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HomeMy WebLinkAbout25671-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-26578 Date: 07/20/99 THIS CERTIFIES that the building ADDITION CUTCNOGUE Location of Property: 600 BEEBE DR (HOUSE NO.) (STREET) (HAMLET) County Tax Map NO. 473889 Section 97 Block 7 Lot 5 Subdivision Filed Map NO. -- Lot No. -- conforms substantially to the Application for Building Permit heretofore filed in this office dated OCTOBER 15, 1998 pursuant to which Building Permit No. 25671-Z dated APRIL 7, 1999 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 'SUNROOM ADDITION TO AN EXISTING DECK AS APPLIED FOR. The certificate is issued to RICHARD SIRIANO & WF. (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED N/A N/A N/A ~ B~i ding'Inspector Rev. 1/81 FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Hall Southold, N.Y. (THIS BUILDING PERMIT PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) PERMIT NO. 25671 Z Date APRIL 7 99 Permission is hereby granted to: RICHARD SIRIANO 2105 63RD ST BROOKLYN~NY 11204 for : ENCLOSING AN EXISTING DECK ADDITION AS APPLIED FOR AND TO THE CONDITIONS OF DEC. at premises located at 600 County Tax Map No. 473889 Section 097 pursuant to application dated OCTOBER Building Inspector. BEEBE DR Block 15 98 CUTCHOGUE 0007 Lot No. 005 and approved by the Fee $ 75.00 ~ev. 2/19/98 ORIGINAL · ~ =~-~e~ti~n must be filled in by typewriter OR ink and submit to the buildiz ~~g~ thel following: for new building or new use: - ~. ~i~tv'~y~o~.property with accurate location of all buildings, property linea 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 build~ and installations, a certificate of Code Compliance from architect or engineer responsible for the building. ~.Submit Planning Board Approval of completed site plan requirements. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings Vpre-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 %he applica~ If a Certificat~ ~f 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, Sw~ming pool $25.00, Accessory building $25.00 Additions to accessory building $25.00. Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Butldin~ - $100.00 3. Copy of Certificate of Occupancy - = 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $17~00, Commercial $15.00 ~ Date .... ~/~ i/f2. ..................... New Construction ..... Old Or Pre-existing Building ................. z.o Dr. ... Location of Property ............................ · .......... House No. Street Hamlet Onwer or Owners of Property ..... ~J..~.~-- --~- --.~.;.f-f-Q~--- --'' ........................ '' County 1000, Section...%7 ....... Bloc ...q ............ .............. Subdivision..,.....,.-.. ............... · . Filed Map ............................ ~. ~ ~ ~ .-~.D ~ Appli '' Permit No ...... ~. ate Of Permit ............... cant ...................... - Health Dept. Approval .................. Underwriters Approval .................... Planning Board Approval........-. ........ .. -..- Request for: Temporary Certificate ........... Final Certicate.% Fee Submitted: APPLICANT 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION2ND [ ] INSULATION [ ] FRAMING [~] FINAL [ ] FIREPLAC~. HIMNEY REMARKS: ~ 765..1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ]ROUGH PLBG. [ ] FOUNDATION 2ND [ ] FRAMING [ ] INS~ILATION [ ~'~NAL [ ] FIREPLACE & CHIMNEY REMARKS: 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] FOUNDATION 2ND [ ] FRAMING [ ] FIREPLACE & CHIMNEY [ ] ROUGH PLBG. [ ] INSU~TiON [/~'~AL ~ REMARKS: , ~/g~, (/~2 // ...... ~~~~ ~ ~~ DATE INSPECTOR EDWARD FORRESTER Director of Code Enforcement BUILDING DEPARTMENT TOWN OF SOUTHOLD Southold Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (516) 765-1823 Telephone (516) 765-1802 July 14, 1999 Riverhead Glass & Screen 389 Rte. 24 Riverhead, NY 11901 RE: Richard Siriano, 600 Beebe Drive, Cutchogue. 