HomeMy WebLinkAbout24429-z FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No Z-25337 Date OCTOBER 27, 1997
THIS CERTIFIES that the building ADDITION
Location of Property 945 FLEETWOOD ROAD CUTCHOGUE, N.Y.
House No. Street Hamlet
County Tax Map No. 1000 Section 137 Block 4 Lot 23
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated JULY 30, 1997 pursuant to which
Building Permit No. 24429—Z dated OCTOBER 24, 1997
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 DECK ADDITION TO NON—CONFORMING BUILDING "AS BUILT" & AS PER
ZBA #4515.
The certificate is issued to TIMOTHY McNALLY
(owner)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE NO. N/A
PLUMBERS CERTIFICATION DATED N/A
Building In ector
Rev. 1/S1
FORM NO.3
TOWN OF SOUTNOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTNOLD,N.Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
Date......OCTOBER.,,.,..24.......................... 19,,.97,,.
24429 Z
Permission is hereby granted to:
TIMOTHY MCNALLY
945 FLEETWOOD ROAD
..............................................................................I.........
..
CUTCHOGUE,NY 11935
.............. ................. .........................................................
to.,,,,.CONSTRUCT A DECK ADDITION TO A NON CONFORMING._BUILDING. WITH,.A
NONCONFORMING USE AS PER Z .B.A/ APPEAL #4515 10-9-97 AND TRUSTEES
.... . ..........................................................................................................................................................
��, .. .. ' ' .....-................ ...............................................................
.. ................................... ........... . ..............................,.,.,................................... . ...
.................................................................................................................................................................
at premises located at................ ...945 FLEETWOOD RD CUTCHOGUE
.......................................... .......................
................................................................................................................................................................
County Tax Map No, ......473889.... Section .,,,137 .......„ Block ....,.0004.....,, Lot No. „023..............
pursuant to application dated .....�ULY...............30......................, 19.......97..., and approved by the
Building Inspector.
Fee$.........75.00...
y�
y
............... ....... ... ........................
Building in for
Rev. 6/$0/QO
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 .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_OcCVp_a ��- w dwelling $25.00, Additions to dwelling $25.00,
Alterations"--t,-
to dwelling $25.0 Swimming pool $25.00, Accessory building $25.00,
c�3 t onn�s� Fo�Z' spat buil ng $25.00. Businesses $50.00.
2. Certificate of Occupancy on Pre-existing Buildine - $100.00
3. Copy of Certificate of Occupancy - .25r.
4. Updated Certificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00
Date . . . . . �I3, I4 ! . . . . . . . . . . . . . . . . . . . . . . . . .
New Construction. . .
. . . . . . . . Old Or Pre-existing Building. . �t . . . . . . . . . .
Location of Property. . RP. . . . . . YIq � . . . . . . . . . . . . . . .
House No. 1 Street Hamlet
Onwer or Owners of Property. .
County Tax Map No 1000, Section. 7d'!5'. . . . . . .Block. . 7 . . . . . . . . . . . .Lot.! 3. . . . . . . . . . . . . . . . .
Subdivision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Filed. Map. . . . . . . . . . . .Lot. . . . . . . . . . . . . . . . . . . . . .
Permit No. A74aq.:-�. .Date Of Permit. 10 I'2N / 97 . . .Applicant. . . . . . . . . . . . . . . . .
Health Dept. Approval. . . . . . . . . .Underwriters A roval`1 . . . . . . . . . . . . . . . . . . . . . . .
Planning Board Approval. . . . . . . . . . . . . . . . . . . . . . . .
Request for: Temporary Cer.tificate. . . . . . . . . . . F
inal C7-1cate. . . . .
Fee Submitted . $. . . . .�'5. ... . . . . . . . . . . . . . . . . .....
/ l
. .%
APFLICANT . . . . . . . . . . . . . . .
. . . . . . . . .
S3Vf
�� �a� 337
APPEALS BOARD MEMBERS
Southold Town Hall
Gerard P. Goehringer,Chairman �y` �y� 53095 Main Road
Serge Doyen o = P.O. Box 1179
� O ' Southold.New York 11971
!rdia
L 41, Fax(516)765-1823
rtora �O! �a� Telephone(516)765-1809
5 �'
BOARD OF APPEALS
Wii D�OUT. TOWN OF SOUTHOLD
FINDINGS, DELIBERATIONS AND DETERMINATION
REGULAR MEETING OF OCTOBER 9, 1997
Appl. No. 4515 - TIMOTHY McNALLY PARCEL 1000-137-4-23
STREET & LOCALITY: 945 Fleetwood Road, Cutchogue
DATE OF PUBLIC HEARING: October 9, 1997
FINDINGS OF FACT
PROPERTY FACTS/DESCRIPTION:
This property is located in an R-40 Low-Density Residential Zone
District, being situate on the north side of Fleetwood Road,
Cutchogue. This lot contains a total area of approximately 12,500
sq. ft. and its boundaries are more particularly shown on a survey
map dated October 24, 1994 prepared for Timothy McNally by Rod-
erick VanTuyl, P.C. The subject premises is improved with two
one-story frame buildings (single-family uses), an "as built" garage
and an "as built" deck, both of which are the subject of this
application.
