HomeMy WebLinkAbout26515-z FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-27124 Date: 06/06/00
THIS CERTIFIES that the building AIR CONDITIONER
Location of Property: 4070 ROCKY POINT RD EAST MARION
(HOUSE NO. ) (STREET) (HAMLET)
County Tax Map No. 473889 Section 21 Block 4 Lot 1
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated MARCH 31 2000 pursuant to which
Building Permit No. 26515-Z dated MAY 23, 2000
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 INSTALLATION OF CENTRAL AIR CONDITIONING UNIT IN EXISTING ONE FAMILY
DWELLING AS APPLIED FOR.
The certificate is issued to WILLIAM & ARTEMIS GONTZES
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
ELECTRICAL CERTIFICATE NO. H-067453 03/24/00
PLUMBERS CERTIFICATION DATED N/A
(14 A64,-
Authorized Signat re
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. 26515 Z Date MAY 23, 2000
Permission is hereby granted to:
WILLIAM & ARTEMIS GONTZES
PO BOX 355
EAST MARION,NY 11939
for
INSTALLATION OF CENTRAL AIR CONDITIONING UNIT AS APPLIED FOR.
at premises located at 4070 ROCKY POINT RD EAST MARION
County Tax Map No. 473889 Section 021 Block 0004 Lot No. 001
pursuant to application dated MARCH 3, 2000 and approved by the
Building Inspector.
Fee $ 75 . 00
Authorized Signa re
ORIGINAL
Rev. 2/19/98
Form No. 6
TOWN OF SOUTHOLDV-7
/ Z7�
II �(J 2�y0yy� {lt�iBUILDING DEPARTMENT �7 Firf CORA! TOWN HALL f�
765-1802 0
APPLICATION FOR CERTIFICATE OF OCCUPANCY
A. This application must be filled in by typewriter OR ink and submitted to the building
inspector with the following: for new building or new use:
1. Final survey of _property with accurate location of all buildings, property 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.
5. Commercial building, industrial building, multiple residences and similar buildings
and installations, a certificate of Code Compliance from architect or engineer
responsible for the building.
6. Submit Planning Board Approval of completed site plan requirements.
B. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and
.'pre-existing" land uses:
1. Accurate survey of property showing all property lines, streets, building and
unusual natural or topographic features.
2. A properly completed application and a consent to inspect signed by the applicant.
If a Certificate of Occupancy is denied, the Building Inspector shall state the
reasons therefor in writing to the applicant.
C. Fees
1. Certificate of Occupancy - New dwelling $25.00, Additions to dwelling $25.00,
Alterations to dwelling $25.00, Swimming pool $25.00, Accessory building $25.00,
Additions to accessory building $25.00. Businesses $50.00.
2. Certificate of Occupancy on Pre-existing Buildine - $100.00
3. Copy of Certificate of Occupancy - .25c,.
4. Updated Certificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00
Date . . (.. . �u . . . . . . . . . . . . . . . . . . . . . .
New Construction. .. . . . . . . Old Or Pre-existing Building. . . . . . . . . . . . �
Location of Property.. . v7 �. .!At*yztA.s . ...4:.�T.
House N//o__..� Street Hamlet
Onwer or Owners of Propertyk!M4. . Y7 fi�Fy. ST .. . . . N. . . . . . . .. . . . . . . . .
County Tax Map,�173 100, Section. . . . .. . . ..Block. QA0.)L . . . . . .Lot. . . . A .0. 1. . . . . . . . . . .
Subdivision. . . .]]. . . . . ... .. . . . . . . . . . . . . . .. . . . . . . .. .Filed Map. . . . . . . . . . . .Lot. . . . . . . . . . . . . . . . . . . . . .
Permit No. . �G P.jai . .Date Of Permit. . ? . . . . . .Applicant. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Dept. Approval. . . .. . . . ... . . . . . . . . .. . .. . .Underwriters Approval. . . . . . . . . . . . . . . . .
Planning Board Approval. . . . . . .. . .. . . . ... . . . . . . .
