HomeMy WebLinkAbout24811-z FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-25950 Date: 09/08/98
THIS CERTIFIES that the building ACCESSORY
Location of Property: 1850 NINTH ST GREENPORT
(HOUSE NO. ) (STREET) (HAMLET)
County Tax Map No. 473889 Section 49 Block 1 Lot 23
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated MARCH 23, 1998 pursuant to which
Building Permit No. 24811-Z dated APRIL 3, 1998
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 TWO CAR GARAGE IN FRONT YARD AS APPLIED FOR.
The certificate is issued to BERNARD KIRSCH
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
ELECTRICAL CERTIFICATE NO. N462452 08/17/98
PLUMBERS CERTIFICATION DATED N/A
Bu' dingnaI pector
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. 24811 Z Date APRIL 3, 1998
Permission is hereby granted to:
BERNARD KIRSCH
1217 PARK AVE
NEW YORK,NY 10028
for
CONSTRUCTION OF A TWO CAR ACCESSORY GARAGE IN THE FRONT YARD
AS APPLIED FOR.
at premises located at 1850 NINTH ST GREENPORT
County Tax Map No. 473889 Section 049 Block 0001 Lot No. 023
pursuant to application dated MARCH 23 1998 and approved by the
Building Inspector.
Fee $ 35 . 00
Buildin(g"InspectoW
ORIGINAL
Rev. 2/19/98
L5 Q Form No. 6 4p� �� Of
TOWN OF SOUTHOLD
AUG I BUILDING DEPARTMENT
TOWN HALL
FB(D OFPT. 765-1802
�Nry
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.
Be 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 Building - $100.00
3. Copy of Certificate of Occupancy - .25e
4. Updated Certificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00
Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
New Construction. . . . . . . . . . . Old Or Pre-existing Building. y-. . . . . . . . . . .
Location of Property. .�!0? .
House No. �p ' Streety� J Hamlet
Onwer or Owners of Property.De l : . E�. 1'C`ee
?% . 6� �. . . . . . . . . . . . .
County Tax Map No 1000, Section.`.�.1pp. . . . . . ..Block. .. . . . . . . . . . . . .Lot. .�3 . . . . . . . . . . . . . . .
Subdivision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..Filed Map. . . . . . . . . . . .Lot. . . . . . . . . . . . . . . . . . . . . .
Permit Nod'.•..'.�[ � . . . . . .Date Of PermitlT c��L . ��G7. .Applicant(�/.ti/.[l .caC�ktA 7—
Permit
Health Dept. Approval. . . .. . . . . . . . . . . . . . . . . . . . . .Underwriters Approval. . . . . . . . . . . . . . . . . . . . . . . . .
Planning Board Approval. . . . . . . . . . . . . . . . . . . . . . . .
Request for: Temporary Certificate. . . . . . .. . . . Final Certicate. . . . . . . . . . .
Fee Submitted: $. . . . . . RA.. . . . . . . . . . . . . . . . . . _
5 sK- S56 . . . . . . .t./ :P!t� � . . . . . . . . .
Cd '2,5 756 APPLICANT
O��SpFFO(K�,O
o Gys
Town Hall,53095 Main Road yy. T Fax(516)765-1823
P.O.Box 1179 Oy • ��` Telephone(516)765-1802
Southold,New York 11971
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
August 18, 1998
Bernard Kirsch
1217 Park Avenue
New York, New York 10028
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) /
XX No Underwriters Certificate on file'./
XX The check is (not on file. )$25.00 P
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 # 24811-Z
Please contact our office on this matter. Thank you for
cooperation.
SOUTHOLD TOWN BUILDING DEPT.
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I' JUDITH T. TERRY L� •`;� Town Nall. 53095 Main Rood
TOWN CLERK P O. [lox 1 179
Southold, New Cork 11071
REGISTRAR OF VITAI,STATISTICS I' e%1Gfl`•'�� �.
Fax (516) 765-1823
MARRIAGE OrrICER ��tl� y-�� Telephone (5 16 1 765-1801
RECORI)S MANAGEMEM•OFFICER ' O•(
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION WAS ADOPTED BY THE
SOUTHOLD TOWN BOARD AT A REGULAR MEETING HELD ON AUGUST 24, 1993:
RESOLVED that the Town Board of the Town of Southold hereby adopts
two (2) new forms to be used under the Flood Damage Prevent regulations
of the Code of the Town of Southold: "Floodplain Development Permit
Application" [FDP(93)] , and "Certificate of Compliance for Development in
Special Flood Hazard Area [C/C(93) ] .
