HomeMy WebLinkAbout22726-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
office of the Building Inspector
Town Hall
southold, N.Y.
CERTIFICATE OF O~CUPANCY
No Z-25267 Date SEPTEMBER 15, 1997
THIS CERTIFIES that the buildin~ DWELLING
Location of Propert~ 2850 MAIN HAYVIEWRD.
House No. Street
County Tax Map NO. 1000 Section 75 Block 4
Subdivision Filed Map No.
SOUTHOLD, N.Y.
Hamlet
Lot 22.3
Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated B~RIL 11, 1995 pursuant to which
Building Permit No. 22726-Z dated MAY 5, 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 RELOCATE AN EXISTING DWELLING ON SITE ON NEW FOUNDATION
AS APPLIED FOR & TO CONDITIONS OF ZBA $4300.
The certificate is issued to
GLENN K. SMITH & ELLEN ROSENBUSH
(owners)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL INSPECTION CERT.
PLUMBERS CERTIFICATION DATED
R10-94-0099--AUG. 19, 1997
%9119 DATED NO~/EMBER 20, 1995
MAY 27, 1997-PERFECTION PLUMBING & HEATING
Rev. 1/81
FORM NO.3
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y.
BUILDING PERMIT
ITHI$ PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
corvlPLETION OF THE WORK AUTHORIZED)
22726 Z
....................................................... ~.~M,~..l..d ...... z~..'/.,. ......................................
oo,m~a×~opNo. ~ooo ~eo,on ~S'~ ~Ioo~ ...... .H.... LotNo. p--~-' ~
' ,/, and approved by the
pursuant to application dated ................ .~.,~,-~..../.. ......... {...,,19..~..~.,
Building Inspector.
Fee $ ~j~t ....................
Rev. 6/30/80 (~,.,~E, ~ ~00~ ~..
Building Inspe~Cfor
This application must be filled in by typewriter OR ink and submittad'~
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.
Final Approval from Heatch Dept. of water supply and sewerage-disposal(S-9 form).
3. Approval of electricai installation from Board of Fire Underwriters.
4. Sworn statement from plumber certifying chat che solder used in system contains
tess than 2/I0 of i% 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 Beard Approval of c6mpleted si~e 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 co inspec~ sig-ned 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
i. CartificaZe of Occupancy - New dwelling ~25.00, Additions to dwelling $25.00,
A3-terations.to dwelling $25.00, S~imming pool $25.00, Accessory building $25.00,
Additions to accessory building $25.00. Businesses $50.00.
2. Certificate of 0ccupanc7 on Pre-e-~isting Buildin~ - $I00.00 /
3. Copy of Certificate of Occupancy - ...25¢.
4. Updated Certificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residential $I5.,00~ Commercial $15.00
New Construction ..... /.... 01d Or Pre-existing Building .................
House No. StrUt Haml e~
County Tax Ylap ~o lO00, Section .......... Block .............. Lot....~. .................
Subdivision .................................... Filed Map ............ Lot ......................
Health Dept. Approval .......................... Under~T%ters Approval .........................
Planning Board Approval .............. ; .........
Request for: Temporary Certificate ........... Fin~ C.~ticate .... .~./.,
CO 7
Town Hall, 53095 Main Road
P. O. Box 1179
Southold, New York 11971
Fax (516) 765-1823
Telephone (516) 765-1802
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
CERTIFICATION
Owner: (~ L~-N ~ S~IT~ (please print)
Plumber:
(please pr£nt)
I certify that the solder used in the water supply system
contains less than 2/10 of 1% lead.
(Plumbers Signature)
Sworn to before me this
Notary ~b. lic A~ /~ County
(516) 286-6642
ELECTRICAL INSPECTION SERVICE INC.
375 DUNTON AVENUE
EAST PATCHOGUE, NEW YORK 11772
DATE: 11/20/95
ADDRESS: 2850 Main Bayview Rd.
ISSUED TO: Glen Smi%h
VILLAGE: Sou%hold
9119
APPLICATION NO. ON FILE
INTRODUCEDBY: Lademann Electric, Inc.
TOWN:SOuthold
LIC. NO. 4141-E
AREAS LISTED WERE INSPECTED ON: 1 1 / 2 0 / 9 ~ND WERE FOUND TO BE IN COMPLIANCE WITH THE
NATIONAL ELECTRICAL CODE.
LOCATION: X BASE X IST X 2ND __$RD ATTIC ___.POOL
2 SMOKE DETECTOR
OUTSIDE, RES. ~ Hood
23 Switches 1'-O~1 Burner
37 Receptacles
23 Fixgure/Outlegs
3 GFI
I
METERS ^MPS / P~SE I
DETACHED GARAGE
PRESIDENT
Ellen Rosenbush Smith
2850 Main Bayview Road
Southold, NY 11971
September 9, 1997
Office of the But[ding Inspector
Town of Southold
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, NY 11971
To Whom This May Concern:
Enclosed please find Health Department approval for our house and property
(building permit # 22726-Z). I believe there is nothing else needed by your office to
complete our Certificate of Occupancy. We look forward to receiving it in the very
near future.
Sincerely,
Ellen Rosenbusb. Smith
Town Hall, 53095 Main Road
P. O. Box 1179
Southold, New York 11971
Fax (516) 765-1823
Telephone (516) 765-1802
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
June 10, 1997
Glen & Ellen Smith
2850 Main Bayview Rd.
Southold, N.Y. 11971
To Whom This May Concern:
We are unable to complete your Certificate of Occupancy
because of the following reasons:
An application for Certificate of Occupancy is
not on file. (Enclosed)
No Underwriters Certificate on file.