Request for: Temporary Certificate. . . . . . .. . . . Final Certicate. . .' . .
Fee Submitted: $Y?. . . . . . . . . . . . . . . . . . . . .
.,� . . . . . . . . . . . . . . . . . . . . . . . . .
APPLICANT
C.a �a �12y
MANE" TWE-D- 1
1 .1/2 - 5 Ton
Split System
Cooling or Heat Pump
Air Handlers
Models
TWE018,0249030,0365
042,048C;060C/D
w
r: t Akj'�N°sa
yic.o
l
PUB.NO.22.1298-04
0 American Standard Inc.1996 Tab 25— March 1996
Sent By: Nalloork uroup Inc; 16315802792; mar-3-00 1 :21PM; Page 2
TAMW� FAC ID X03 DwSO. No. 21 X14M7P01
ICs Hard 7b StopA 7)ux P"Ouct s°Cd°"
ModM
Uwrnun Type
SERVICE FACTS Date
F1N No.
Split System (Cooling Condensers Superro"s
Model: TTX042C100A1
Oro llaMMl—ThMd0VU"*rlloltdeW4 Nuk ftdhWwn a peRs6s1,and vwvkouderw Won.This to custonwr propsny snd Is r4 sn s n
srlNh tblsuMt.Plw►MsrTrWes.YketrfenadW Pastupon"oq&Mfi"Mw&
4 eY ► SCON N ECT POW Eri L3E FoR
IX"
000000 mir t0oA1
PINR.ODBNIL—wph4Y 200,23plU60 TUBING IF�ORMAT(ori
Min,Yrch.Cir.Anwo* 23
W Or,—Mo.(m") 40
ruWrq tN1we Addman.l
Prot.Rip.•••Reu1d.(Angry to iuoko CIW W Tubing Length RdNyvsm
DESS ;" �6 7ro' am zs o M.
N0.Und—Spoofs 1.1 74, 3m. 3Y 5 w
VN wphmT 20N23011140 Ire• 3W 40 11 oz.
RL Amps—L.R.AV" 16.41 7/8. 3w 37 1401.
0%.Ct.SeNC.Cur.Mips 17 1Jny IwgYwN ewY.etsNy(/Al r.Ywe ut+Iere,Kip YnoY,r
OUTDOOR TAN 6r"wior nw..aY•u.YTwr1aN,
OK(in.)—No.Us" 24.1
Type 000—No.Speeds tinct-2
CFM 0 OA in.wV. $642
No.1496pra—HP 1-114
MOW Speed R.P.M. 625
VobAlhlix 2000MI180
F.L.Amg 1 A
OUlOOOR OWL—Type ----.- Ftl^ `� ons.amwo.rauw"wr wni.rnwnnaow
Roy—F.P.I. 1 -7r1 mllree♦ereer4YV Mnw X.I rrww4l0.
Fen Anu(sq.A) 2601 mewuewr NYwne..�wn ws sl.e.rae...sal.w Y.w wm rUCR
Ywwres.Y er en .
I441i�^) 3S Ne
_ eewwssw .olc.. owYr
LIms.—H ERA-2 mnY mvw rspFY.MrY.ro.menu«wre eY uiw.wmem4M rM
Lbs,�pr0(DD.Unto Lbs•tooz. nerurNee.
py voted Yee eY
A
""wv"P.rwN.sO R:Ynr lM.imYr ep A;Ma M•Umw.
LinoSlra�-In.On.Got 7A1 "w+e+•a wo. ra pw"r rips.wvN Mn.se Pmn.