TOWN OF SOU-MOLD
Ju Ith T. Terry
Southold Town Clerk
August 25, 1993
APPLICATION #_
PAGE 1 of 4
TOWN OF SOUTHOLD
FLOODPLAIN DEVELOPMENT PERMIT APPLICATION
This form is to be filled out in duplicate.
SECTION 1: GENERAL PROVISIONS (APPLICANT to read and sign):
1. No work may start until a permit is issued.
2. The permit may be revoked if any false statements are made herein.
3. If revoked, all work must cease until permit is re-issued.
4. Development shall not be used or occupied until a Certificate of Compliance is issued.
5. The permit will expire if no work is commenced within six months of issuance.
6. Applicant is hereby informed that other permits may be required to fulfill local, state and federal regulatory
requirements.
7. Applicant hereby gives consent to the Local Administrator or his/her representative to make reasonable
inspections required to verify compliance.
8. I, THE APPLICANT, CERTIFY THAT ALL STATEMENTS HEREIN AND IN ATTACHMENTS TO
THIS APPLICATION ARE, TO THE BEST OF MY KNOWLEDGE, TRUE AND ACCURATE.
(APPLICANT'S SIGNATURE) DATE
SECTION 2: PROPOSED DEVELOPMENT (To be completed by APPLICANT) q.77 X5/7
NAME ADDRESS TELEPHONE
AP LI ANT
BUILDER
ENGINEER
PROJECT LOCATION:
To avoid delay in processing the application, please provide enough information to easily identify the project
location. Provide the street address, lot number or legal description (attach) and, outside urban areas, the
distance to the nearest intersecting road or well-known landmark. A sketch attached to this application showing
the project location would be helpful.
FDP(93)
APPLICATION #
PAGE 2 OF 4
DESCRIPTION OF WORK (Check all applicable boxes):
A. STRUCTURAL DEVELOPMENT
ACTIVITY STRUCTURE TYPE
❑ New Structure ❑ Residential (1-4 Family)
f7 Addition ❑ Residential (More than 4 Family)
❑ Alteration ❑ Non-residential (FloodprooFmg? ❑ Yes)'
❑ Relocation ❑ Combined Use (Residential & Commercial)
❑ Demolition ❑ Manufactured (Mobile) Home (In Manu-
0 Replacement factured Home Park? 0 Yes)
ESTIMATED COST OF PROJECT S
B. OTHER DEVELOPMENT ACTIVITIES:
O Fill ❑ Mining ❑ Drilling 0 Grading
❑ Excavation (Except for Structural Development Checked Above)
0 Watercourse Alteration (Including Dredging and Channel Modifications)
❑ Drainage Improvements (Including Culvert Work)
❑ Road, Street or Bridge Construction
O Subdivision (New or Expansion)
❑ Individual Water or Sewer System
❑ Other (Please Specify)
After completing SECTION 2, APPLICANT should submit form to Local Administrator for review.
SECTION 3• FLOODPLAIN DETERMINATION (To be comuleted by LOCAL ADMINISTRATOR)
The proposed development is located on FIRM Panel No. , Dated
The Proposed Development:
❑ Is NOT located in a Special Flood Hazard Area (Notify the applicant that the application
review is complete and NO FLOODPLAIN DEVELOPMENT PERMIT IS REQUIRED).
❑ Is located in a Special Flood Hazard Area.
FIRM zone designation is
100-Year flood elevation at the site is: Ft. NGVD (MSL)
❑ Unavailable
D The proposed development is located in a floodway.
FBFM Panel No. Dated
❑ See Section 4 for additional instructions.
SIGNED DATE
APPLICATION #
PAGE 3 OF 4
SECTION 4: ADDITIONAL INFORMATION REQUIRED (To be completed by LOCAL ADMINISTRATOR)
The applicant must submit the documents checked below before the application can be processed:
❑ A site plan showing the location of all existing structures, water bodies, adjacent roads, lot
dimensions and proposed development.
CI Development plans,drawn to scale, and specifications,including where applicable:details for
anchoring structures,proposed elevation of lowest floor (including basement), types of water
resistant materials used below the fust floor,details of floodproofmg of utilities located below
the fust floor and details of enclosures below the first floor.
Also,
❑Subdivision or other development plans (If the subdivision or other development exceeds 50
lots or 5 acres, whichever is the lesser, the applicant must provide 100-year flood elevations
if they are not otherwise available).
❑ Plans showing the extent of watercourse relocation and/or landform alterations.
❑ Top of new fill elevation Ft. NGVD (MSL).
13 Floodproofing protection level (non-residential only) Ft. NGVD (MSL). For
floodproofed structures, applicant must attach certification from registered engineer or
architect.