BASIS OF APPEAL: Building Inspector's two Actions of Disapproval
(a) dated August 8, 1997 which reads as follows:
". . .under Article XXI V, Section 100-242B, the nonconforming
old tin garage with a conforming use {has been replaced with a
new wood structure) shall not be rebuilt or repaired if it has
been damaged by fire or other causes to the extent more than
50% of its value, until the building is made to conform to the
required height and yard requirements. . .
and
(b) dated September 8, 1997 which reads as follows:
". . .under Article XIV, Section 100-243A a nonconforming
building with a nonconforming use shall not be altered,
enlarged or structurally reconstructed unless such building
is changed to a conforming use. . . ."
Page 2 - October 9, 1997
Appl. #4515: 1000-137-4-23 (McNally)
Southold Town Board of Appeals
AREA VARIANCE RELIEF REQUESTED BY APPLICANT
For approval of "as built" 10' x 18' accessory garage building
with a setback at a variable between 4 inches (shown on the survey
map) , or four feet maximum setback (measured by applicant) from
the side property line, and (2) for approval of "as built" open
deck construction as an addition to nonconforming dwelling, an
extension of this building which contains a (second) dwelling use on
this lot. Deck construction is shown to be not larger than 20' by
20' as sketched on the survey map, and accessory garage is shown
to be 10 ft. wide by 18 feet, for a total height of 10 ft.
REASONS FOR BOARD ACTION, DESCRIBED BELOW:
The Town Building Inspector has confirmed accessory cottage is
eligible for a Pre-Existing Certificate of Occupancy. (Note:
The application has been on file with the Building Department for
issuance, pending the outcome of the garage and deck variances) .
(1) The granting of the area variance will not produce an
undesirable change in character of neighborhood or a detriment to
nearby properties because the "as built" deck has been attached to
this accessory cottage for at least 18 years and is approximately 20
feet (more or less) at its closest point to a natural revetment
(stone) barrier between rear of property and wetland area.
(2) The benefit sought by the applicant cannot be achieved by some
method, feasible for applicant to pursue, other than an area variance
because of the uniqueness of said parcel with one principal dwelling
and one seasonal accessory cottage, and 10' x 18' nonconforming
accessory storage building.
(3) The requested area variance is not substantial because as
stated above attached deck has been in place for at least 18 years
prior to code restriction, and for a longer period of time for the
10' x 18' accessory storage building which was in poor condition and
has been reconstructed.
(4) The proposed variance will not have an adverse effect or impact
on the physical or environmental conditions in the neighborhood or
district because variance requested is for an attached open deck as
built which has remained unenclosed since its existence and
reconstruction (10' x 18') of a nonconforming storage building in
place, in kind, at a variable between 4" and 4 feet from the west
property line; and no encroachment whatsoever.
(5) The situation has been self-created.
Page 3 - October 9, 1997
Appl. #45i5: ' 1000-137-4-23 (McNally)
Southold Town Board of Appeals
(6) This action is the minimum that the Board deems necessary and
adequate and at the same time preserves and protects the character
of the neighborhood, and the health, safety, welfare of the
community.
RESOLUTION/ACTION: On motion by Chairman Goehringer,
seconded by Member Dinizio, it was
RESOLVED, to GRANT the relief as applied and SUBJECT TO THE
FOLLOWING CONDITIONS:
1. "As built" deck construction shall remain as built and not be
enclosed into a porch or other type of room;
2. "As built" deck shall remain unroofed.
3. "As built" garage shall not be enlarged in any manner.
4. "As built" garage shall not be used or converted for
sleeping quarters or any use other than accessory storage or
garage purposes.
5. Re-construction of this garage by 50% or more will require
moving the garage to conform with a three ft. minimum setback
from the side property line and at least 21 feet from the front
property line along Fleetwood Road.