Ltr Sins—M.O.C.Uq. 3m m.r.,e:eIA w ar-7ros.
i SOV
Folmaw Orton lS2e .063
S N W M
c - tin.) 46.1,2 X 4/X 37
MMDM
ppWV Ms.) 341
DIN(IbeJ 313
SAFETY WARNING
THIS INFORMATION IS IWENMD FOR USE 6Y tNDIMUALS POS- ALL PARTS OF TM PRODvOr WAKE OF CONDUCTING
11ESSING AOEOUATE BACKGROUNDS OF ELECTRICAL AND MECHANI- ELECTRICAL CURRENT ARE GROUNDED.IF GROUNDING
(:AL EXPERIENCE.ANY ATTEMPT TO REPAIR A CENTRAL AMI CONDI- WIRES, SOREM, STRAPS. CLIPS, NUTS OR WASNEM*
TIMING PRODUCT MAY RESULT N PERSONAL I LIURY AND OR USED TO COMPLETE APATH TO GROUND ARE REMOVED
PROPERLY DAMAGE.TME MANUFACTURER 09 SELLER CANNOT 6E FOR SERVICE, THEY MUST SE RETURNED TO TMEIR
RESPONB{61.E FOR THE NMRPF40TATION OF THIS INFORMATION, ORIGINAL POSMON AND PROPERLY FA3TENE0
?4OA CAN rr ASSUME ANY LIMRM N OONNEC110N YM-H ITS USE.
G2l011t;.ft"ew wNNrArmNY w•Mwr M4bwN+YwsweM selrs��l
NweenreMrl/4 YYYNeN INNrINIeNerllMeeslel mNM11 Pop CWWYVV
"�' PL 1161
4)Amwim SORY3e d Inc. 1964
TRANS' 1- 1/2 — 5 Ton XL 1200
TTX018 - 060C Split System
It's Harr/7b Stop A Vane Cooling�y
Specifications: 1 Phase
Nom. Cap. Required Uncrated
Model Power Cooling FCCV Dimensions(in.) Mfg. Shipping
Number Supply (BTUH) Size H W D Plant Weight
TTX018C100A 200/230/1/60 18,000 .055 35 32 29 TY 241
TTX024C100A 200/230/1/60 24,000 .061 39 32 29 TY 254
TTX030C100A 200/230/1/60 30,000 .069 43 32 29 TY 293
TTX036C100A 200/230/1/60 36,000 .077 43 39 35 TY 340
TTX04 OA 200/230/1/60 42,000 .083 43 39 35 TY 341
- X048C100A 00/230/1/60 48,000 .086 43 39 35 TY 345
TTXU6UCTOOA 200/230/1/60 60,000 .092 51 39 35 TY 354
Accessories:
Model -- Mfg. Shipping
Number Description Used With Plant Weight
Extended Warranties—(1 yr - 5 yr - 10 yr—See Extended Warranty Section)
TAYSTAT300 XT 300 Programmable Therm. All Cooling Models TY 2
TAYSTAT302B XT 302 Elec. 2 Stg. Htg/1 Clg All Cooling Models TY 1
TAYSTAT241 Manual 2 Stq Htg.!1 Clg All Cooling Models TY 1
TAYSTAT250A Outdoor Thermostat Cooling & Heat Pump Models TY 1
BAY28X182O 1-Stage Htg/Clg Therm. All Cooling Models TY 1
BAY28X183O 2-Stage Htg/Clg Therm. All Cooling Models TY 1
BAY28X185O Subbase (Man. Changeover) BAY28X182,183 TY 1
BAYSTAT304 Cooling Only w/Fan Switch Ali Cooling Models TY 1
BAYSTAT305 Heat/Cool (Vertical) Therm. All Cooling Models TY 1
AY28X092 Heat/Cool (Horiz.) Therm. All Cooling Models TY 2
BAY28X1900j Locking Thermostat Cover Room Thermostats TY 2
AY28X079 Evap. Defrost Control Kit All Cooling Models TY 1
BAY24X045 ID Fan Delay Relay Kit All Cooling Models TY 1
TAYASCT501A 5 Minute Delay Relay All Cooling Models TY 1
C)Requires Subbase
OSpecifically designed for electric heat applications(instant on fang
O Not for use with programmable thermostats.
