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HomeMy WebLinkAbout27219-z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-27636 Date: 04/25/01 THIS CERTIFIES that the building ACCESSORY Location of Property: 890 COX NECK RD MATTITUCK (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 113 Block 14 Lot 7 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated JULY 28, 1993 pursuant to which Building Permit No. 27219-Z dated APRIL 10, 2001 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 INGROUND SWIMMING POOL AS APPLIED FOR. The certificate is issued to JEFFERY L. , & LAURIE M. EVANS (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. N-287532 08/25/93 PLUMBERS CERTIFICATION DATED N/A Authorized gnature Rev. 1/81 FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Hall Southold, N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) PERMIT NO. 27219 Z Date APRIL 10 , 2001 Permission is hereby granted to: JEFFERY L EVANS PO BOX 1585 MATTITUCK,NY 11952 for ACCESSORY INGROUND SWIMMING POOL AS APPLIED FOR. (THIS REPLACES BP #21565-Z WHICH HAS EXPIRED) at premises located at 890 COX NECK RD MATTITUCK County Tax Map No. 473889 Section 113 Block 0014 Lot No. 007 pursuant to application dated JULY 28, 1993 and approved by the Building Inspector. Fee $ 150 . 00 tX or' zed Signature ORIGINAL Rev. 2/19/98 Form No. 6 177 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 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 ,p'roperty with accurate location of all 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, industrial building, multiple residences and similar buildings and installations, a certificate of Code Complianoe 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: i1. 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 Buildine - $100.00 3. Copy of Certificate of Occupancy - .25tp 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 Date /: r/� ./. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New Construction. . . .. g. . Old Or Pre-existing Building. . . . . . . . . .. . . . . . . Location of Property. . . . . . . . . . . . . . . . . . . . . . . . House No. Street Hamlet Onwer or Owners of Property.. . . .FF t. . L v IC �tUS /q /V County Tax Map No 1000, Section. . .a 0a . . . . .Block.( .1. . . . . . . . . . . . .Lot. . .I. . . . . . . . . . . . . . . . . Subdivision. . . . . .,. . . . . . . . .. . . . . . . . . . . . .Filed Map. . . . . . . . . . . .Lot. . . . . . . . . . . . . . . . . . . . . . Permit No.oki 556. .x? . . .Date Of Permit. . ! .1. .i. . . . . . .Applicant. . . Z- UR�./E. .eUgI.'.��. . . . Health Dept. Approval. . . . . . . . . . . . . . . . . . . . . . . . . .Underwriters Approval. . . . . . . . . . . . . . . . . . . . . . . . . Plamiino Board Approval. . . . . . . . . . . . . . I . . . . . . . . . Request for: Temporary Certificate. . . . . . . . . . . Final Certicate. . . . . . . . Fee Submitted: $ �`�' l) GZsz. 51397 . . . . . . ././1. . � ct' viv . . . . . . . . . . . . . . . . . . . . Co 9-- a 7G 3(D APPLICANT THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 2 11@86f19 BUREAU OF ELECTRICITY 83 JOHN STREET. NEW YORK. NEW YORK 10038 Date AUGUST 25, 1993 Application No.onfile 04923993193 N 287532 THIS CERTIFIES THAT only the electrical equipment as described below and introduced by the opplicont named on the above application number in the premises of JEFFREY EVANS , 890 COX NECK ROAD, HATTITUCK, N.Y. in thefollowinXlocation; I Basement I IAt Fl. ❑ 2nd Fl. OUT Section Block Lot was examined on AUGUST 