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Home My WebLink About23059-zFORM TOW~ OF $OUTHOLD TOW~ HALL $OUTHOLD, N.Y, BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UN'~L FULL COMPLETION OF THE WORK AUTHORIZED) N-~ 23059 Z Permission is hereby grcl~ed to: /¢ ~,- , .,O._~./.~.....~...../._¢..~.,r...¢. ~ ........................... .4:../.........¢~...~ ........................................... .... ~~~....~:.¢....~..~..z~..~... , ,o..~?'...;.....~...~ ......... ~,.....~......~..,..~.~ ........... .... ~~....~..~..,~.~...., .;,.......c...~ .......................... ~..,.~..,....~.,;¢.,¢¢_~..../.¢.?Z...~..: ............................................................ .......................... ~< .../~.....-.....~..¢../...-.....~.~..~,/2....¢........: ......................................... ot premises located ot ........... ~...¢~....~...........~. ~,,~¢¢~..~...,¢1~.__________~...~ .~.....:. ................ Butldlng Inspeclor. / ...... ~j. ..... Rev. 6/30/80 FORM NO. 4 TOWN OF SOUTHOLD B~ILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. ~TIFICATE OF OC~umANCY No Z--24560 Date AUGUST 8~ 1996 THIS CERTIFIES that the building. NEW DW~W-ING Location of Property 2422 WESTPHALIA ROAD Rouse No. Street County Tax Map No. 1000 Section 114 Block 7 Subdivision Filed Map No. MATTITUCKr N.Y. Hamlet Lot 10.6 Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated SEPTEMBER 22~ 1995 pursuant to which Building Permit No. 23059-Z dated OCTOBER 13f 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 ONE FAMILY DWELLING WITHATTA~D GARAGE AS APPLIED FOR. The certificate is issued to (owners) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL UNDERWRITERS CERTIFICATE NO. PLUMBERS CERTIFICATION DATED Rev. 1/81 LOUIS & ELIZABETH FOP~4I~A R10-94-OO71-MAY 6f 1996 N-387548 - MAy 31, 1996 MAY 29~ 1996 - pE~ONIC PLUMBING & HKATING Form Nc. TO~ OF $OUTEOLO BUILDING TOWN 765-!802 ~OPLiCATiON FOR CERTIFICATE OF OCCO~.~NCf This appiicamion must be filled ~ by :yp. ewrizer 0R ink a-nd subminnad co :he building inspector wlzh the fo!io~ng: for new building or new use: i, Final su~ey of property with accurate location of all buildings, property lines, screens, and unusual natural or topographic features. 2. Final Approval from Hea!~h Dept. of water supply and sewerag-=-disposal(S-9 3. Approval of electrical instaLiacion from Board of Fire Unde~rizers. a. Sworn statement from plumber cart!fyi_rig ~hac the solder used Ln system contains less than 2/10 of !% lead. 5. Commercial building, industrial building, mu!cipie residences and similar buildings and insta!iarions, a certificate of Coda Compliance from erahiumcu or engineer responsibia for the building. 6. Submit Planning Board Approval of com?leuad size plan requirements. For ax~sm~_ng Duo-,cc-nas (prior :o April 9, 1957) non-conforming uses, cr ou__~n_s and '~'pre-exls~ing" lard uses: I. Accurate su_--~ay of property sho%-~_ng ail property lines, srrae~s, building a_nd unusual natural or topographic features. ~. D=ooe--. com?!etad app!icaeion and a consent to inspect si_°-ned by :he cool!cane. 2f a Certificate of Occu.oa~cy is de~-ied, :he Building r_nsoecuor shall=-ua:"= the reasons therefor in ~-ritins to the applicant. Fees S=~.O0, S~-%mming oool Additions nc gccesso~- bu~ding 525.00. Businesses $50.O0. 