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FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No Z-23802 Date AUGUST 2, 1995
THIS CERTIFIES that the building ALTERATIONS
Location of Property 150 GRIFFING ST. CUTCHOGUE, NEW YORK
House No. Street Hamlet
County Tax Map No. 1000 Section 102 Block 5 Lot 3
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated MARCH 9, 1995 pursuant to which
Building Permit No. 22656-Z dated APRIL 4, 1995
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 ALTERATION TO EXISTING COMMERCIAL BUILDING FOR DENTAL OFFICE
AS APPLIED FOR.
The certificate is issued to ALFRED J. TERP
(owner)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL-6/29/95-REG. #51021523
UNDERWRITERS CERTIFICATE NO.-N-354929 - JUNE 13, 1995
PLUMBERS CERTIFICATION DATED MAY 26, 1995 - JOEL RESNICK
ilding Inspector
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) a
Date 0
N2 22656 Z
Permission Is here y nted to,
. /
q
..r
at premises located at....e~ ....6~Aq- : r
.
County Tax Map No. 1000 Section ....,,/..9.Z...... Block Lot No.:-
pursuant to application dated ......`Op 19.?..~.... and approved by the
Building Inspector.
Fee $/J~~./..
wilding Inspector
Rev. 6/30/60
Form No. 6 h0bte, 7~v~{ll
TOIaN OF SOUTUOLD
BUILDING DEPAR'T'MENT
_ 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 electricmi 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 buildin industrial building, multiple residences and similar buildings
` and installations,~a certificate of Code Compliance from architect or engineer
responsible for the building.
r
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 - $20.00
4. Updated Certificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residential $15.00., Commercial $15.00
Date ....5J.+71.1 .
New Construction.....)(..... Old Or Pre-existing Building.. .X.
.
Location of Property..... II.*.. Sau. G.t.;~Rt'ly~ 1~}•
House No. 5. In~.C_.~1a
Mc. r Street Hamlet
Onwer or Owners r.f Property. .Atf;:'G(~...).4°..C.k )
County Tax Map No 1000, Section..!(1,Z;
Subdivision..
. ................................Filed P1;ip. .......Lot..
?ermit No.
.cR~~•TlJ.... Date Of Permit. ej
.Applicant. !C'.7~CL!- ~Q.......
health Dept. Approval ..........................Underwriters Approval Tanning Board Approval
tequest for: Temporary Certificate........... Final Certicate..)~„
lee Submitted: $
Jtk
A
,s STATE OF NE1N~ORK ,mss r DEPARTMENT OF HEALTHY v
ra x n 5 v
."Fe@ Paid
Reglstratlon Number
51021523 t 9 -A > s. >$50 00
CERTIFICATE OF REGISTRATION
?This is to certify that the following RADIATION INSTALLATION is registered
at the premises _indicated pursuant to section 16.50 of the New York State Sanitary Code
PRIETO RICHARD R DDS Date of Issuance
Type oflnstallation 150 GRIFFING ST PO BOX942
DENTIST CUTCHOGUE NY 11935-0942, 6/29/95
Maximum
Survey Interval Date of Expiration -
3 1/01/98
Year(s)
VIN. --%~G~da"v!`•:[JLf~~'w""'r 'f~f~
Director, Bureau of Environmental Radiation Protection Commissioner of Health
? a _ ,oa+aa~e P~zl - 6 5 19 v' HIS CERTIFICATE MUST BE CONSPICUOUSLY POSTED AT THE RADIATION INSTAL Ll.TION ,
Town Hall, 53095 Main Road Fax (516) 765-1823
j Telephone (516) 765-1802
P. O. Box 1179
Southold, New York 11971
- S
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
C E R T I F I C A T I O N
DATE: 4
Building Permit No.
Owner: 7-f2-P
(`please print) nM
Plumber: L24IC'(please print)
I certify that the solder used in the water supply system
contains less than 2/10 of 1% lead.
(Y umbers Signature)
z - ~ p~a e
~ C1r€a
Sworn to before m this
c^ 19'~
day of
Notary Public, l ~nty JAYNG 0.