Features:
• Super high efficiency up to 14 SEER •Top cover/motor mount/grille
•Trane built Climatuff compressor combined
• Spine FinT" aluminum outdoor coil • Rubber isolator pads
•Brazed refrigerant connections • Fast draining base pan
• Multi-use service valves •Compressor crankcase heat
•Two-speed fan for quiet operation provided
• Noise enclosure • Liquid line filter-drier = —
•WeatherGuardT" top shields unit • Single side service access = c—
• Steel cabinet, full coil protection • Improved appearance and c
• Powder paint covers uniformly to performance — c
resist rust & corrosion • Low noise rating number
•Attractive silver gray color • Built-in start kit '
• Compressor internal overload • Low ambient cooling to 40°F.
protection for over temperatures & with accessory AY28X079, aaaa��
low pressures 30°F. with TXV
• Internal pressure relief valve, pro- • 10 year limited warranty on
vides high pressure protection for compressor & coil, 2 year on
compressor parts (Residential use)
• Easy top cover removal •Optional extended warranties
Effective date: January 1, 1998 Page 6
Mechanical
Specifications
General Fan
Blower coil units shall be completely Forward curved,dynamically and
factory assembled including coil, statically balanced with 3 speed direct
condensate drain pan,fan,motor, drive shall be standard,fan motor
fitters and controls in an insulated bearing shall be permanently
casing that can be applied in horizontal lubricated.
or vertical configuration.
This new line of TWE-C Air handlers Controls
provides.exclusive compact size Low voltage terminal board,fan
combined with simple 4-Way contactor,and plug in module for
convertibility in sizes up to 5 Tons. accessory electric heat control shall be
The unit ships in the right hand included.TWE models shall also
horizontal configuration and converts include check valves.
to vertical upflow just by standing the
unit on end.No tools required.Simple Fitters
coil rotation provides downflow and Filters shall be included as standard,
horizontal left applications. One inch low velocity semi-permanent
The 4-Way convertibility provides you type(except 5 ton-washable filter).
inventory benefits and service/
installation flexibility.The simple Accessories
conversion provides opposite side Electric Heaters—Shall be available
access for installation and service. in a wide range of capacities and
These Air Handlers enjoy the best voltages with various staging options,
reputation in the industry.Superior and plug-in control wiring.Heaters
airflow,great sound level,reliability shall fit inside internal compartment.
and performance are responsible for
the industry leadership.We are not
about to give up such top
performance.
Units shall be UL listed and C.S.A.
certified.
Casing
Units shall have rugged sheet metal
and steel frame construction and shall
be palmed with an enamel finish.
Casing shall be insulated and
knockouts shall be provided for
electrical power and control wiring.
Refrigerant Circuits
The TWE units shall have a single
refrigerant circuit.TWE030-048C
refrigerant circuit shall be controlled by
a flow control check valve(FCCV)
TWE060C.Refrigerant circuit shall be
controlled by a factory-installed
thermal expansion valve.
Coil
Aluminum fin surface shall be
mechanically bonded to 3/8 Inch OD
copper tubing.Coils shall be factory
pressure and leak tested.
13
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1
8079026 BUREAU OF ELECTRICITY
F 40 FULTON STREET, NEW YORK NY 10038
Date MARCH 24,2000 Application No. on file 8800/00 H 067453
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicant named on the above application number is in the premises a,
WILLIAM GONTLES, 4070 ROCKY POINT ROAD, E. MARION, NY
in the following lac-ftcq r°wr
Elist PL E] 2.d Pl. ATTIC/OUT section stock Lot
was examined on and found to be in compliance with the National Electrical Cade.
FIXTUREFIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FAN
OUTLETS RECEPfAC1ES SWITCHES NCAMESCE FLUORESCENT I OTHER AMT. K.W. AMT. K.W. AMT. K.W. AMT. K.W. AMT. H.P.
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'P[. TIME CLOCKS SELL UNIT HEATERS MULTI-OUTLET DIMMERS
SYSTEMS
AMT. K.W, OIL N.P. GAE H.P. AMT. NO. A.W.G. AMT. AMP. AMT, AMPS. TRANS. AMT. X.P. NO.OF FEET AMT. WATT=
SERVICE DISCONNECT NO.OF S E R ' V I - C E
METER . CONO. A W.G.& . .G. .