2. Car%ificaua of Occupancy on Pr~xisu~ 3u!idin~ - Si00.0O 3. Copy of Car%ificaua of Occupancy - A. Updated Certificate of Occupancy - 550.00 5. iamporary Certificate of Occupancy - 5ouse No. Screen Ham] lawn Hall, 53095 Mnin Road P.O. Box 1179 Soulhold, New York 11971 -> ..,j ,,,. -. ¢. ,>:.-5' Fa'~ (516) 765-18.23 Telephone (5i6) 765-1802 OFFICE OF THE BUILDING INSPECTOR TOWN OF SOUTFIOLD C E RTI F I C A T I O~ Building Permit NO. "~-...~'-~ "Z.. (please print) (please print)-- I certiiy that the solder used in the water supply system contains less than 2/10 of 1% lead. (Pl~m~er~ Signature) Sworn to before me this ~F day of Notary Public, BARBARA STEP~IOWSKI Notary Public, Stale al New Ye"lc No, ~1ST4844752 C'; "? :s ~ i: $utfolk Courtly Board Of Southold Town Trustees SOUTHOLD, NEW YORK PERMIT NO. 4z81 DATE: .~eb. 25, 1994 ISSUED TO Louis & Elizabeth Formica Pursuant to the provisions of Chapter 615 of the Laws o' 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- titled "REGUEATINC~ AND THE PLACINg= OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC LANDS and the REMOVAL OF SAND, C~RAVEL OR OTHER MATERIALS FROM LANDS UNDER TOWN WATERS;" and in accordence with the Resolution of The Board adopted at a meeting held on Pcb, 24, 19 94 , and in consideration of the sum of $ 150.00 paid by Louis & Elizabeth Formica of N.Y. and subject to the Terms ~nd Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes and permits the following: to construct a single family dwelling with well and septic system and a 31X40~ stairway from top of bulkhead to bank. 25' buffer ,, will be placed from top of bank landward as per plan submitted. Disturbed soil will be kept on site. all in accordance with the detailed specifications as presented in the originating application. IN WITNESS WHEREOF, The said Board of Trustees here- by causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Board as of this date. FOIINDAT ION ( Dt,'r t~ COHHENTS FOUNDAT I Obl {'~.OUGII FRAHV. & I1 [NSIH.A'FION I'ER N. Y. STATE ENERGY CODIr. CONSULTING ENGINEERS To: Building Department Mattituck New York Re: Energy Calculations Proposed Residence Mr. and F~rs. Louis Formica March 23, 1995 Dear Sir: Enclosed please find the '~Summary Sheet for The New York State Energy Conservation Construction Code." As demonstrated by the calculations, the proposed residence will comply with the Code. If you have any questions or require additional information,please do not hesitate to contact our office. Submitted by, ~nce R. Gilman, P.E. "Nexus Engineering" P.E. ~ 46097 202 OLD RIDGEFIELD ROAD. WILTON, CT 06097 203-762-9752 * ..... NEXUS ..... * Engineering Associates 202 Old Ridgefield Road Wilton, Ct. 06897 (203)762-9752 SUMMARY SHEET FOR NEW YORK ENERGY CALCULATIONS Prepared for : Dock House, Inc., Acton, Mass. Customer : Mr and Mrs Louis Formica Location : Mattituck New York County : Suffolk Degree Days : 6000 Inside Design Temperature : 83 Degrees F Outside Design Temperature : 10 Degrees F March 23, 1995 A. "U" Values for Envelope Subsystems System Area Component sq. ft. Walls Frame 369.60 Cavity 2094.40 2464.00 U(avg) = 173.19 = .0703 2464.00 Glass Double Glazed 553 Sliding Doors 41 Actual U x A .111 41.03 .0631 132.16 173.19 .2941 162.64 .235 9.64 