❑ Certification from a registered engineer that the proposed activity in a regulatory floodway
will not result in any increase in the height of the 100-year flood. A copy of all data and
calculations supporting this finding must also be submitted.
❑ Other:
SECTION 5: PERMIT DETERMINATION (To be completed by LOCAL ADMINISTRATOR)
I have determined that the proposed activity: A. ❑ Is
B. ❑ Is not
in conformance with provisions of Local Law #_, 19 . The permit is issued subject to the conditions
attached to and made part of this permit.
SIGNED DATE
If BOX A is checked, the Local Administrator may issue a Development Permit upon payment of designated
fee.
If BOX B is checked, the Local Administrator will provide a written summary of deficiencies. Applicant may
revise and resubmit an application to the Local Administrator or may request a hearing from the Board of
Appeals.
APPLICATION # _
PAGE 4 OF 4
APPEALS: Appealed to Board of Appeals? ❑ Yes ❑ No
Hearing date:
Appeals Board Decision --- Approved? ❑ Yes ❑ No
Conditions
SECTION 6: AS-BUILT ELEVATIONS (To be submitted by APPLICANT before Certificate of Compliance
is issued
The following information must be provided for project structures. This section must be completed by a
registered professional engineer or a licensed land surveyor (or attach a certification to this application).
Complete 1 or 2 below.
1. Actual (As-Built) Elevation of the top of the lowest floor, including basement (in Coastal High Hazard
Areas, bottom of lowest structural member of the lowest floor, excluding piling and columns) is:
FT. NGVD (MSL).
2. Actual (As-Built) Elevation of floodproofmg protection is FT. NGVD (MSL).
NOTE: Any work performed prior to submittal of the above information is at the risk of the Applicant.
SECTION 7: COMPLIANCE ACTION (To be completed by LOCAL ADMINISTRATOR)
The LOCAL ADMINISTRATOR will complete this section as applicable based on inspection of the project to
ensure compliance with the community's local law for flood damage prevention.
INSPECTIONS: DATE BY DEFICIENCIES? 0 YES ❑ NO
DATE BY DEFICIENCIES? ❑ YES 13 NO
DATE BY DEFICIENCIES? 0 YES ❑ NO
SECTION 8: CERTIFICATE OF COMPLIANCE(To be completed by LOCAL ADMINISTRATOR)
Certificate of Compliance issued: DATE: BY:
Attachment B
SAMPLE
CERTIFICATE OF COMPLIANCE
for Development in a Special Flood Hazard Area
TOWN OF SOUTHOLD
CERTIFICATE OF COMPLIANCE
FOR DEVELOPMENT IN A SPECIAL FLOOD HAZARD AREA
(OWNER MUST RETAIN THIS CERTIFICATE)
PREMISES LOCATED AT: PERMIT NO.
PERMIT DATE
OWNERS NAME AND ADDRESS: CHECK ONE:
❑ NEW BUILDING
O EXISTING BUILDING
❑ VACANT LAND
THE LOCAL ADMINISTRATOR IS TO COMPLETE A. OR B. BELOW:
A. COMPLIANCE IS HEREBY CERTIFIED WITH THE REQUIREMENTS OF
LOCAL LAW #_, 19
SIGNED: V DATED:
B. COMPLIANCE IS HEREBY CERTIFIED WITH THE REQUIREMENTS OF
LOCAL LAW # , 19_1 AS MODIFIED BY VARIANCE #
DATED
SIGNED: DATED:
CIC(93)
I
M-1802
BUILDING DEPT.
INSPECTIO
[ ] FOUNDATION IST [ OUCH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
L l FRAMING [ ] FINAL
[ ] FIREPLACE A CHIMNEY
REMARKS:
1-01
DATE INSPECTO
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BUILDING DEPT.
INSPECTION
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[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ ] FINAL
[ ] FIREPLACE & CHIMNEY
REMARKS:'
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DATINSPECTOR
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THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1
1001071 BUREAU OF ELECTRICITY
40 FULTON STREET, NEW YORK, NY 10038
Date AUGUST 17,1998 EL Licat on No, on�zZe 16316698/98 N 452452
THIS CERTIFIES THATER[�IIT N0. 24811 Z
only the electrical equipment as described below and introduced by the applicant named on the above application number is in the premises of
BERNARD KIRSCH, 1850 NINTH STREET, GREENPORT, NY
in the following location; ❑ Basement ❑ Zst Fl. ❑ 2nd Fl. GAR/OUT Section Block Lot
was examined on AUGUST 12,1998 and found to be in compliance with the National Electrical Code.