Notpry puWb, Sut``~~~ork
No. aeee
aud"I III Suiiolk County `1~1
Cmmnlaton Evo" July 6,10" 6
1CtI01EDL' m 5/23 95 5,30 OM, created: 5123!95 8:38 flM POge 1 or.
't
1 ALBERTSON AVENUE - P,O, BOX 170, ALBERTSON, NY, 118WA170
II~ 816-484.060D • WAT$ 8004328237 • PAXR518i84.8818 {
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C & B FLCICRING a
ASSOCIATES
FACSIMILE TRANSMITTAL $MIEET
opts
Number of pages
Incluoina this shoats„-w
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Locot tons
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Telephone Mw„-4•MYVw~+ir-5 _•_au-M_in--_-----------
From s -
special or
special fnsltruotfonss (r~`M~------ --i'-'~
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If you have auny prolslamc with transmfssfony
Plea%* Celli (016) 484-000 Ssst. 33
creereo: stzsras usu nn •
V VIYYI V RII l? - r• ~
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TEST bilmagR
Independent Textile 2243 ,
P.O. Box 79!119 Service, Inc, IN3 Murray Ave.
Dalton, Georgia 30722.7948 a Phone 404.270,3073 a Fax 272.70,57 i
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CUSTOMER. Conq°,xest carpet Millo, Inc. January 27, 1992 i
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8U8JF,CTr , 3ycci:'nana of the aubmittcd eamplea were proparod and tostod
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in accordance With ASTM E-b48 and/or r'ederal 'l'est, Method
i 372, :I4LrPA 253.
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FLOORING R?DIANT_p& B7; TEST i
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.S'AMinat, vEsc ,i TION:
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Sty1r: Straten;y i
34031 I
Cieaondary Baca'list Woven Synthetic I ,
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cr3sssIay;
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Mounr ed on Storlinq Rnr;rr9
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TEv~li RE51]LTS:, 5 ecim Saeeime 8 2 -.99-ecimen
Crit~cal Radiant r1ux: .4B watts/cma 50 watts/am4 .45 watts/rm
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rota }Burn LGnth: 44.0 cm 41.0 cm 42.0 cm i ;
Flame, VrOnt Cut: 7,9.n minutes 2910 minutes 20.0 minutes i
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AVLHAtiI _CRTT]iCAL RADIANT, rAUX: .47 WATT3/CM2
taattsicm'
F,oti{nated stlindard Deviation: 103
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cotorliciont to Variation: 6
Qn' ~ • ~ r~ ! Ire ,
AUTHC. F II TUBE
our lettem an3 ropom an for Ilia e:rlaeva uoa of the customer m +,•hom shay al
ilia aoe of dlc rams a Ind~Pm4ent TeeNU'MNnp Service Ina„ rnuat rMlIT al
" only I the "o fit teRed M ,n gat necnsaOly IndleaNve of ihegnnllNH 9f aPPan
f nnA lFn n+mll nRth.lnd,r"dem Twilehain[Senke. lnc„ ur tot to t4 umd un, i
City of New York ENVIRONMENTAL HEALTH SERVICES Departure of He th _ .T-..-
~•v INSPECTION REPORT - NOTICE OF VIOLATION PG. oP 0~
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s~ ER D/B/A',•,I m O yo>
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72, 7,793;
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A r ESS /yam BORO PERMIT NO.
BUREAU 1- PRO AM t\ DATE C
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CxCJ~~1\D~ d~.1.8 0.~1o- ~~ti IA.\
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'NUMBER ~ • DESCRIPTION OF VIOLATIONS
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NOTICE: Department of Health employees must show identification on request. - 4'
RECEIVEDB SUPERVISORSSIGNATURE DATE
P NALTY FOR FALSIFICATION: Falsification of any statement made herein is an offense punishable by a FINE of not w'°
ore than $500 or not more than 60 days imprisonment or both..- NYC ADMINISTRATIVE CODE, SEC 1151-9.0. M w
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148E '350M-013018 (781° - :1 faw{'i,
FIFrD INSPECTION REPORT DATE COMMENTS N
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FOUNDATION (1ST) II II
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II
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FOUNDATION (2ND) ~ I
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ROUGH FRAME r4
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PLUMBING I n
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INSULATION PER N. Y. II
it
STATE ENERGY -ri
CODE 11 j 11
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FINAL
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BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST ( ) ROUGH PLBG.