Doors 40 .51 20.40 Concrete Walls (above grade) U 247 3345 U (actual) = 397.59 = .12 3345 Allowable ~U~ Roof .042 1489 .1284 31.72 397.59 (allowable) = .17 Actual .0362 53.90 Floor (over unheated) .053 1509 .0448 67.60 * ..... NEXUS ..... * Engineering Associates 202 Old Ridgefield Road Wilton, Ct. 06897 (203)762-9752 March 23, 1995 B. Heat Loss From Infiltration Allowable Infiltration Rates : Windows = .37 cfm/lin.ft./crack Sliding Glass Doors .5 cfm/sq.ft, area Swinging Doors = 1.00 cfm/sq.ft, area Actual Infiltration Rates : Windows = .18 cfm/lin.ft./crack = 10.8 cfh. Sliding Glass Doors = .14 cfm/sq.ft. = 8.4 cfh Swinging Doors = .80 cfm/sq.ft, area = 48 cfh Note : Infiltration rates cited above are as per manufacturer's standards; Casement Windows are custom made by Deck House, Sliding Glass Doors manufactured by North American Man. Comp Infiltration rate for weatherstripped swingin~ door from ASHRAE Handbook of Fundamentals. Actual Heat Loss in BTU/hr. Method of Calculation : Crack Method Formula : H = .018 L V (ti-to) H = Heat Loss in BTU/hr. .018 = .24 x .075 (.24 is specific heat of air in BTU/pound; .075 is density of air in pounds per cu. ft.) L = Length of all cracks in lineal ft. V = Volume of air infiltration per foot of crack per hour (as per ASHRAE Handbook) ti = inside design air temperature to = outside design air temperature Infiltration from Casement Windows : Q = (.018)(126)(10.8)(73) = 1788.09 BTU/hr. Infiltration from Sliding Glass Doors : Q = (.018)(41)(8.4)(73) = 452.54 BTU/hr. Infiltration from Swinging Doors : Q = (.018)(40)(48)(73) = 2522.88 BTU/hr. * ..... NEXUS ..... * Engineering Associates 202 Old Ridgefield Road Wilton, Ct. 06897 (203)762-9752 March 23, 1995 C. Heat Loss in BTU/hr. from Exterior Facades Walls Roof : Floor : Infiltration Q = u (actual) Q = ~.12)(3345)(73) Q = (.0362)(1489)(73) Q = (.0448)(1509)(73) : (from Section B) x A (area) x (change temp.) 29302 BTU/hr. = 3935 BTU/hr, = 4935 BTU/hr. 4764 BTU/hr. TOTAL = 42936 BTU/hr. Furnace at 78% Eff. = 55046 BTU/hr. Use 60000.00 BTU/hr. * ..... NEXUS ..... * Engineering Associates 202 Old Ridgefield Road Wilton, Ct. 06897 (203)762-9752 ATTACHMENT "R" Values of Insulating Materials : (Deck House) Roof Exterior air surface .17 Asphalt Shingles .13 3" Rigid Insulation w/foil Vapor Barrier 21.60 Wallboard 4.80 Inside air surface .92 TOTAL R = 27.62 U = .0362 Wall Exterior air surface Cedar Siding 1/2" Plywood 3 5/8" Fiberglass Insulation Gypsum Inside air surface 17 94 62 13 00 43 68 TOTAL R = 15.84 U = .0631 Floor Deck : Inside air surface Oak Flooring 7/8" Comply 9" Fiberglass Insulation Exterior air surface .92 .71 1.50 19.00 .17 TOTAL R = 22.3 U = .0448 Concrete Wall Section : Exterior air surface 10" Poured concrete 1/2" Rigid Insulation Inside air surface .17 2.7 4.0 .92 TOTAL R = 7.79 U = .1284 Misc. Double Glazing Low "E" Glass U = .60 U = .30 I - FACIL1TY/PROBRAH NUMREN(E) PERHIT Un,er the Err~irc~me~tat EFFECTIVE DATE E×PIRAT[ON DAle(S) jTYPE OF PERMIT · New a Renewal D Modification g Permit to Construct ~ Permit to Operate a o g Article 15,' Title 5: Protection of gaters Article 15, Title 15: gater Supply Article 15, Title 15: Water Transport Article 15, Title 15: Long Article 15, Title 27: gild, Scenic ar~:l Recreational Rivers Other: 