AMT. AMP. TYPE EQUIP. 1 e 2W 1 R 3W 3 e SW 3 e 4W NOOf PERCC Of bM NO.OF 111-LEG OAHIWLEG NO.OF NEUT M OAW.O.
FNEUTRAL
OTHER APPARATUS:
4 TON AIR CONDITIONER-1
MOTORS:1-4 H.P. ,1-F H.P.
PANELBOARDS:1-1 CIR. 60
KOLB MECHANICAL CORP
11500 OLD SOUND AVENUE
P O BOX 106 GENERAL MANAGER
MATTITUCK, NY, 11952 11
Per _ _. �'75
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.
765-1802
BUILDING DEPT,
INSPECTION
[ ] FOUNDATION IST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ J.FINAL
[ ] FIREPLACE S CHIMNEY
REMARK '
DATE INSPECTO
765-1502
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [[ ] INSU ATION
[ ] FRAMING =NA
[ ] FIREPLAC & CHIMNEY
REMARKS:
DATE a" INSPECTOR
FIELD INSPECTION RFPORT DATE COMMENTS
----- ----- — ---- ----�___=====s----- --------------------
FOUNDATION
FOUNDATION OST)
u
II B w"
FOUNDATION OND) j
________________________ __ ___ _______________________________________________________
u
II
ROUGH FRAME &
PLUMBING
II _Ji
II II
II II �
II jj H
INSULATION PER N. Y. 11
STATE ENERGY
CODE a ii
u ,1
u II
n u
it jj A
II
FINAL p
II �ryl
--------------------- ------=-- — N
��__=--________--- ----------------- O So
ADDITIONAL COHM[ENTS: N
H
i
H �
z
a
r�
ro
H
BOARD OF HEALTH
FORM NO. 1 3 SETS OF PLANS . • • • • . .
. . . . . . . . . . . . . .
TOWN OF SOUTHOLD SURVEY . . . . . . . . . . . . . . . . . . . . . . . .
BUILDING DEPARTMENT CHECK . . . . . . . . . . . . . . . . . . . . . . . . .
TOWN HALL SEPTIC FORM
SOUTHOLD, N.Y. 11971
TEL: 765-1802 NOTIFY:
CALL . :Z
Examined..... �J1. ..... 20.... MAIL TO: . . . . . . . . . . . . . . . . . . . .
x10515 -�
Approved...../ .�.... '...... Permit No. .. ...................................
Disapproveda/c .................................. ...................................
......................................................
..D,
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
Date. . . . . . . . . . . . . . . . 20. . . .
INSTRUCTIONS
a. 'lois application must be cxnpletely filled in by typewriter or in ink and submitted to the Building Inspector wi
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 mist be drawn on the diagram which is part of
this application.
c. The work covered by this application my not be oortmenced before issuance of Building Permit.
d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such
permit shall be.kept on the-premises available for inspection throughout the work.
e. No building shall be occupied or used in whale or in part for any purpose whatever until a Certificate of
Occupancy shall have been granted by the Building Inspector.
APPLICATION IS HEREBY MALE to the Building Department for the issuance of a Building Permit pursuant to the
Building lone 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
describe. 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 neves inspections.
................
(Si tune of applicant, orrn me, if a co ration)
):VAIZ-4 - 1';AAA , P/-
-;1. v. ,. ........................��.%�Gr ...
Ve, ,.4 IMA ,. tt;;` �„ (Mailing address of applicant) 1 /-0/7
4prt=r-ft-oar ;9 lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
`'.' ,a y -� g,3.�•...,. ` i'C':{................................... ............... ............................
"!?T AIS 16 QT ': F d C �'I;c1� Lo
Name ofr .. .......
00'. f { ' -( on the tax roll or latest deed) .....................................
signaUwe of duly authorized officer.
., ..� ................