VOTE OF THE BOARD: AYES: MEMBERS GOEHRINGER, DINIZIO and
TORTORA. This resolution was dul opted. (Member Doyen of
Fishers Island was absent.) i
z",
GERARD P. GO RI ER, C IRMAN
RESOLUTION ADOPTED
Actions.all/137-4-23
�!Y
Board Of Southold Town Trustees
} SOUTHOLD, NEW YORK
Ib'
PERMIT NO. / _ .. DATE: ....9126L9.7..........
_.... .
,...::.: ISSUED TO ..........'I'.ZlY1.Q'I':t�Y....&...A..E.IyIS..E...MC...NALLY. ... .............
I
' Pursuant to the provisions of Chapter 615 of the Laws of I!
a the State of New York, 1893; and Chapter 404 of the Laws of the
State of New York 1952; and the Southold Town Ordinance en- I
titled "REGULATING AND THE PLACING OF OBSTRUCTIONS
IN AND ON TOWN WATERS AND PUBLIC LANDS and the
r. REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM
a LANDS UNDER TOWN WATERS;" and in accordance with the
s
i„
Resolution of The Board adopted at a meeting held on ....91.24!9.7...... „
� 19. ...97, and in consideration of the sum of $J.5.0....9.U. . _.. paid by
TIMOTHY MC NALLY
;I . _... .....I.......... ... ............. .... ........................................
of .......Cut.chog.ue............ . ......... ........... .. N. Y. and subject to the
Terms and Conditions listed on the reverse side hereof,
\ of Southold Town Trustees authorizes and permits the following:
'h Wetland Permit for an 18' X 20' existing deck. Also to Transfez
Permit #1881 from Cindy Moloney to Timothy Mc Nally for a
3' X 44' dock.
all in accordance with the detailed specifications as presented in
IT the originating application.
IN WITNESS WHEREOF, The said Board of Trustees here-
by causes its Corporate Seal to be affixed, and these presents to
a be subscribed by a majority of the said Board as of this date.
�p
.. ........
per.
............. ... ...............
Trustee
I
Albert J. Kru ski,President \�gQFFU( Town Hall
G
John Holzapfel,Vice President �� �� 53095 Main Road
Jim King y Z P.O. Box 1179
Martin H. Garrell O Southold, New York 11971
Peter Wenzel y�l�l ��0� Telephone (516) 765-1892
Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
September 26, 1997
Timothy & Denise Mc Nally
905 & 945 Fleetwood Road
Cutchogue NY 11935
Re: SCTM #137-4-23
Dear Mr. Mc Nally,
The following action was taken by the Board of Town Trustees
during its Regular Meeting held on September 24, 1997, regarding
the above matter:
WHEREAS, TIMOTHY & DENISE MC NALLY, applied to the
Southold Town Trustees for a permit. under the provisions of the
Wetland Ordinance of the Town of Southold, application dated
September 2, 1997, and,
WHEREAS, said application was referred to the Southold Town
Conservation Advisory Council for their findings and
recommendations, and
WHEREAS, a Public Hearing was held by the Town Trustees with
respect to said application on September 24, 1997, at which time
all interested persons were given an opportunity to be heard,
and,
WHEREAS, the Board members have personally viewed and are
familiar with the premises in question and the surrounding area,
and,
WHEREAS, the Board has considered all the testimony and
documentation submitted concerning this application, and,
WHEREAS, the structure complies with the standard set forth in
Chapter 97-18 of the Southold Town Code,
WHEREAS, the Board has determined that the project as proposed
will not affect the health, safety and general welfare of the
people of the town,
NOW THEREFORE BE IT..
RESOLVED, that the Board of Trustees approves the application of
TIMOTHY & DENISE MC NALLY for an existing 1.8' X 20' deck,
and to Transfer Permit #1881 from Cindy Moloney to Timotny &
Denise Mc Nally. for a 3 ' X 44' dock.
BE IT FURTHER RESOLVED that this determination should not be
considered a determination made for any other Department or
Agency which may also have an application pending for the same.
or similar project.
Permit to construct and complete project will expire two years
from the date it is signed. Fees must be paid, if applicable,
and permit issued within six months of the date ofthis
notification.
Two inspections are required and the Trustees are to be notified
upon completion of said project.
FEES: None
Very truly yours,
A4-�6
Albert J. Krupski, Jr.
President, Board of Trustees
AJK/dj h
cc. DEC
ACE
Dept. of State
Bldg. Dept.