1000-97-7-5. If electrical is installed, an Underwriters Certificate is required. To Whom This May Concern: We are unable to complete your Certificate of Occupancy because of the following reasons: ~//XX An application for Certificate of Occupancy is not on file. (Enclosed) No Underwriters Certificate on file. ~ ~ . _ XX The check is (not on file.)$25.00 No Health Department Approval on file. No final inspection has been made. No Plumber Solder Certificate on file. (All permits involving plumbing being issued after April 1, 1984). BUILDING PERMIT # 25671-Z Please contact our office on this matter. Thank you for cooperation. SOUTHOLD TOWN BUILDING DEPT. APPROVED AS NOTED NOTIFY BUILDING DEPAflT~NT 78B.1802 9 AM TO 4 PM 'FOR THE FOLLOWING INSPECTIONS: 1 FOUNDATION - TWO REQUIRED FOR POURED CONCRETE ~. ROUGH - FRAMING & PLUMBING $. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE N STATE CONSTRUCTION & ENERGY CODES. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS USE ~8 U~1BWFUL W~TH@UT CERTiFlCXI'E OF CERTIFICATE & .e~ © ® ~C'TION.~ X-X [-N. crm- E,o~ 'cmo To t' N' \THERMAL BREAK EXTRUSIONS NEW ONE PIECE E-GUTTER 3:12 GABLE RIDE BEAM ROOF PANEL CONNECTION 3A2 FLAT I TOP CAP FASCIA CORNER POST DRC CHANNEL RECEIVING CHANNEL H-MULL BASE CHANNEL HEADER (Support Wall Structure) We at ELITE Panel Products, believe that pictures speak louder than words. With just one look the advantages of our THERMAL BREAK EXTRUSION SYSTEM can be seen. This system totally, thermally separates outside surfaces from inside. Our Thermal Break Extrusion System offers many benefits to an exterior application. One of the most important is its ability to deliver a consistant resistance to heat or cold value (R-Value) to the entire structure not only the panels. Furthermore, condensation which could occur on the inside of the structure, due to a difference in out side temperature, is literally eliminated. The ELITE Thermal Break Extrusion System separates outside surfaces from inside by means of a centrally located pocket filled with a non-thermal conductive material, urethane resin with hardener. This filled pocket does not have any diverse affects on the quality or strength of the structure. Full structural integrity is guaranteed and assured. The ELITE Thermal Break Extrusion System is now available as an option to our existing system and, as with all ELITE manufactured products, is covered by our FULL 10 YEAR WARRANTY. Consult the ELITE Price List & Estimating Guide and/or the General Specifications Sheet for more information. ELITE Panel Products ON[sion of ELITE Aluminum Corp. 3126 John P. Curci Drive · Pembroke Park, Florida 33009 (305) 966-1050 · (800) 421-0682 FL · (800) 5-ELITE-7 (535-4837) USA ° FAX (305) 962-4172 ISULATION PER N. ¥. STATE ENERG'Y CODE II II Fe~-01-99 02:19P Dynacote 718 499 0291 Town Hall S$0OS Main ~gd P.O. Box 1179 Southold, New York 11971 Telephone (5 lS) 765-1592 Fax (516) 705-1823 BOARD OF TOWN TOWN OF $0UTHOLD January 22., 1999 Richard & Theresa Siriano 2105 63rd Street Brooklyn NY 11204 RE: SCTM #97-7~5 Dear Mr. Siriano, The following action was taken at the Southold Town Board o£ Trustees meeting on Januaz~ 22, 1999: RESOLVED, that the Southold Town Beard of Trustees grant the request for a Waiver to enclose an existing deck with roof, glass and screens. However, this does not constitute approval from any other agencies. If you have any questions, please call our office at 765-1892. ~incerely, Albert J. Krupski, Jr. President, Board of Trustees AJK/djh cc. Bldg. Dept. 95-20-1 (8/87)--9d New York State Department of Environmental Conservation NOTIC The Department of Environmental Conservation (DEC) has issued permit(s) pursuant to the Environmental Conservation Law for work being conducted at this site. For further information regarding the nature and extent of work approved and any Depa. rt.mental .c. onditions on it, contact the Regional Permit Administrator I~sted below. Please refer to the permit number shown when contacting the DEC. Permit Expiration