19,19 9 3 and found to be in compliance with the National Electrical Code. FIXTURE FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS OUTLETS ACLES SWITCHES INCANDESCENT1 FLUORESCENT OTHER AMT, K.W. AMT, K.W. AMT. K.W. AMT. K.W. A.T. H.P. DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL RK'PT TIME CLOCKS KU UNR HEATERS MULTI-OUTLET DIMMERS OIL H.P. GAS H.P. AMT. NO. A.W.G. AMT. AMP. AMT. MWS. TRANS. AMT. H.P. SYSTEMS AMT. WATTS NO.OF FEET SERVICE DISCONNECT NO.OF S E R V I C E AMT. AMP. E � TYP1,0 2W 1.6 3W 3/3W 3 0 4W NO-OF CC.COND. A.W.G. NO.OF WLEG A•W.G• NO.OF NEUTRALS A.W.G. PER.N OF CC.GOND. OF HI LEG OF NEUTRAL OTHER APMRATUS: made by a qualified person. z2m��,a KORRIS ELECTRIC LIC. #220 E 3 8ATELITE DRIVE ISLIP TERR. , NY, 11752 onreta MANAGE 11 �` Per- m er `1 This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by their credentials. COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER. THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1 1000609 BUREAU OF ELECTRICITY F 85 JOHN STREET. NEW YORK. NEW YORK 10038 Date AUGUST 25,1993 Application No.on file 04923993/93 P 287532 THIS CERTIFIES THAT only the electrical equipment as described below and introduced by the applicant named on the above application number in the premises of JEFFREY EVANS , 890 COS NECK ROAD, MATTITUCK, N.Y. in thefollowinR location; ® Basement ® 1st Fl. ❑ Ynd Fl. OUT Section Block Lot Ryas examined on AUGUST 19,19 9 3 and found to be in compliance with the National Electrical Code. FIXTURE RXTURES RANGES COOKING DECKS OVENS I DISH WASHERS EXHAUST FANS OUTLETS RECEPTACLES SWITCHES INCANDESCENT FLUORESCENT OTHER AMT. I K.W. I AMT. I K.W. AMT. I K.W. AMT. K.W. AMT. H.P. 1 1 1 1 DRYERS MENACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'FT TIME CLOCKS NU UNIT HEATERS STI-OUTLET DIMMERS AMT. K.W. Olt H.P. GAS H.P. AMT. NO. A.W.G. AMT. AMP. AMT. AMPS. TRANS. AMT. H.P. SYSTEMS No.OF FEET AMT. WATTS 1 40 SERVICE DISCONNECT NO.OF S E R V 1 C E AMT. AMP. TYPE EQW 1.9 1W 1,/3W 3/31N 30 4W NO.°PER Cc. of CC.W.GO.ND. NO.OF HIAEG of•W.G.I No.OF NEUTRALS of I W.G. OTHER APPARATUS: SWIMMING POOL-1 MOTORS 1. 5 H. P. -1 G.F.C.I-1 PANELBOARDS: 1-3 CTR. 100 *(SWIMMING POOL) This certificate covers compliance at the date of knspection only. Because of unusual environsents it is advisable to have frequent testland or repairs <<< Continued on Page 2 »j GEN MM MANAfiBI per This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by their credentials. COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER. 70-1802 BUILDING DEFT. INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] IN ATION [ l FRAMING [ FINAL [ ] FIREPLACE & CHIMNEY REMARKS: ,DATE W01 INSPECTOR, 04/20/2001 15:00 6312983801 STRONGS MARINE INC PAGE 01 PO Box 7109Stronq's Marine, Inc. MxWbj .NV 11952 Phone:(631)2961770 Fax:(631)29&3601 To: HWbft Dep=la Wt F1awe IAA*Eva" raw 765-1323 Data April 20,2001 Fha•o• pagan 3 imch•dlue cover no UndamitesCert CC• Please find a copy of my Undaw iters oatificate for my pool. Please process my CO ASAP. I would like to pick up the CO on Tuesday,April 241'. I will bring the original with me at that time. Thank you o � N x Town Hall, 53095 Main Road p • Fax (516) 765-1823 e9Telephone (516)765-1802 Southold, NewYork 11971 OFFICE OF THE BUILDING INSPECTOR TOWN OF SOUTHOLD December 14, 1995 Mr. Jeffrey Evans 17 Vistas Drive North Manorville, NY 11949 Re: Building Permit #21565-Z Premises : 890 Cox Neck Road, Mattituck Suff. Co. Tax Map #1000-113-14-7 During a review of our files it was noted