[ ] FOUNDATION 2ND INSULATION
[ ] FRAMING [ FINAL
REMARKS:
l~
DATE INSPECTOR
c==.._...{_f
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1
1000854 BUREAU OF ELECTRICITY
F- 85 JOHN STREET, NEW YORK, NEW YORK 10038
Date JUNE 13,1995 Application No, on file 87272695195 N 354891
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicant named on the above application number in the premises of
MR. AL TERP, MAIN STREET, CUTCHOGUE, N.Y.
in thefollowing location; ® Basement ® Ist Fl. ? 2nd Fl. OUT Section Block Lot
was examined on .7m 138, 1995 and found to be in compliance with the National Electrical Code.
FIXTURE FIXTURES RANGES COOKING DECKS OVENS DISHWASHERS EXHAUST FANS
OUTLETS ECEPTACLES SWITCHES INCANDESCENT FLUORESCENT OTHER AMT. K W. AMT K. W. PMT JIM AML. K W AMT. H P
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIALREC'PT TIMECLOCKS BELL UNIT HEATERS MULTI.OUTLET DIMMERS
AMT. K. W. OIL K'. GAS H. P. AMT. NO A. W. G AMT. AMP AMT. AMPS. TRANS. pMT. H P. 6 A,Ai. WATTS
NO. O F FEET
SERVICE DISCONNECT NO. OF S E R V I C E
AMT. AMP. TYPE METER t $ 2W 1 $ 3W 3 R 3W 3,e' 4W N0. OF CC COND. A. W. G NO. OF HIAEG A' W. G NO.Of NEUTRALS A. W. G.
EQUIP. PER .e OF CC. COND. OF HIAEG OF NEUTRAL
2 200 CB 2 2 2 3I0 2 3I0
OTHER APPARATUS.
SERVICE ONLY-1
NORTH ELECTRIC LIC.#890-E
121 ACACIA ROAD
ROCKY POINT, NY, 11778 GENERAL MANAGER
11
per
This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by their Credentials.
COPY FOR BUILDING DEPARTMENT. THIS CORBY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
f ` THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1
1000854 BUREAU OF ELECTRICITY
85 JOHN STREET, NEW YORK, NEW YORK 10038
Date JUNE 13,1995 Application No. on file 07283195195 N 354929
THIS CERTIFIES THAT
only ~,e electrical equipment as described below and introduced by the applicant named on the obovIR application number in thepremises of
RICHARD R. PRIETO, ~150 GRIPPING STREET, CUTCHOGUE, N.Y.
in thefollowinglocation• yt L J Basement ® lst Fl. ? 2nd Fl. OUT Section Bieck Lot
was examined on JULIE A, 1995 and found to be in cotnpttance with the National Electrical Code.
FIXTURE ECEPTACIES FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS
OUTLETS SWI7CHE5 INCANDESCENT FLUORESCENT OTHER AMT K W. AMT K. W. T. K W. AMT K. W. AMT. H. P
24 25 18 11 13 2 E
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIMECLOCKS BELL UN 17 HEATERS MULTI-OUTLET DIMMERS
AMT. K. W. OIL H. P. GAS H. P. AMT. NO. A W. G. AMT. AMP. AMT. AMPS. TRANS. AMT N P. HOST SYSTEMS FEET AMT. WAITS
1 F 6 20
SERVICE DISCONNECT NO. OF S E R V I- C E - -
METER NO OF CC COND. A.W G A.W.G. A.W G.