Number //"~-~:~'~ 01-,<-¢// Date Regional Permit Administrator ~'OHN W: PAVkACiC NOTE: This notice is NOT a permit AREA = ~ / ~° 30 ,~ . LOp $0 NYSDEC ANTLER LANE I0' CONTOUR REFERENCED TO N.G.V.D. AREA = 21,542 sq.!), (0~ 30 ANTLER LANE SURVEY OF LOT 29 AT EAST CUTCHOGUE TOWN OF SOUTHOLD SUFFOLK COUNTY, N. Y. Iooo - 097 07 05 SCALE )" -' 40' Mar. 26,f 997 April 17) 1997' #0' Contouri · CERTiFiED TO 86 - 664 ?New York State Department of Environmental Conservation D~vislon of Environmental Permits, Region One R,,ildinn ztO. SUI~yf Stony ~Brook, NY 11790-2356 4 4 3 444-0360 ~ ~0','. "~IOL~ John P. Cahill Commissioner April 2, 1999 Mr. Richard Siriano 2105 63rd Street Brooklyn, NY 11204 RE: 1-4738-01541/00005 Dear Permittee: In conformance with the requirements of the State Uniform Procedures Act (Article 70, ECL) and its implementing regulations (6NYCRR, Part 621) we are enclosing your permit. Please read all conditions carefully. If you are unable to comply with any conditions, please contact us at the above address. Also enclosed is a permit sign which is to be conspicuously posted at the project site and protected from the weather. Very truly yours, Claire K. Werner Environmental Analyst I CKW:cg enclosure NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION DEC PERMIT NUMBER 1-4738-01541/D0005 FACILITY/PROGRAM NUMBER(S) PERMIT Under the Environmental Conservation Law EFFECTIVE DATE April 2r 1999 EXPIRATION DATE(S) April 30, 2003 TYPE OF PERMIT · New [] Renewal [] Modification · Permit to Construct [] Permit to Operate [] [] [] [] [] Article 15, Title 5: Protection of Waters Article 15, Title 15: Water Supply Article 15, Title 15: Water Transport Article 15, Title 15: Long Island Wells Article 15, Title 27: Wild, Scenic and Recreational Rivers 6NYCRR 608: Water QuatiZy Certification [] Article 17, Titles 7, 8: SPDES Article 19: Air Pollution Control [] Article 23, Title 27: Mined Land Reclamation [] Article 24: Freshwater Wetlands · Article 25: Tidal Wetlands [] Article 27, Title 7; 6NYCRR 360: Solid Waste Management [] Article 27, Title 9; 6NYCRR 373: Razardous Waste Management [] Article 34: Coastal Erosion Management [] Article 36: FLoodplain Management [] Articles 1, 3, 17, 19, 27, 37; 6NYCRR 380: Radiation Control PERMIT ISSUED TO Richard Siriano ADDRESS OF PERMITTEE 2105 63rd Street Brooklyn? NY 11204 TELEPHONE NUMBER (718) 499-0291 CONTACT PERSON FOR PERMITTED WORK TELEPHONE NUMBER Same as above NAME AND ADDRESS OF PROJECT/FACILITY Siriano Property 600 Beebe Drive LOCATION OF PROJECT/FACILITY Cutchogue COUNTY TOWN WATERCOURSE NYTM COORDINATES Suffolk Southold East Creek DESCRIPTION OF AUTHORIZED ACTIVITY: Enclose existing 12 foot by 55 foot deck. By acceptance of this permit, the permittee agrees that the permit is contingent upon strict compliance with the ECL, att applicable regulations, the General Conditions specified (see page 2 & 3) and any Special Conditions included as part of this permit. PERMIT ADMINISTRATOR: Mark C. Carrara AUTHORIZED SIGNATURE CKW ADDRESS Bldg. #40, SUNY, Stony Brook, NY 11790-2356 DATE April 2? 1999 Page 1 of 4 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS Item A: Permittee Accepts Legal Responsibility and Agrees to Indemnification The permittee expressly agrees to indemnify and hold harmless the Department of Environmental Conservation of the State of New York, its representatives, employees, agents, and assigns for all claims, suits, actions, damages, and costs of every name and description, arising out of or resulting from the permittee's undertaking of activities or operation and maintenance of the facility or facilities authorized by the permit in compliance or non-compliance with the terms and conditions of the permit. Item B: Permittee to Require its Contractors to Comply with Permit The permittee shall require its independent contractors, employees, agents and assigns comply with this permit, including all special conditions, and such persons