that the above building permit has expired, and a Certificate of Occupancy has never been issued. According to the Code of the Town of Southold, Article XXVIII 100-284, it is unlawful to occupy or use a structure until a Certificate of Occupancy has been issued. Please contact this office as soon as possible so that we may clear up this matter. Thank you for your cooperation in this matter. Very truly yours, SOUTHOLD TOWN BUILDING DEPT. M-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INS ION [ ] FRAMING [ f FINAL [ ] FIREPL & CHIMNEY r REMARKS: l 70 ,DATE4161e)lINSPECTO M-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH , PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ 4-141NAL _1 REMARKS: DATE INSPECT I i ' I , i 19`` 32 i L -, I i "ONEDI ATELY" UNDERWRITERS CERTIFICATE dw IN�06ElOflF:� i1E"� REQUIRED ; Q .'•; �1 v <`/ / ':•> � -'rte';;' • '.'IS7U:51LN�LDN%1NFa' f Vic. ,U.z. '', :•.. .:k"�. « _HlA`f R.. Z (42EizeQVEti FOtZ -P.455+f� [.T .Furu[ZE4IGHVJa,Y bE PIAN . Se T CAc ki- J'n ' 'S. - il�� i� c:rrir xr� Iy J i I H 5�-OUIIDATION I 'OUNDATION (2nd ) _ _ m , I o �OUGH FRAIME & •PLUMBING cn IIrn !IJSULATIOJ! PEA N. Y. I , • .-� STATE ENERGY II CODE 1 1711 &1 / / •�y FINAL ` ADDITIONAL OMMEP7 S : x H -------------------- r \ • O H ir v V H FFOJ4-C 0�0 OGy� I Z Town Hall, 53095 Main Road p O Fax (516)765-1823 9y�Ol 0� Telephone (516) 765-1802 Southold, New York 11971 OFFICE OF THE BUILDING INSPECTOR TOWN OF SOUTHOLD December 14 , 1995 Mr. Jeffrey Evans 17 vistas Drive North Manorville, NY 11949 Re: Building Permit #21565-Z Premises : 890 Cox Neck Road, Mattituck Suff . Co. Tax Map #1000-113-14-7 During a review of our files it was noted that the above building permit has expired, and a Certificate of Occupancy has never been issued. According to the Code of the Town of Southold, Article XXVIII 100-284 , it is unlawful to occupy or use a structure until a Certificate of Occupancy has been issued. Please contact this office as soon as possible so that we may clear up this matter. Thank you for your cooperation in this matter. Very truly yours, SOUTHOLD TOWN BUILDING DEPT. 1 200 --rem- 43 I ice, 1 �q,��,, n.� 28 r 2 Sy G CCR 32 ' 2kF3 dem �6°ocari p G�vLff✓_ -- { � I� FORM NO.3 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD,N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED)D Date................ O 19.../... N° 21565 Z j(„� Permisslon Is hereby granted to: ....:..1.rf 1.4 ........1f�/�,,,JJJ.......................... to......... -q.f✓ !.I 4f ....... v...,.. ..-4.^. .ra /.�dr� / ........,. + �:........ .5.......A ' '�.s. . .......F©IC............11s........A.N..........t c«.5-'JQef .Sy.... ` .....,.,` ad.�.......�.x�s� 7,✓ ..........©- ....... . .`Gy......... .w%"/LG�.�G ..................................................p.......,................................,................./......................................... l .Ftr(.` .y............. ��i'..d,.$'............................ at premises located aT...... ....... x...✓..' ....../... 4.x......................I..................I....... !/�m (........... / *................................... County Tax Map No. 1000 Section ......f/...3........ Block......... T....,:.... Lot No. .......®.�?.......... pursuant to applicatlon dated .............. l?.................. ........ 