FIXTURE RECEPTACLES FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS
SWITCHES
OUTLETS ,NCANDESCENT FLUORESCENT OTHER AMT. K.W. AMT. K.W. AMT. K.W. AMT KW. AMT. H.P
2 17 6 1 2
DRYERS FURNACE M070RS FUTURE APPLIANCE FEEDERS jsPEciALRwpT.j TIME CLOCKS BELL UNIT HEATERS I MULTI-OUTLET DIMMERS
AMT. K.W. OIL HP, j GAS I X.P. AMT NO. A.W.G. AMT. AMP. I AMT. AMPS. TRANS, AMT. j H.P. j NOSYSTEMS.OF FEET AMT. WATTS
2 2@
SERVICE DISCONNECT NO.OF S E - 'R V I - C E
METER NO.OF CC GOND. A.W.G. A.W.G. A.W G.
AMT. AMP TYPE EQUIP.. 10 2WJI 0 3W 3 0 3W 3 D dW pER 0 Of k WG.COND. NO OF HFLEG Of HI-LEG NO.OF NEUTRALS OF NEUTRAL
2 200 CB 1 X i 4/0 1 2/0
OTHER APPARATUS:
PANELBOARDS:1-5 CIR. 100
G.F.C.I:-2
G & S CONTRACTOR LIC.#578 EL LBOX 215 ANN
SOUTHOLD, NY, 11971 GENERAL MANAGER
11
NPer
This certificate must not be altered in any manner; return to the office of the Board if incorrect.Inspectors may be i entified by their credentials.
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
MAY 5 .-'
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BOARD OF -
FORM NO. 1 3 SETS OF PLANS . . . . . . . . . . . . . . .
TOWN OF SOUTIIOLD SURVEY . . . . . . . . . . . . . . . . . . . . . . . .
BUILDING DEPARTMENT CUECK I . . . . . . . . . . . . . . . . . . . . . . . .
TOWN BALL SEPTIC FORK . . . . . . . . . . . . . . . . . . .
80117.1101.0, N.Y. 11971
TEL: 765-1802 NOTIFY: dam^
CALL
�Cf MATT. TO: . . . . . . . . . . . . . . . . . . . .
lxanirted... 19.. l Lf 1 7
Approved. „ 191 Permit No. .......,.{.. ..........I.........................
Disapproved a/c .................................. ................................... .
p'...................................................... ..
.. ..
(Building In tor)
b
MAR 2 3 rpee b�.
S APPLICATION FOR BUILDING PERMIT
i. .,-,..... ................... Date. . . . . . . . . . . . . . . . , 19. . . .
,.. .ztans cicioisl�or_D
_ INS'IIIUC'riONS
a. 'this application mast be completely filled in by typewriter or in ink and submitted to the Building Tnapector wi
3 sets of plans, accurate plot plan to scale. Fee according to schedule.
b. Plot plan abwing 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 time diagram which is part of
this application.
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 wily, 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 wixule or in part for any purpose whatever until a Certificate of
Occupancy shall have been granted by the Building Inspector,
APPLicNilorl IS dLWiBY MADE to the Building Department for lite Issuance of a Building Permit pursuant to the
Building Zone ordinance of the Tam of Southold, Suffolk County, New York, and other applicable laws, Ordiummes or
Regulations, for tie construction of tuildings, additions or alterations, or for removal or demolition, as herein
described. The applicant agrees to empty with all applicable laws, ordinances, building code, housing code, and
re' ulations,aand to admit authorized inspectors on premises and in building for necessary inspections.
.....................................................
(Signature of applicant, or name, if a corporation)
...................................................
(Mailing address of applicant)
State whetter applicant is owner, lessee, agent, architect, engineer (general contractor,. lectrician, plhrduer or doilde
...... !i4! - /�.�./ � c�61����:{........ PPR�Y oAS*GM..........,
Norte of owner of premises ��. `.! fZS-.',/... ;J�':`!,........... riwre�:P.�. ��1� � ...
(as on the tax roll or latest deed) F�.�.N
'if applicant is a corporation, signature of duly authorized officer. MOM" SUILDINO OMtlt EN AT
ns-11M Y ANF TO 4 PM MR THE
POUAIN 1aFIFir1ECFI W.
e and title
.f corporate
...icer.................... f �M • Im MMIRED
(Name and title of corporate officer) NACOMM
I RO M • rRAMM t PLUMSM
WSULAW
Builders License No. .f•-• S.••••••••�•••-•• 4. FINAL. - CQNB'►RUCTIQM MUST
Plumbers License No. ............ SE COMPLETE FOR C.Q.
� L� T21� ALL CONSTRUCTION SHALL MEET
Electricians License No. .. THE REQUIREMENTS OF THE N.Y.
