Town of Southold 1. Type of Development Proposed: Now St'ructure (including storage tanks~ E ' Addition and/or Alteration[] Flood P~oof Below Base Flood levatzon~ Other ( sp~cify~ 2. Elevation Data in relation to above mean sea level of: (a) Lowest floor elevation, including basement .__~_~. feet _~_Ltnches (b) In a V Zone, bottom of lowest structural member ~_ feet ~ inches ). FIRM--Flood Insurance Rate Map, Zone designations Caunty Tax Map No., District, 1000, Section ~Block ~ Lot(s)~ 7. -Approval from other(s) before Pe~tt is issued: HEALTH 8ERV ICE..__~_~~ WETLANDS (Town BUILDING PERMIT PLANNING 0~-~~ ~e~[~, Under Oon.tractl~, Ls.ssee~, Agent[~, Con- tract~j~,~afi_-d agree to comply w~th all applicable s?ctions of the Code of the To~ of Southold; Co~ty, and State ~d to a~t authorized in- specters to premises authorized to perfo~ or have performed the said work ~d to make and file this application, that all statements contain- ed in this application are true to the best of my knowledge and belief and that the work will be perfo~ed in the mannerset forth in the application filed therewith. ~$~k~[~ - k GLENN F. HEIDTMANN & SON, INC. CUTCHOGUE, NEW YORK 11935 Applicant,s mailing address and phone # if not given above: 4/80 P.O. BOX 728 SOUTHOLD, NY 11971 FORM NO. hO TOWN OF S0 HOLO BUILDING DEPARTMENT (516) 765-1802 TOWN HALL MAIN ROAD SOUTHOLD, NY A~PLICATiON F0~' DEVELOPMENT PEtI.iiT_ ...... /instructions: The application to the Building Inspector includes (each ~n dUpliCate) 1. Forth No. l0 filled out in ink or typewritten, 2. Sur- vey of premises with ielevations above mean sea level, 3. Drawings of pro- posed work. The application must give complete information to show· that the proposed can comply' to the Local Law,, No. 1-1980, Chapter 46 of'the (;ode of the Town of Southold known as Flood Damage Prevention Law" of the Town of Southold. The applicant must submit approvals that any.other agency requires, i ~ene~al damage: A. B. C. D. S~anda~.ds aslrequired in Section 46-17 of the law to minimize flood Anchoring or'structures, including tanks and mobile homes Use of construction material and methods Design and location of utilities Subdivision Droposal with d~ainage, public utilities design and base flood e~evatlons ~.peci~.ic Standards as required in Section 46-18r A. Re sidenti~l Construction B. Non-residential construction C. Mobile homes' The applicant must submit plans and specifications as well as any other information requested by the Building Inspector to substantiate the facts that the structure has or will have the lowest floor, including basement/ eellar, elevated above the base flood elevation or; if pemnitted by the Federal Regulation, that: 1. such structure is flood proofed in such mann.er that below the base flood level the structure is water tight with walls substantially And impermeable to the passage of water, 2. that structural component~ are capable to resisting hydrostatic and .hydrodynamic loads and effects oflbuoyancy, 3. applicant must sub~it certifmcAtion by a registered profess$onal engineer or architect that the standards set forth in Section 46-18B (1) (2) (3) of the Southold Code are satisfied. Coastal Hi.~h Hazzard i area (V Zone) 46-19. Applicant shall submit plans, 'specifications including-the required certifications and such other in- formation as the Building Inspector may require in that :~e provisions of 46-19 are complied with. Mobile homes are prohibited. The lowest portion of the structural merabers of the lowest floor cannot be lower than the ~ase flood elevation lwith all space ~below open except breakaway walls. .S. and dunes. If sandidunes exist on the premises and the ap~l~cant.pro- poses to ~lter same, plans and specification must be shown inJdetamled nature of any altera$i.on submitte.d. ~ B_uildin~ Permit. A Buzlding Permmt is also required for any Ytructure. ~Both a ~evelopment and a Building Permit must be issued before any work can start in a special flood hazzard zone. A~ w~itten, disapproval or a permit must be issues within ten (10) working days. During construction, lthe inspector ~hall be notified in time so he may make the required in~pections. Upon completion, the irequired certification fo the final elevations and work must be submitted before the approval to use or occupy can be approved. (Fill but the form on the back of this sheet) 4/80: STATEMEN1 THE WATER SUPPLY A SYSTEMS FOr CONFORIV~ TO THE SUFFOL~ CO~ DEPT C SUFFO~K COUNTY CONSTR UCTi~ DATE:~ SUFFOLK CO. TAX D~ST. SECT. OWNERS ADDRESS: DEED: L.%~ P. "TEST MOLE 'FORM NO. 1 TOWN OF SOUTHOLD RUILDING DEPARTMENT TOWN HALL $OUTHOLD, N,Y. 11971 TEL.: 765-1802 ^pprove ...... ...... , ~ Inspector) APPLICATION FOR BUILDING PERMIT December 84 Date ................... 