AMT. AMP. TYPE EOUIP 10 tW 1 9 3W13 9 3W J3 9 ,w PER % OF CC. COND. NO OF H6lEG OF HI LEG NO Of NEUTRALS OF NEUTRAL
OTHER APPARATUS:
X RAY MACHINE-1
HOTORSil-1 H.P.,1-F H.H.
PANELBOARDSil-24 CIR. 200
ELEC. WATER HEATERStil-4.5 K.W.
G.E.C` Is-1
NORTH ELECTRIC LTC,#890-E
i 121 ACACIA ROAD
ROCKY POINT, NY, 11778 GENERAL MANAGER ,
Per '
This certificate must not be altere in any manner; return to the office of the Board if incorrect. Inspectors may be identified by their credentials.
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUSTNOT,BE ALTERED IN ANY MANNER.
BOARD OF HEALTH
FORM NO, 1
3 SETS OF PLANS
•
4'l lt; 91 1 0 1995 TOWN OF SOUTHOLD SURVEY - - - • • • • • .
BUll-DING DEPARTMENT CHECK
i3LDG ~ TOWN HALL SEPTIC ',FOR: • •
TO^INOFSOMtl_,_t SOUTHOLD, N.Y. 1197 J< d~
TEL.: 765-1802 t: oT I FY ; 7": C~ {
Examined CALL
...,19
? LG _ tIAIL T0: o~ ff r/
Approved 705........, 19//. Permit No. ! pp ~(/17 . iJ... .
Disapproved, a/c tl.. Wit..... .
(B ' ding I pector)
APPLICATION FOR BUILDING PERMIT
Date 3.71 191f
INSTRUCTIONS
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a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with
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 stieet
or areas, and giving a detailed description of layout of property must be
cation drawn on the diagram which is part of this appl
.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such permi
shall be kept on the premises available for inspection throughout the work.
e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupant,
shall have been granted by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to th,
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances o
Regulations, for the construction of buildings, additions or alterations, or for re al or de olition, as herein described
The applicant agrees to comply with all applicable laws, ordinances, buildin ode, usi c de, and regulations, and tc
admit authorized inspectors on premises and in building for necessary inspect'ons.
(Sign ure of applicant, or name, if a corporation)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
C S S.
Name of owner of premises :J;... T Q
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
(Name and title of corporate officer)
Builder's License No. . , lsr~ 3 t71
Plumber's License No. , Is-e3 P
Electrician's License No. . <7 , , , ,
Other Trade's License No. ,
1, Location of land on which proposed work will be done. , ..q' ,5%R,Ets' 7~ y p J~ j c HG~v~
a~~ . . . . .
r~g~'... '
House Number Street Hamlet
County Tax Map No. 1000 Section ! r........ Block S~ , . , , , , , , , 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 occupancy ZIP If 9 FR 0-1.
b, Intended use and occupancy r! C 4, .
3. Nature of work (check which applicable): New Building , , , , , , , , Addition Alteration . K.
Repair Rerpoval , Demolition Other Work , .
(Description)
4. Estimated Cost ®C2Cn J Fee
.(to be paid on filing this application)
, number
of o dwelling units' Number of dwelling units on each floor . . . . . . .
S. If dwelling,
If garage, number 6. If business, commercial or mixed occupancy, specify nature and extent of.each type of use ,Q IiN'tAt c7Fr°rc~
7. Dimensions of existing structures, if any: Front , Rear Depth ,
Height Number of Stories , , , , . .
Dimensions of same structure with alterations or additions: Front Rear .
Depth . . Height , : Number of Stories , , .
8. Dimensions of entire new construction: Front . . . . . Rear Depth
.Height Number of Stories , .
9. Size of lot: Front 11 , . Rear, Depth , , .
0. Date of Purchase ' Name of Former Owner
11. Zone or use district in which prlemises are situated . . .
12. Does proposed construction violate any zoning law, ordinance or regulation: . N o
13. Will lot be regraded , • . . , , , . , Will excess fill be removed from premises: Yes No
14. Name of Owner of premises A4tlePP.T. XA q R. , Address , , , , , , , , , , , , , , , , , Phone No.. .
Name of Architect . Address . . . Phone No.