Other Trade's License No. ....... �/n1. cD�&ATF CONSTRUCTION & ENERGY
"" !' ODES. NOT RESPONSIBLE FOR
1. location of land on which proposed work will be &ne......,.�.i.. y............DESIGN•0%40ONSTRUGTION•ERROR&...
a �..OF cll vl. 577-12672 1 !o �o-h'10 f�ll�/1�� PW1411 ` %�
Clouse Nmt*r Street G Hamlet �'
County Tax Map No. 1000 /Section ...`..f......... Blocdd•............... Tot
Subdivision P � .�c�Jllu••��1)/Dr ........ Filed Map No. ............... Lot .. ��......
(Name)
2. State existing use and occupancy /of premises and intended use and occcquancy of proposed construction:
a. Existing use and occupancy ..1... z.�.� .. U G�......................................
b. Intended use and occupancy ........., �%� �'
moval applicable): New Sullding .. ........ txklltion .,,....... Alteration .........
RAille
Re
1. Repair of work (dieck tuiidl ql........... beumliti«1 ............ Other Work ..................................
A (Description)
����
4. Idstiniated Cost {.......... fee ..............................................
(to be paid oil filing tills application)
5. If rNaalii)q;,$rxnlieryof dwell a"
Isliits .... ....... bailer of A00IIng units on eadl floor ................
ifgarage, )xnlx r of care ...,t v.............................
6. If Ixualess, mmlercial or mixad'Occupancy. specify nature and extent of each type of use......................
7. Diuienalons of existing atnx:turea. If any: Front................ (tear ............... Depth .,.,..,...,....,.
lk:ight ........................L Mnber of Stories ......I...............
DI'
RI t alterations or additional Front ............... Rear ...............
iansions of
Ido1 pill ...........!.., ure �t .................... Umber of Stor,�ieesrys ....,
IS. gbienafexusOfe)elretnew tecxetrliclacxi: Front . � :(...., Fear .�`7 r,,,,,, Depth ,.r ,r.,...
Ilei it C .,....SIN caber of Stories .....!�..............
. SY.....,/../n
9. Size of lot: Front ! fr✓ Rear f
M. (Nita of pre])ase S� �f ., �,.... Nate of Former (mier // ,
11. Zone or use district In wild) pregiisea are situated rDlF,�.fil,!„E:
12, Does prolosed construction violate, any zoning law, ordinance or regulation: .,l.N -�.............
I:d. Will lot be regraded ...<...:...Q.,�,....,.. Will excess fill Ix: r/ors�awHed frgrxn promises: YFS � .T ,r�
14. Nines of O,iner of pirminea ,,1D, `f14 tuklreaal4 1.!.�9 )�'C .!Y,!y !.... fl)«le Nose&',1�,?q ?Rl
N)*ne of Arciliteet .... S ?� � ....,`,......... Aokireas ........................ Lc° I'lione No. ...........,..
ikue of Contractor l,.-,. , !. / Monte No,T,77,fV 7,
... .
15, Is t °�g2L0/�
* r Ia tiobl r�neClarxlt Y[�S .��. NO ......,...
this property within 300 feet,of
Ill YLS, SOWIICYII lam 31dd51TlI$ I'llIMT MY lY: 12G(l11 ,
64'r DIAGRAM 1
locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimenadons
front property linea. Give street and block nnber or description according to Gleed, and allow street mores and Indicate
+oi)alher Interior or corner lot.
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IXRINIY (Mr ��OO
Y �A .• •�. to f lxaing duly awcrrn, deposes aux) says Clint he is the appl.iciul:
ulxu{ ti mcvrjtu) 'Y 03 AU IAOI834
Ifs in Lite ....,. %t! 2 ....... 6. \�'e° 7-0 re �
(Ccxitractor, agent;corporate Officer, etc.)*
of said crux+r or o mle.rs, and Is duly authorized to� perronn or line ;xerrortied the said work and to srike and file I.his
4114AIcation; that all atatevients collLahxxl it, this application are tax: to the beat of his kotmledge and Ixil.def; a)xl
that the work will be perfo/toed in the neo)er sect�'fOrlh in Lite application filed therewith,
t)rxrrn�0 flare rre lnysof
Notary public i. ..11^ Ll1✓!G, �;;� � Y %
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JOYCE M.WILKINS (Signature of Applicant)
Mtn Public,State of New York
Na.4952246,Suffolk County
Term Expires June 12, 19
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4, FINALAnCONSTRUCTION MUST �'�'���ITHO, T CERTWFICA �' -
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ALL CONSTRUCTION SHALLWEET
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