6NYCRR 6OB: ~ater Quality Certification Article 1T, Titles 7, 8: SPDES U Article 191 Air Pollution Control Article 23, Title 27: Mined Land Recl~nation D Article 24: Freshwater Wet[ar~ds · Article 25: Tidal UetEands PENny,HIT ISSUED TO ~orEssO ~rM,tteE ~'~..z~ LZ CONTACT PERSON FOR PERMITTED ~RK TELEPHONE NUMBER NAME AND ADDRESS OF PROJECT/FACILITY DESC~FI'PTION OF AUTHORIZE~ ACTIVITY E: N: Construct, replace, ~ify or repair a stairway or walkway on a bluff or dune to provide private access to the beach on a res dent al property. The stairway shall have a maximur~ ~idth of four feet except as provided for under Special By acceptance of this permit, the permtttee agrees that the parmit is contingent upon strict ccx~ptiance with the AUTHORIZED sI~RATURE DATE DEPARTMENT OF HEALTH SERVICES COUNTY OF SUFFOLK PERMIT TIIE ATTACItED PLAN, WHEN DULY SIGNED BY A REPRESENTATIVE OF THE DEPARTMENT, CONSTITUTES A PERM1T TO CONSTRUCT A WATER SUPPLY AND/OR A SEWAGE DISPOSAL SYSTEM FOR THE PROPERTY AS DEPICTED. CONSTRUCTION MUST CONFORM WITIq APPLICABLE STANDARDS INCLUDING TIlE STANDARDS FOR CONSTRUCTION OF SUBSURFACE SEWAGE DISPOSAL SYSTEMS FOR SINGLE FAIVliLY RESIDENCES AND STANDARDS AND PROCEDURES FOR PRIVATE WATER SYSTEMS. TIlE PERMIT (PL,adN) EXPIRES THREE (3) YEARS AFTER THE APPROVAL DATE. ANY MODIFICATIONS WHICH MAY AFFECT THE PROPOSED SEWAGE DISPOSAL SYSTEM OR WATER SUPPLY REQUIRE SUBMISSION OF A REVISED PLAN AND ANY ADDITIONAL FEES, PRIOR TO CONSTRUCTION. NO INSPECTIONS WILL BE PERFORMED BY TIlE DEPARTMENT ON EXPIRED PERMITS. PERMITS MAY BE REISSUED UPON TItE SUBMISSION OF NECESSARY APPLICATIONS, PLANS AND FEES, AND WILL BE REQUIRED TO NIEET THE STANDARDS IN EFFECT AT THE TIME OF REISSUANCE. A PERMIT MAY BE[ TRANSFERRED INTO ANOTHER PARTY'S NAME UPON RECEIPT OF WRITTEN PERIVlISSION FROM TIlE ORiGINAL APPLICANT AND TIlE RECE1PT OF ANY REQUIRED TRANSFER FEES. IN TttIS CASE, TIlE PARTY PAYING THE ORIGINAL APPLICATION FEE WILL BE CONSIDERED TO BE TIlE ORIGINAL APPLICANT. WWM-058 PAGE I OF 2 RODErlc ..,~;, ~'. LICENSEr GREENP{_ THE NEW YORK BOARD OF FIRE UNDERWRITERS ~"~ ,~ ~tT~?] BUREAU OF ELECTRICITY ~- 85 JOHN STREET, NEW YORK, NY 10038 THIS CE~IFIES THAT [f~UF~}tICA. S~'f POINT, (C~T OF ~S~I~,IA}, ~TTIT~CK, N?r. in the foNewing locatlon; ~ ~,nt ~ I~t FI. ~ ~na ~], GAR /O%~ Section Sl~k Lot ~ exemin~ o~ ~Y 2~, i 996 ~ foung W be l~ compli~ce ~ith ~he N~o~al El~cl~cal Code. , .x,u..s DRYERS ] FURNACE MOTORS I FUTURE AI~'I. IANCI~ FEEDERS iP~IALR~'PT PADD~ F~- 1 ~LI, P~ 'I P~I~Q~DS~ 2-1 aiR. 6~ G.F C, I:~8 EXHAUST ~:AN~ DIMMERS ..,O [ BOXG & 2 ;~1COI,ITRAC[~3R5 LIC, #578,-E?~i1,i Per ~AL ~GG This ce~ficate m~l not be altered in any manner; return to ~e office of ~e ~ara if inco~ct, inspectors may be ~ntifled by their c~denfial COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED 1N AN~ MANNER. 765-].802 BUILDING DEPT. iNSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] FRAMII~IG [ ] IN~ILATION [ ~FINAL [ ] FIREPLACE & CHIMNEY REMARKS: ~~,/-/ _/-~/"'~ DATE 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATIONlST [ ] FOUNDATION 2ND [ ] FRAMING [ ] ROUGH PLBG. [ ] INSULATION [ ~L [ ] FIREPLACE & CHIMNEY REMARKS: r3'~---/,/,/,/,/,/,/,/,/,~c.c- /*'-~ ,/~'./-- DATE I NSPECTOR//~~~/ 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ ] ROUGHPLBG. [ ] FOUNDATION 2ND [ /.