Name of Contractor ?.R?.° ,~tIP14 c q,~!?,e W
e SAddress , ~4,rs~;,!/e! , . Phone No. S%~. 4'Y. YA g
15.' Is this property within 300 feet of a tidal wetland?*
etland? *yes........ No..
*If yes, Southold Town Trustees Permit may be required.
PLOT DIAGRAM
Locate clearly and distinctly alll, buildings, whether existing or proposed, and, indicate all set-back dimensions from
property lines. Give street and block'number or description according to deed, and show street names and indicate whether
interior or corner lot.
I~
STATE OF NEW Y RK
L(c-, Sls
COUNT. O U,,.,.
ame of individual si.gnin' . being duly sworn, deposes and says that he is the applicant
g contract)
above named.
"le is the . . .
(Contractor, agent, corporate officer, etc.)
>f said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this
application: that all statements contained in this application are true to the best of his knowledge and belief; and that the
vork will be performed in the manner set forth in the application filed therewith.
iworn to before me this
ddajylo/f .......p.. /4,~1., 19
lotary P lic, vV D`.'.;~U.S--,/.~...... County
BARBARA STEPNOW (1
Notary Public, state of New Yank . , . , , , , . .
No.01574044752
Qualified in SOO!:( Couray (Signature of applicant)
Commission C:,.lroc ^r 1.30,19 S
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Prepared in ccccr,ianoo. with the niiniihUyn
the L. 1standards for 'IN'd s.vve;s as established by
. A. 1. S. and approved and adopted SURVEY FOR
for such use by The New
Title Association. York State Land
ALFRED J. TERP
CERTIFIED TO AT CUTCHOGUE
EASTERN FEDERAL TOWN OF SOUTHOL D
SAVINGS 8 LOAN SUFFOLK COUNTY N.Y.
1000 - 102 - 05 - 03
SCALE I11 = 30
JUNE 20,1986
JAN. 13, 1987
O LAND JAN. 28, 1990(revise)
f 4o~g5 QN A. fHC G~~
N.Y. S. LIC. NO. 49668
EC 4'0. aee86qY Si P.C.
( 516 )
P. 0. BO
MAIN ROAD
SOUTHOLD , N. Y, 11,971 REVISION 7-7-87,
86, 293
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CERTIFi-
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i SOL( ,IOT IF..I r i" 4P9~ E
SUPP_ uti,l TPf~L'EE4RWrN PJO~ Opa,.'f.+ij /'6u X31", KAcH
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two New wNV~.„ J PLUMQERCERTIFICATION TERS CERTIFICATE
3 zo x L 'non ON LEAD ERS CERTIFICATE CONTENT BEFORE REQUIRED /u' /fEnouK w' H 3"w'3^ x'/L S [-ea n rcL UNDERWRIT EQWREO i
F / /fv r F~ - CERTIFICATE OF OCCUPANCY j - r - _
SOLDER USED IN V?ATfl7
SUPPLY SYSTEM CANNO J
- 3%'o " EXCEE02110 OF 1%LEA { ~ i - _ ! F - = I
I ~ ~I_-- 6'xX"ao.'~ RE ;viFf~R_<t PL.UMC~~INC~ 4
y ~ I I ~~~C~ 6 Yg Pao ~ I ~ I _ I I ~INC~ VVAI.!_
PLUeneING TO SE<U K - dA<. K ANA I_ WA I_ I_ GKA"Er
1 1"4/~. ALL PLUMBING WASTE
I ILL/ WATER LINES NEED FTA K
I ! 1 TESTING BEFORE COVERING
U
) MUST FIE= ;
- - ( , WALL ~I<Ef FOK
N K t L_ QM I I iCs G II
po°K ( r f
I U~~1~77iZ ~,Q,!?-G o ~iz~~fG~ F~ If copper tubing la usw St HAVE A ~
" T6 for water distributing ~A r KC) C7 M 7`~ V/' l) " H(= in9Shall be I 1 6C9UFC 'ENO G F- '(C) F- AS tt_Y
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