19...../� ..... and approved by the Bullding Inspector. Fee$.../ . .. .... /11Z ............. Bspector Rev. 6/30/80 UNDERWRITERS CERTtFlCATE d i 11IONi0M�lON REQUIRED Jul- alj 61 'cs' STs' L r vi W :.. .. . . .. - _.SVT.. --• , �� � rw ---._- _WAY 2 (REiSEQVEG fiClfL.P.O5a7E�+R .Fcr{uIZE�"GHWAY DE dk5t icoc> sect ?CA aCx`�3 LrI �eol -Ita C-CDA� . ��Se�F lok c��cn%o� s�F ��cs�{ti' ���� • { _III r:l vb * 17['f.:.Y'.:.s .v:l M..v 1':. ^ T 11.r.L rA'V.V.:J.i 1 ._. r.-•:.1. �. �•• G, 1! 3 19 r I ' Lo % 1 � =rte coo¢.•::F�.. p � QETAIL_ 1 Ni $ 't 2 ,SL: -i:VILLIA. ra Is •• Q f.-""VITf i:.:re1:F � - . Lf Si LKft a:nn•.c` LINF.P- 1 t� ,lA •J _ 5't sif.'lL• 1� `'.i>a 1S`.Sio - - 8. :i U�1 .2. E�iCAVA(tONDE �/irtYt- u+'�ELL POUR°MI;vZttlM OF 4F' CONCRETE AkOUND F N ENTIRE PERDIETER & IN ADDITION MOUND AT LEASTI: AM /FT OVER EACH "A" FRE• *WARNING* _ m f � °P 2) FINISH T .CUHE POOL BOTTOM WITH A MINIMUM' DO NOT DIVE IN SHALLOW �d r b ` OF 27, CONTACTED SAND OR A VEMICULITE END OF FOOL! SCcTIo� - 'A s z to . - AND CEMENT MIX.. * < : USE DIVING EQUIPMENT SPECIFICALLY DESIGNATED FOR & INSTALLED IN acs G/�T2��Q�E-"S.A11fY�Y�`11�JCo ACCORDANCE WITH NATIONAL SWIMMING '- POOL INSTITUTE RESIDENTIAL STANDARDS. OFES, c�I BOARD OF HEALTH FORM NO. 1 . • • . • • . . \ 3 SETS OF PUNS . . . . . . . . . & JUL 1 51993 TOWN OF SOUTHOLD SURVEY . . . . . . . . . . . . . . . . . . BUILDING DEPARTMENT C116CK . . .I Fo TOWN HALL SEF� . . t 4LC:f(�. 5.' SOUTHOLD, N.Y. 11971 �� TOWN OF 50UiS!f��4!'�., , . ; o TEt: 765-180�---___ NOTIFY — �.� . . ., 19 ./ -7 � CALL . . . . . . Examined . . popp a I q MAIL TO : Approved . . . . . . .jal0. . . ., 19fJ. Permit No. . . . . . . . . . . . . . Disapproved a/c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (B)4ing Inspector) APPLICATION FOR BUILDING PERMIT Date . . . . . . . . . . ., 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. I b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public stiects 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. APPLICATIO to tBuilding Department for the issuance of a Building Permit pursuant to the Building Zone 0we old, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, forc it s, additions or alterations, or for removal or demolition, as herein described. The applicant agco ly 1 laws, ordinances, building code, h sing a and regulations, and to admit authorized r p g for necessary inspections -- I � li (CERTIFICATE (Signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Signat re of applicant, or e,, if eor`rNion) OF CCU . . . . . . . . . . � � � IN, 4. �`q 5� (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ` . . . . . :. . . . . . . . . . . . . . . . . Name of owner of premises (as on the tax roll or latest de6dd � ' If applicant is a corporation,signature of duly authorized officer. DAM FE16E• NOTIFY BUILDING DEPAKrMENT AT UNDERWRITERS CERTIFICATP 765-1802 9 AM TO 4 PM FOR THE (Name and title of corporate fficer) REQUIRED FOLLOWING INSPECTION$: Builder's License No. , , . . . , , , , . , 1. FOUNDATION : TWO REQUIRED FOR POURED CONCRETE Plumber's License No. . . . . . . . �IMMEDIATELY" 2• ROUGH - FRAMING & PLUMBING B. INSULATION CWKVVX4, FINAL - CONSTRUCTION MUST Electrician's License No. . . . . . . . . . . . . . . . . . . ..SNE BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET Other Trade's License No. THE REQUIREMENTS OF THE N.Y. ST TE CO RU N EP�RGY 1. Location of land on which proposed work will be done. f .S SSR ,eke, . M. p �- �.� SIGN OR GONSTRUCTI g��?. . . . . . .C�?1�:. . . . . . . . . . . . .C�(�.1 �. er c � . . . . . . . . . . . ... . . . . . . . . . . . . . .. House Number Street Hamlet County Tax Map No. 1000+ Section . . . . . . . . . . . Block . . . .�..