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o�OS�fFO��-coG
Town Hall, 53095 Main Road y Z Fax(516)765-1823
P. O. Box 1179 -o • Telephone (516)765-1802
Southold, New York 119714-4
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
ORDER TO REMEDY VIOLATION
Date: July 30, 1997
TO: Mr. Timothy McNally
25 Mill Creek Rd.
Port Jefferson, N.Y. 11777
PLEASE TAKE NOTICE there exists a violation of:
Zoning Ordinance - CHAPTER 45
Other Applicable Laws, Ordinances or Regulations 45-8
at premises hereinafter described in that:
A DECK ADDITION HAS BEEN CONSTRUCTED ON A DWELLING WITHOUT A
BUILDING PERMIT, ALSO A METAL GARAGE HAS BEEN REPLACED WITH A
NEW WOOD STRUCTURE WITHOUT A BUILDING PERMIT.
In violation of CHAPTER 45-8
YOU ARE THEREFORE DIRECTED AND ORDERED TO comply with the
law and remedy the conditions above mentioned IMMEDIATELY
The premises to which this ORDER TO REMEDY VIOLATION refers
are situated at: 945 FLEETWOOD RD. , CUTCHOGUE, N.Y.
SUFFOLK COUNTY TAX MAP #1000-137-4-23
Failure to remedy the conditions aforesaid and to comply with the
applicable provisions of law may cons ' ute an offense punishable
by fine or imprisonment or both.
J N M. BOUFIS
LDING INSPECTOR
encl .
(Cert. Mail)
�?� /�'g�
___�
�-�� _-
__
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�1r1 S,4FFO(,f� '�
S(��O�o CpGy'
Town Hall, 53095 Main [load ti 2-- Fax (516)765-1823
P. 0. Box 1179 �� Telephone (516) 765-1802
Soulhold, New York 11971
?27�77.l�1flf
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
ORDER TO REMEDY VIOLATION
Date:
T0:
✓N �. K/
PLEASE
PLEASE TAKE ICE there exists a violation of :
I
Zoning Ordinance
I
i Other Applicable Laws , Ordinances or Regulations
I•
at premises hereinafter described in that :
le��
In violation of
YOU ARE THEREFORE DIRECTED AND ORDERED TO comply with the
law and remedy the conditions above mentioned IMMEDIATELY
The premises to whichthis ORD
are situated at : ER TO REMEDY VIOLATION refers
9«�'
/ TT
SUFFOLK COUNTY TAX MAP / � „ / 7 7
Failure to remedy the conditions aforesaid and to comply with the
applicable provisions of law may constitute an offense punishable
by fine or Imprisonment or both .
LDING INSPECTOR
encl .
(Cert . Mail)
BOARD OF HEALTH . . . . . . . . . . . . . . .
FORM NO. 1 3 SETS OF PLANS . . . . . . . . . . . . . . .
TOWN OF SOUTHOLD SURVEY
- U .. . BUILDING DEPARTMENT CHECK . . . . . . . . . . . . . . . . . . . . . . . . .
TOWN HALL SEPTIC FORM . . . . . . . . . . . . . . . . . . .
SOUTHOLD, N.Y. 11971
Tr`v 'I p� SiYI� r � y TEL: 765-1802 NOTIFY:
CALL . . . . . .?�� � . .
Ex mined A. ., 19.... MAIL TO: . . . . . . . . . . . . . . . . . . . .
Approved -�•- --� 19.... �.. ....................................
Disapproved a/c . ... .. .
� ",r' '„�.. ......... .. ....................................
.......... .
....(Bui••ing.inspector)
........
APPLIC ON FOR BUILDING PERMIT
..Date. . . . . . . . . . . . . 19- D
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.
b. Plot pian 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 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 will issue a Building Permit to the applicant. Such
permit shall be kept on the premises available for inspection throughout the work.
e. Na 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.
APPLICATION IS HEREBY MM 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 Ordinances or
Regulations, for the construction of buildings, additions or alterations, or for r tion, as herein
described. The applicant agrees to comply with all applicable laws,i:* or
, ildi , housing code, and
regulations, and to admit authorized inspectors on premises and in ng for ry inspections. /
/ 17
.... ............ ...................uc !� P
gnature of applicant, or name, if a corporation)
Ci4 ll�i�� •a7�-/77i�L.(.!444�..!l�..� ;ISt��.l' -/V•Y.
p.t,e
(Mailing address of applicant 117"1
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises J!,1N® ED .
(as on the tax roll or latest deed) r ATE.• 8.11
If applicant is a corporation, signature of duly authorized officer. FEE:
NOTIFY BUILDING B P AT
. • • - • • ...................