shall be subject to the same sanctions for violations of the Environmental Conservation Law as those prescribed for the permittee. Item C: Permittee Responsible for Obtaining Other Required Permits The permittee is responsible for obtaining any other permits, approvals, lands, easements and rights-of-way that may be required to carry out the activities that are authorized by this permit. Item D: No Right to Trespass or Interfere with Riparian Rights This permit does not convey to the permittee any right to trespass upon the lands or interfere with the riparian rights of others in order to perform the permitted work nor does it authorize the impairment of any rights, title, or interest in real or personal property held or vested in a person not a party to the permit. GENERAL CONDITIONS General Condition 1: Facility Inspection by the Department The permitted site or facility, including relevant records, is subject to inspection at reasonable hours and intervals by an authorized representative of the Department of Environmental Conservation (the Department) to determine whether the permittee is complying with this permit and the ECL. Such representative may order the work suspended pursuant to ECL 71-0301 and SAPA 401(3). The permittee shall provide a person to accompany the Department's representative during an inspection to the permit area when written or verbal notification is provided by the Department at least 24 hours prior to such inspection. A copy of this permit, including all referenced maps, drawings and special conditions, must be available for inspection by the Department at all times at the project site. Failure to produce a copy of the permit upon request by a Department representative is a violation of this permit. General Condition 2: Relationship of this Permit to Other Department Orders and Determinations Unless expressly provided for by the Department, issuance of this permit does not modify, supersede or rescind any order or determination previously issued by the Department or any of the terms, conditions or requirements contained in such order or determination. General Condition 3: Applications for Permit Renewals or Modifications The permittee must submit a separate written application to the Department for renewal, modification or transfer of this permit. Such application must include any forms or supplemental information the Department requires. Any renewal, modification or transfer granted by the Department must be in writing. The permittee must submit a renewal application at least: a) 180 days before expiration of permits for State Pollutant Discharge Elimination System (SPDES), Hazardous Waste Management Facilities (HWMF), major Air Pollution Control (APC) and Solid Waste Management Facilities (SWMF); and b) 30 days before expiration of all other permit types. Submission of applications for permit renewal or modification are to be submitted to: NYSDEC Regional Permit Administrator, Region 1, SUNY Bldg #-40, Stony Brook, NY 11790-2356 General Condition 4: Permit Modifications, Suspensions and Revocations by the Department The Department reserves the right to modify, suspend or revoke this permit when: a) the scope of the permitted activity is exceeded or a violation of any condition of the permit or provisions of the ECL and pertinent regulations is found; b) the permit was obtained by misrepresentation or failure to disclose relevant facts; c) new material information is discovered; or d) environmental conditions, relevant technology, or applicable law or regulation have materially changed since the permit was issued. DECPERMITNUMBER PAGE 2 OF 4 1'4738-01541/00005 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION ADDITIONAL GENERAL CONDITIONS FOR ARTICLES 15 (TITLE 5), 24, 25, 34 AND 6NYCRR PART 608 ( TIDAL WETLANDS) If future operations by the State of New York require an alteration in the position of the structure or work herein authorized, or if, in the opinion of