~:~U~ATION [ ] FRAMING [ ] FINAL []FIREPLACE&CHIMNEY INSPECTOR 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION2ND [ ] INSULATION [ ] F~AI~G [ ]FINAL [ ~ FIREPLACE & CHIMNEY DATE INSPECTOR ~.//~ /~ / 765-1802 BUILDING DEPT. FOUNDATION 1ST FOUNDATION 2ND FRAMING FIREPLACE & CHIMNEY REMARKS: INSPECTION [ R~~OUGH PLBG. INSULATION FINAL DATE iNSPECTOR.//~~'~/ 765-~.802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION2ND [ ] INSULATION [ ~'~=RAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY j. REMARKS: ~~' DATE INSPECTOR 765-1802 BUILDING DEPT. INSPECTION [ ]/~UNDATION 1ST [ ] ROUGH PLBG. [ I./J FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ ] FINAL ] FIREPLACE & CHIMNEY ,, ~.~/~ / /h DATE INSPECTOR 765-1802 BUILDING DEPT. INSPECTION I~"DAT.O. ,~ I I ROUO. P,.BO. [ ] FOUNDATION 2ND [ ]INSULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY INSPECTOR ..///~~ ~? gOARD OF HEALTH ......... I] IL TOWN sou'mo, 2 2 '- TOWN HALL SOUTHOLD, N.Y. 1197.]. (Building Inspector) ' INSTRUCTIONS a. Tlds application must be compietely filled in by ~pewfiter or in ink and submitted to the Build~g Inspector, witl sets of plans accurate plot plan to scale. Fee acco~g to schedule. ~ b. Plot plan show~g location of lot and of build~gs on premises, relati0n~ip to adjoining premises or pubic stye, 9r areas, and giv~g a det~led description of layout of property must be drawn on the diagram which is pa~ of this api cation. c. ' The work covered by t~s application may no~ be commenced before issu~ce of Budding Pemit. d. Upon approval of this applic~ion, the Building Inspector will i~sued a Bufld~g Pe~it to the app~cant. Such pert, ~h~l be kept on the premises available for ~spection throughout the work. e. No~ building shall be occupied or used in whole or in p~t for any purpose whatever until a Ce~ificate of Occupan shall have been granted by fl~e Building Inspector. . APPLI~TION IS HEREBY MADE to the Build~g Dep~tment for the issuance of a B~Iding Pemit pursuant to t ~uilding Zone Ordinance of the Town of South01d, Suffolk County, New York, ~d other app~cable Laws~ Ord~ces Regulations, for the construction of bu~d~, additions or alterations, or for removal or demolition, as here~ descfib~ The app~cant agrees to comply with all applicable laws, ordinances, build~g code, ~ousing code, and regulations, and admit authohzed ~specto~ on premises and ~ build~g for necessa~ inspections. ~ . ........... ......... ' -- . (Signatur~ applicant, or name, if a corporation) (Mailing address of hpplicaat) State whether applicant is owner~ lessee, agent, architect, engineer, genera~ contractor, electrician, plumber or builde (as on the tax mi1 or latest deed) If applicant is a corporation, signature of duly autl~oriz~d officer.' (Name and title of corporate of fleer) Builder's License No ........ . ................. Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... 1. Location of land on which proposed work will be done .... ~.~'~-~},,~;~IB. · . .... : ....... .... · ' llouse Number Street Hamlet County Tax MapNo. 1000Section ...i..l[~..~ ..... Block ~.~ ......... J... Lot..t~,.~ ........... Subdivision .... ~.~l~..