�. . . . . . . : . . . Lot . . .77 . . . . . . . . . . . . . . Subdivision 1 J� . D.f . .(7�:Q 4 + p G P �(lcj.4-. . . l� (�C4-�fJO.(t-.'. Filed Map No. Lot . . .-7 : . (Na e) ' 2: State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy . . . . . . . . . . . . . .I. . . . . . . . . . . .!. . . . . . . . . . . . . . . . . b. Intended use and occupancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Nature of work (check which applicable): New Building . , . . . . - . . . Addition .. . . . . . . . . Alteration . . . . . . . . . Re rljov�J . , , , , , , , , , , , Dam li4io V. :.. . Other Work . . . . . c� rr � ���rv� S l�� ` Sw� v'11vY\�i De c lrptfoh) . . Re 4. Estima ed est . . . . . . . . . . SoPQ.�... . . . . . . . . Fee . . . .C `-'.l . . . . . . . . . . . . . „ " " . . . . . . . g (to be paid on filing thi4.application) If garage, namberof ears units . . . /J r , . . . . ._ Number of dwelling units on each floor . . . . . . . . . . . . . . . . S, if dwelling,number of dvwellin Sg . . . .I,. . . . . . . . . . . . . . . . . • 5. If business,commercial ormixed occupancy, specif nature and extent of each type of use . . . . . . . . . . • , , 7. g , . , . . . .existing. . , . es,if any: Front .9J �. . . . . . . . . . Rear . . . . . . . . . . . . . . Depth . . . . . . . . . . . . . . . Dimensions of same structure H ber of Stories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . i fight .n. of. . . . structures,ur with alterations or additions: Front . .�.�'.(. . . . . . . . . . . . . Rear . . . . . . . . . . . . . . . . . . Height Nu Depth . . . . , . . . . . . . . . Height . . . . . . . . . , : , . Number of Stories . . . . . . . . 8. Dimension of entire new construction: Front . .y'5. . . . . . . Rear . . �� . . . . . . . . Depth - ... . . . . . . . . Height 1�' . %,A� �hT' ber of Stories . {J�.(i. . 9. Size u. lug. :runi �� V Rear . . . ` A . .�J.P^. . . . . . . . Depth �l J . . . . . . . . . . . . . . • • • . • • • • • • . . . . . . . . . . Name of Former Owner . N�1 . . . . . . . . ... . . . 10. Date of Purchase ��g�Ci 11. Zone or use district in which premises are situated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 14. Name of Owner of remises • late any zoning law,ordinance or regulation:removed �. . . . . . . . . . . . . . . . Does proposed construction vie' 13. Will lot be regraded . . . . i �, . . . . . , .i. . . . . . . . . , , Will excess fill be removed r p J QJH(JS. . . Address Name of Architect �X . . . . . . . , . . . . Address Name of Contractor . ,Q4!? ��p R . . . . . . ... . . . . Address . 15. Is this property within feet of a tidal wetland? * � " " " 'Oone . . . .31 P P X Yes. . . . . . . . Na . . . . . . . *If yes, Southold Town Trustees Permit may be required, t PLOT DIAGRAM Locate clearly and distinctly all! buildings, whether existing or proposed, and,indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. I \ f-c_` -,E ,4 j4�'. X19{/'�.'(•�`� F..11�'i1 � :f Cv STATE OP'NEW YORK,' &S �r , � y. {ia \ COUNTY OAF . . . . . . . . . . . . . . . . . fit=tom � _p (Name of individual si � � n P Y gn r,g contract) ��."9iw" �i' g dui .X sworn, deposes and says that he is the applicant above.4amed. di He is the (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner let forth, in the application filed therewith. Sworn to beforemethis 1 p . ... . . . . . . . . . •1. . . . . . . .day of. Notary Public, .Qu��`olc . . . ,M. . . ,l my DONNA M. FOSCO Notary Public State of New York . No,52.46 2S ' ' ' Qualified in Suffoi County qq (Signature of applicant) Commission Expires 30, 181 , e(Z-,