the Department of Environmental Conservation it shall cause unreasonable obstruction to the free navigation of said waters or flood flows or endanger the health, safety or welfare of the people of the State, or cause loss or destruction of the natural resoumes of the State, the owner may be ordered by the Department to remove or alter the structural work, obstructions, or hazards caused thereby without expense to the State, and if, upon the expiration or revocation of this permit, the structure, fill, excavation, or other modification of the watemourse hereby authorized shall not be completed, the owners, shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill and restore to its former condition the navigable and flood capacity of the watemourse. No claim shall be made against the State of New York on account of any such removal or alteration. The State of New York shall in no case be liable for any damage or injury to the structure or work herein authorized which may be caused by or result from future operations undertaken by the State for the conservation or improvement of navigation, or for other purposes, and no claim or right to compensation shall accrue from any such damage. Granting of this permit does not relieve the applicant of the responsibility of obtaining any other permission, consent or approval from the U.S. Army Corps of Engineers, U.S. Coast Guard, New York State Office of General Services or local government which may be required. All necessary precautions shall be taken to preclude contamination of any wetland or waterway by suspended solids, sediments, fuels, solvents, lubricants, epoxy coatings, paints, concrete, leachate or any other environmentally deleterious materials associated with the project. Any material dredged in the prosecution of the work herein permitted shall be removed evenly, without leaving large refuse piles, ridges across the bed of a waterway or floodplain or deep holes that may have a tendency to cause damage to navigable channels or to the banks of a waterway. 6. There shall be ne unreasonable interference with navigation by the work herein authorized. if upon the expiration or revocation of this permit, the project hereby authorized has not been completed, the applicant shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove ali or any portion of the uncompleted structure or fill and restore the site to its former condition. No claim shall be made against the State of New York on account of any such removal or alteration. If granted under 6NYCRR Part 608, the NYS Department of Environmental Conservation hereby certifies that the subject project will not contravene effluent limitations or other limitations or standards under Sections 301,302, 303, 306 and 307 of the Clean Water Act of 1977 (PL 95-217) provided that all of the conditions listed herein are met. 9. At least 48 hours prior to commencement of the project, the permittee and contractor shall sign and return the top portion of the enclosed notification form certitying that they are fully aware of and understand all terms and conditions of this permit. Within 30 days of completion of project, the bottom portion of the form must also be signed and returned, along with photographs of the completed work and, if required, a survey. 10. All activities authorized by this permit must be in strict conformance with the approved plans submitted by the applicant or his agent as part of the permit application. Such approved plans were prepared by Richard Siriano on 2/15/99 . I OECPERMITNUMBER I PAGE 3 OF4__ 1-4738-01541/00005 I NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION SPECIAL CONDITIONS Any debris or excess material from construction of this project shall be completely removed from the adjacent area (upland) and removed to an approved upland area for disposal. No debris is permitted in tidal wetlands and or protected buffer areas. There shall be no disturbance to vegetated tidal wetlands or protected buffer areas as a result of the permitted activity. There will be no further additions or decks authorized seaward of this project in the future. I DEC PERMIT NUMBER I I PAGE 4 OF 4 1-4738-01541/00005 I I FORM NO. I TOWN OF SOIJTUOLD BUILDING DEPARTMENT TOWN UALL SOUTHOLD, N.Y. 1J971 TEL: 7~5- 1802 Disapproved a/c ............................ .. . .. . SURVEY ....................... CHECK ............... -~ ..... .~... SEPTIC FORM ................ . .. · ~ ~"'MAIL TO: ............ ' ....... ~_~?~.¥,~ : Date ............ , ~ . .. ~~i~_~o___J I~ST~UCTiO~S a. 'Ibis applicetion must ~ ~letely fill~ in by ~iter or in i~ ~ ~itt~ to ~ ~ildi~ Ins~ctor w 3 ~ts of pl~, ~ate plot pl~ to ~le. F~ ~co~i~ to ~le. b. Plot pl~ ~ l~ti~ of lot ~ of ~ildi~s ~ pr~s, ~lati~ip to ~joini~ pr~s or ~lic struts or ~e~, ~ glvi~ a ~tail~ ~ripti~ of lay~t of ~ ~t ~ ~ ~ ~e di~ ~i~ is ~rt of this c. '~m ~ c~r~ ~ ~is a~licati~ my ~t ~ ~ ~fore isle of ~ildi~ Pemit. . d. ~it ~11 ~ ~pt ~ ~ ~s avail~le for i~tim thr~mt ~ ~rk. e. ~ ~ildi~ ~11 ~ ~i~ or ~ in ~le or in ~rt for ~ ~ ~tever ~til a ~rtificate of ~ ~all ~e ~n ~t~ by ~ ~ildi~ ~tor. R~I~I~ IS ~ ~ to t~ hildi~ ~mnt for fl~e isme of a ~ildi~ Pe~t ~t to t~ ~ildi~ ~ ~i~ of ~ ~ of ~ld, ~ffolk ~, ~ Yo~, ~ o~er a~li~le ~, ~i~es or ~lati~, for ~ mt~tim of ~ildi~, ~itim or alterati~, or for r~al or ~llti~, ~ ~rein ~ri~. r~lati~, ~ to ~{t ~ri~ i~tors ~ ~s ~ i~ldi~// for ~s~ i~ti~. (Si~t~e of a~li~t, ~r ~, i~ a ~ration) .... (~ili~ ~mse of ~plic~t) State wlmti~e, r applicant ia c~ner, ~essee, agent, architect, engineer, general contractor, electrician, plunber or beilde~ N~ae of ~mer of premises ........... (as on tim tax roll or latest deed) If applicant is a corporation, si~uature of duly auti~orlzed officer. (Nmm and title of corporate officer) Plumt~ers License Eo ................... Electricians License No .... ..................... !. Iocation of land tm which proposed work will be done ...................................................... .................................................................... ............................ CountyTaxMapNo, 1000 Section .,~.~.. ......... Block ..... :~.. ....... I~t ..... ~ ....... S~bdivision ..~..0 ....~.~.0.$.'~..two ..... Filed Mm,~ Not ~ ~ ../! ........ ...... . ................................... 2. State existing use and occupancy of premises 'and inten~d use and occupancy of proposed co~strnetion: a. E~dsting u~ and occupancy....~.. .... ~.: ................................................ .': - 'q e%on - . ~., o~ ~.,.. neo~--r~ .... ~.~ .... ~. ..... ~ ................. 4' .......................... ........... I0. II. 12, 13, 15. From properLy lines. Give steer ~/aether interior or corner lot. F,~ture of ~ork (check gldch apphcable): Ne~ Doildin§ .......... Mdltion ......... Alterationl .......... ~ir ............ ~1 .. ~ .......... l~litt~ ............ Other ~ .~ fi~..~ ........... (to ~ ~id m filina this a~li~tim) If ~ra~ ~r of ~rs I[ ~i~ss~ ~u~rcial or ~ ~ ~ei~ ~mre ~ ~[ent of ead~ ~ o~ ~ ...................... Di~nsi~s 9i~i~ o[ ~ st~e ~h alterables or ~itions: ~t ............... ~ar ............... ~Ce of ~rdm~ ~ ~ of Four ~r ............ ~ or u~ district in ~i~ p~i~8 am ~imt~ .............................................................. ~ill 1o~ ~ ~ ' ~ill PLOT ~ate clearly ~ dlsti~tly ~11 ~ildi~s, ~mflmr ~isti~ or pro~, ~ i~iea~e, ali ~t-~ dimnsions bl~ ~r or ~scripti~ acco~ing to ~ a~ ~ strut ~s ~ i~icate COUN[¥ OF ....................... (Na~e of individual sigaiug contract)! duly ~m, delxz,~ee ami .qays timt he is tt~ applicant I~ i,~ the ...... ._. ...:...~t~ ......... : ......... ; ................ , ............................... o[ ~id ~r or ~rs, a~ is ~[y ~thori~ to ~rfom or h~ ~r[o~ tim ~id ~ ~ to ~ke a~ ~ile this a~l. ication; that all stat~nts c~t~[~ in ~is a~llcation are tn~ to U~e I~st o[ his ~1~ m~ I~liefl ~m Lo ~fore ~ thi~ ]  RtVERHEAO G~SS _. 389 RT. 24 RIVERHEAO, N.Y. 119m ........ (516) 727-~E~ ont)