(Naee pfficer) ,
T34k. ;.!l+1: yt € t3,vt?I' i�JJ . 1 C3it ' tfc*
YA+
Yraf1311 ..................
Electricians License Pio. .....................
Other Trade's License No. ....................
1. Locatio�np of land on which proposed work will be done..............................................................
House Number v Street Hamlet
County Tax Map No. 1000 Section . /...�
. � Block aS/.:..'.�`.:./.. Lot
Subdivision ...................................... Filed Map No. ............... lot ...............
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and oc ..............................................'...........................
b. Intended use and occupancy ..... ..fi .f. ....... .. .. .�.........................
1. Nature of work (check whidh applicable): New Building .......... Addition ... Al er }�.q�
Repair ............ Removal ............. Demolition ............ Other Work /f�� aGCttt.. .4!i�l./.V
Y (Description)
Estimated Cost .. fee
(to be paid on filing this application)
If duelling, number of dwelling units ............ Nuhber of dwelling units on each floor ................
Ifgarage, cumber of cars ......................................
If business, commercial or mixed occupancy, specify nature and extent of each type of use......................
Dimensions of existing structures, if any: Front................ Rear ............... Depth .................
lleight ......................... Faber of Stories ......................
Dimensions of same structure with alterations or additions: Front ............... Rear .......
Depth .................... Height .................... Number of Stories ...............
Dimensions of entire new construction: Front ................ Rear ................ Depth ..............
Height ......................... Number of Stories .....................
Size of lot: Dont .................... Rear .................... Depth ....................
0. Date of Purchase ..................... Ham of Former Owner ........................................
I. Zone or use district in which premises are situated ..............................................................
2. Does proposed construction violate any zoning law, ordinance or regulation: ........................
3. Will lot be regraded .................... Will excess fill be removed from premises: YES NO
4. Names of Owner of premises ........................... Address .............................. Phone No. .............
Name of Architect .................................... Address ........ ...... .......... Phone No. .............
CAr
Name of Contracto 4� .. .. Address/XliQ ... ...Pho e�No. �I��.SS,3�fC
YES y _
5. is this property within 300 feet of a tidal wetland? * ......
*1F YES, SWMD MW T1alS E S PERMIT MAY 8E MQIIRED. 9✓ v
PLOT DIAGRAM ,
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensilms
rom property lines. Give street and block ember or description according to deed, and show street names and indicate
hether interior or corner lot.
APPROVED AS MD_
DATE' o,
FEE:
1"r. € rl
$$ NOTIFY BUILDING t?EPARt11AENT AT
766-1802 8 AM TO 4 PM FOR THE
fjV. t FOLLOWING INSPECTIONS:
1 FOUNDATION - TWO REQUIRED
FOR POURED CONCRETE
2. ROUGH - FPAM04 i PLUMBING
3. INSULATION
4. FINAL - CONSTRUCTION MUST
UNDEAWRII CERnMTE BE COMPLETE FOR C.O.
RMOp ALL CONSTRUCTION SHALL MEET
THE REQUIREMENTS OF THE N.Y.
TAIr or Nva Yo w, STATE CONSTRUCTION • ENERGY
SS CODES. NOT RESPONSIBLE FOR
owly ar ....................... DESIGN OR CONSTRUCTION ERRORS
, S•..•• ..... ........................being duly sworn, deposes and says that he is the applicant
Name of individual signing contract)
bove named,
eis time .................{ .( f7; ::. .................................................................
(Contractor, agent, corporate officer, etc.)
f: said owner or owners, and is duly authorized to perform or have performed the said work acyl to make and file this
ppl.ication; that all statements contained in this application are true to the best of his knowledge and belief; and
hat the work will be performed in the manner set forth in the application filed therewith.
koorn to before me this
...... ........ day of ................... ........
Notary Public .. ...:llc%�....
!,..
CE M.WILKtNS ..... .............
bile.State of New York (Signature of Applicant
982248,Suffolk County
rfn Expires June 12, 0
)