~r~ ............... '. Filed Map No ............... Lot 1. (Name) , ' 2; State existing use and occuphncy of premises and intended use and occupancy of proposed construction: · ' -- , X,~ la4~ ~ .~[*"~ Y~ ~ Urn ~ ~ . , __~' ~F~,--~* ~ ...... . ......... · 3.Nature of work (check which applicable): New Building .......... ,&ddition ....... Alteration .... : .... Repair Removal . Demolition ..: ..... Othe{iWdrk ......... ; .... .................................. ' ....... Des0rii?t · ' ZZ4-- .o .. ....' . ( n) 4. Estimated Cost . .. * 0 0 Fee ~ ~ $ St~ ~[~ · (to be paid on filing this application) 5, If dwelling, number of dwelling units ... f~.x~.~?E ~. Number ofdwelling units on each floor ..... ~ ...... If garage, number of'c~s ....... ~ ............................................................. 6.' If businys~mmercial or mi3~ccupancy, specify n~e and extent of.ea~ype of use..~,~'.~ .......... pK ~ Dime~s of existing stm~e~, if any: Front.. ~ ......... Rear ~ .......... Depth/ ......... H~ig~ ............. ~um~er o f Stories .~;.:i ............ ~'" .............. ~ ......... ~" ~nsions Cf s~me ~ture with alteratio~ ~ditions: Front ~ ::..j ......... Re~ ........ ~.. ~epth .... ' ...... ~ ........... Hei~t~ ..... z~' ~, "'. . .~.. Number 9f Stories ./ ....... ~.. ~ }. , 8. Dimensions of entire ~ew construction: Front . ~ ~..~. 8~ Rear .~..~ ....... Depth g~. 7,.. Hetght ..... ~ .~..._.= Number of Stones ...... ~ '~ ....... . ................. ; '~ ',;,;' · '~' ~L' 9. Size oClot: Front ... J$.[t~s~: ...... ~.. Rear .... {~, {~- ........ Depth ~,~.,tk].97~.':~ .~. 10. Date of Purchase .... ~ ll~l. ~.~ ...... ' ......... ~ame of Fomer Owner ~[~g ~. ~d.~. ~. 1 I. Zone or use district in which premises are situated .... '~ '~ ............. i / .....s' .............. ~ ..... 12. Does proposed construction violate any zoning law, ordinance or regulation: ..IgP .......................... ~13. Will 10t be regraded ...~lvc~. o~[~ ............ Will excess fill be removed f.rom premi~ Yes 14. Nme of Owner offpremises .~m.q~~X~ress~l.~.~...~. Phone ~'.~77~. Nme of Architect .. P.~.~ .~a~ .~, ........ Address .ff~o~.~ ~.a'..~hone No.(~ .9~ Nme of Contractor ......... O~.~&~r.. Address 5~W,( .... Phone 15.' Is this property within 300 feet of a tidal wetland? ~Yes.~ ..... ~o ........ '. ~If yes, Southold Town Trustees Permit may be required.~[~o~l~ ' PLOT DIAG~ Locate clearly ~d distinctly MI build~gs, Whether existing or proposed, ~d. indicate M1 set-back d~ensions ftc property Hnes. Give strgp) ~d bloc~ number or, desc~?tion acco~g to deed, and show street nines and indicate whetb STA~ OF NEW ~0~, ~ S I J COU~Y OF... ~(~k~ ..... ' ' ' ......... ~ ~,~r~ .............. · ......... being duly sworn, depose~ ~d says that he is thC applic (Name of individual signing contract) above named. He is the~. ~.~.,..' · (Contractor, agent, corporate officer, etc.) ef s2~d ev:zar cr u~xmers, ~d is duly autho~zed to perfom or have peffo~ed the said work and to m~e and file application: that all statements contained ~ this appllcation are ~rue to the best of his ~owledge and belief; and that work w~l Be per[omed in the m~ner set forth ~ the application filed flmrewith. Sworn to beforeme this ~ . : . .... ..... ...... ' ' ' ' ~S'~.~ ~5~(53>~, .'"~ ' ' (Signature or applic T~m ~ M~ 3~ 19~ , ' I "~ ul ,_,1 ,,~ 0 .< Z :~ 0 13 tt ,..,./ >Zoom ~< 0 ,/ 0 '11