19... INSTRUCTIONS a. This application must be completely filled in by typewriter or ih 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 shpll 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 Law% 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. Heidtmann & Son, Inc. (Signature of applicant, or name, if a corporation) P.O. Box>,:932, Cutchogue, I<i.T. I.]9q~5 (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. General Contractor Nameofownerofpremises John K. &Gracc M, Commons (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) 10 Builder's License No .......................... Plumber's License No. Mattituck Plumbing Electrician's License No. t.,L,.,© " ' Other ~rade's License No ...................... 1. Location of land on which proposed work will be done .................................................. /.~. ~7~-- Rambler l[oad, Southold . House Number Street Hamlet County Tax Map No. 1000 Section .......... 0..8.8 .....Block . .5. ............... Lot..3..9 ................ Subdivision .... .B.ay.v. '.l .e?. .................. ' ...... Filed Map No ............... Lot .... 1.~ ......... (Name) ~ 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a.' Existing use and occupancy ................................................... b. Intended use and occupancy ...... ~.. · l' · '~' ~m ' - -a .......... ................ 3. Nature of work (check which applicable): New Building ......... Addition .......... Alteration .......... Repair ............ Removal .............. Demolition .............. Other Work ............... .~././.4 .~. (Description) 4 Estimated Cost .~ 80,09~Q. 00 .......... Fee .......................... (to be paid on filing this application) 5..If dwelling, number of dwellinglunits .......qne... ... Number of dwelling units on each floor ................ If garage number of cars ~ two 6.If business, commercial or mixeld occupancy, specify nature and extent of each type of use ..................... 7. Dimensions of existing structur0s, if any: Front ............... Rear .............. Depth ............... Height ............... Number of Stories ........................................................ Dimensions of same structure with alterations or additions: Front ................. Rear .................. Depth ................... i · · Height ...................... Number of Stories ...................... 8. Dimensions of entire new construction: Front .../a6 ~ ........ Rear ..../4.6.' ......... Depth . .$ J-.' .......... °ne0 ' ......... r 0, ................ Height ....... .1.2. [ .... Number of Stories ...... 1'.' " "'z 113.4 ' "~ ;. ............ 9. ,>l e of lot: Front ......... .[ ........... Rear ................. Depth ...................... 10 Date of Purchase .......... i N ................... amc of Former Owner ............................. 11. Zone or use dlstrlct in which premises are situated Residential 12. Does proposed construction violate any zoning law, ordinance or regulation: .. no 13. Will lot be regraded ........ i ................... Will e~xqqss fill he r~m. oved from premises: Yes No 14. Name of Owner of premises . .J... C.o. mmo.n.s Add~o~O-t~-~Granav~ew ~o..~.hone No. 543-5075 ................... ara~..Ixh t oxon; ..............." Name of Architect ......... i ................. Address ................... Phone No. ;. 'Z~ ...... Name of Contractor ...~{eLd. gm. onn .4, SoO, .In. address Cutchog.ue,..N...Y. Pnone No.7.~.+. y..8..?4. 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 NE'~ORK, ,. iS S COUNTY O~ ..... i ' Henry ~/. Heidtmann QName of individual sig~lng contract) being duly sworn, deposes and says that he is the applicant above named. Heis the ] Agent (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duiy authorized to perform or have performed the said work and to make and file this application l that all statements contgfined in this application are true to the best of his knowledge and belief; and that the work will b~ performed in the manner set forth in the application filed therewith. Sworn to before me this ......... ...... day o{. Notary Public ...... ~, ......... i'" -- i rd)zanvPum, _ .... 5;;/_._...,.2/._;._ ....... ~/ I ' ~m~ff~su~l~~' "' ~ (Signature of applicant) SUFFOLK CO. HEALTH DEPT. APPROVAL ~', H, S. NO. DEPARtH£NT OF 0 ~T SY~EMS FOR THIS R~IDENCE WILL ~,$v~ "~~/' CONFORM TO THE STANDAR~ OF THE ' ,,"~ '~NN ~ ~ ~ SUFFOL~CO~DEPT.,~F~ALTH SERVICES ~ ~ ',-;JN~/ '"~ '~'~ ~ , ~ Q // ~.... , SUFFOLK COUNTY DEPT. OF HEALTH ~ ~ ~.H.~..~:' , ~'~ ~ SERVICES -- FOR APPROVAL OF  ~ 'OWNERS ,--- d soosa fac ~- es ~ua~=n~ t , DUE TO HIGH ~ROU~DWATER CONDITiONS/POOR RODERiCK VAN TUYL. P.C. ~, , r,~ SEWAGE D!SPO~L, SY&I,EM, LICENSED LAND SURVEYORS ~A~ ~)LL ~AY BE ~E~UIRED. GREEN~RT NEW YORK SUFFOLK CO. HEALTH DEPT. APPROVAL SYSTEMS FOR THIS RESIDENCE WILL CONFORM TO THE STANDARDS OF THE SUFFOLK ~OUNTY DEPT. OF HEALTH TEST HOLE STAMP LAND SURVEYORS GREEN~RT NEW YORK