765-180 9 A TO Mmeandtitleofcorporateofficer) FOLLOWING INSPECTIONS-
OCCUPANCY
THE
CR 1e FOUNDATION - TWO REQUIRED
Builders License No. ......................... USE I t t I' s,:c wd 2 UGRFRAl4iI SP
FCONCRETE
VA'T." CUT i EV`4 F ICAT ULATIO NG LU1�I Ir �;
Plumbers License No. ...... u,�ig�wal,. ... CC1fUa1"filpa �
F OCCUP HCY �CTTON NIUsT
Electricians License No. ..................... 8F COMPLETE FOR C.(
^1. .
Other Trade's License No. .................... ��I_L CONSTRUCTION 1A1..L, METTa..$ REQUIREMENT OF THE
I. Location of land on which proposed work will be done.......................... " ATE CONSTRUCTION & ENq?f,7, *
.,
4..:}Ir S' NOT. KESP()NSIRLE FOR
.... 9 0E5 --+ ..�45....'.I e,,A W o�ck QcQ::...... � c k oaU e !... .A. 'R COAIS*MjtgI�I ERRORS
house Number
Street , f Hamlet
County Tax Map No. 1000 Section Block .......q....... Lot ...... .....•
Subdivision ..... .�.....
F)f2{S lv.f'.f� ........ Filed Map No. ..�.�3.7..... Lot ...............
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy .. "WXe..................................... .......... ......
b. Intended use and occupancy .... ...........................................•..............
3. Nature of work (die-a whidt aIVIieable): New Milding .......... Addition .. ,Alte%tion ...::...
14-pair ............ Remaval ............. DecrrolitIon ............ Other Work .1:J:...a. q ..............
(Description)
4. Cstiilated Cost .......................... fee ......................... .
(to be paid on filing this application)
5. if &yelling, mmi►er of dwelling units ....I..... Miller of. dwelling units or► ead► floor ..........
'If garage, rr►nier of cars ..''..PP.� .......................
6. If Ix►siness, asunercial or mixed occupancy, specify nature and extent of each type of use......................
7. Ptic�Uinensiorrs of existing stnrctures, If any: Front:�a Q X??.... Rear ............... Deptl► .................
lleigA►t ... �.................. Nudger of Stories ......................
Dimensions of seine stricture with alterations or additions: Front ............ t%ir,, .....
DepLh ................:... lieiglrt .................... Umber of Stories ...............
B. Dimensi(xi6V entire new constriction: IkonL ................ Rear ............... Depth ..............
lleigi►t ............. Nnber of Stories .....................
9. Size of lot: Fmnt H-5 .......... Rear .... ........... Depth ..� ..°�.��....
'10. bate of Purchase .. �Q� ........... Name of Tourer Owner ..3Qirl...l:" �I��................
11. 7Ax►e or use district in %Arid► premises are situated ..............................................................
12. Does proposed construction violate any tuning law, ordinance or regulation: ...:^..................
13. Will lot be regraded ..... ........... Will excese fill be reanved from premises: YES A ``__rr
M. Nares of Owner of prer►isea .1 .PM,�,.�lnLt� klreas ���..F�tC'J4ciPx. ne No..� �i"ya��...
Nave of Ard►itecl' ..... ... ? �.et_.......F........ _
Address .............. I'Irone No. ..............
Nrme of Gx►tractor ......... Address .................. .........1'ix M No. ...........
15. 'As this property within 300 feet of a tidal wetland? * F .......... N0 ..........
*IF M9, SQinKI<D -ixxm 71t sms PL'RMI'P Kxy III: RG(pim.
PLOT DIAGRAM
rotate clearly and distinctly all buildings, %hether existing or proposed, and itxlicate all set-back dimensions
frcn► prolxarty linea. . Give street and block nnber or description according to deed, and show street nares and indicate
wlietl►er interior or corner lot.
St
:il'KI I (A-N . Yom,
Y SS
COIINIY (me !?.1. ........
//.K .........................being duly sworn, detx►ses aixl says that he is the appl.icanl.'
(Neale of hAividual. signing c ►tract)
alxwe runied,
Ile1, Lhe ..................fx,/ .........................................................................
(CmiLracLor, agent, corporate officer., etc.)
of said (mx-r or owners, arxl is duly autl►orized to perforin or have performed the said work and to mike and file Lhis
apl icalicm; that: all. sLatenents ccntairx-d .in this aplAication are tnue to the best of his kixrwl.edge and ixa.ief; aixl
Ihat: the work will be performed in the nrnn►er set forth in the application filed therewith.
aw<►rn to before me Lhis
........... P....(lay of
Notary Public ,?! ......
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