The check is (not on file.)$25.00
XX 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 # 22726-Z
Please contact our office on this matter.
cooperation.
Thank you for
SOUTHOLD TOWN BUILDING DEPT.
APPEAt,S BOARD MEMBERS
Gerard P. Goehringer, Chairman
Serge Doyen, Jr.
Jasles Dinizio, Jr.
Robert A. Villa
Lydia A. Torlora
Southold Town Ilall
53095 Mais Road
P.O. Box 1179
Southold, New York 11971
Fax (516) 765-1823
Telephose (516) 765-1809
BOARD OF API'EALS
· .T,O.~.N ,QE SOUTIIOLD
ACTION 01~ TIIE BOARD OF APPEALS
I)ATE OF ACTION: March 1~ 1995 APPL. #430f~
APPLICANT: GLENN SMITII and ELLEN ROSENBUSH
LOCATION OF PROPERTY: 2850 Bayview Road~ Southold~ NY
COUNTY TAX MAP DISTRICT 1000~ SECTION 75~ BLOCK 4~ LOT 22.3
referred to as Lot #1 on the Minor Subdivision Map filed 8/3/92.
(This let is also a portion of former CTM Lot 22.1.)
BASIS OF APPEAL: Notice of Disapproval issued by the Building
~m_~pector dated December 19~ 1994. "In an R-80 District accessory
buildings & structures shall be located in the required rear yard.
Relocating the dwelling will create a nonconforming."
PROVISIONS APPEALED FROM: Article II[~ Section. s 100-33.
RELIEF REQUESTED: Approval o£ front yard location of existing barns,
which yard location results from the proposed relochtion of an existing
dwelling, all as shown on survey prepared by Kenneth F. Abruzzo dated
September 2l, 1994.
MOTION MADE BY: Robert A. Villa, Member
SECONDED BY: James Dinizio, Jr., Member
ACTiON/RESOLUTION ADOPTED: Granted as applied, with location of
dwelling shown on the survey dated September 21~ 1994 on this
5.0001-acre iJarcel. %
REASONS/FINDINGS: Single-family dwelling as exists is nonconforming
with a 23.6 ft. setback from Main Bayview Road and 13.4 ft.
nonconforming side yard setback from the northerly property line.
Accessory barn buildings will remain located greater than 75 'feet from
the front yard principal setback line. Dwelling will be placed 60+-
feet from tim northerly line and 245+- feet from Main Bayview Road
which also eliminates tho present nonconforming setbacks. The "con-
servation easement arca" on a l~irge portien of this tract bas' also been
made available flit access and use incidental to tim priacipal dwelling.
VOTE OF TIlE BOARD: Ayes: Serge J. Doyen, Member
James Dinizio, Jr., Member
Robert A. Villa, Member
Lydia A. Tor~ora, Member.
Gerard P. Geehringer, Chairman~Member
This resolatkm was unanimously adopted.
Town Hall, 53095 Main Road
P. O. Box 1179
Southold, New York 11971
Fax (516) 765-1823
Telephone (516) 765-1802
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
May 29, 1997
Glen & Ellen Smith
2850 Main Bayview Rd.
Southold, N.Y. 11971
To Whom This May Concern:
We are unable to complete your Certificate of Occupancy
because of the following reasons:
XX
XX
XX
An application for Certificate of Occupancy is
not on file. (Enclosed)
No Underwriters Certificate on file.
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 # 22726-Z
Please contact our office on this matter.
cooperation.
Thank you for
SOUTHOLD TOWN BUILDING DEPT.
FIELD ~NSPECTION REPORT
FOUNDATION
FOUNDATION
CONNENTS
FRA~ &
PLUMBING
INSULATION PER N. Y.
STATE ENERGY
CODE
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ]/~:)UNDATION 2ND [ ]INSULATION
[//x~' FRAMING [ ] FINAL
[ ] FIREPLACE & CHIMNEY
REMARKS: ~,/~//,~ /~~ ~
DATE
765-1802
BUILDING DEPT.
INSPECT!O~
[ ] FOUNDATION 1ST [/'] ROUGH PLBG.
[ ] FOUNDATION2ND [ ]INSULATION
[ ] FRAMING [ ] FINAL
] FIREPLACE & CHIMNEY
INSPEC~
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST
[ ] FOUNDATION 2ND
[ ] FRAMING
ROUGH PLBG.
[ ~'IN-'~ATION ~~-~
FINAL
[ ] FIREPLACE & CHIMNEY
DATE INSPEC
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST
[ ] ROUGH PLBG,
[ ] FOUNDATION 2ND
[ ] FRAMING
[ ] INS~JL'A~ON
[ ~'~NAL
[]FIREPLACE&CHIMNEY
INSPECTOR
765-t802
BUILDING DEPT.
INSPECTION
[ ] FRAMING [ ]FINAL
[ ] FIREPLA% & C.IMNE~__
REMARKS: ~~*'~
DATE
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ]/'R~UGH PLBG.
[ ] FOUNDATION 2ND [//}/INSULATION
[ ] FRAMING [ ] FINAL
[ ] FIREPLAC~&~,C_HIM~Y
765-1802
BUILDING DEPT.
NSPECTION
ATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION2ND [ ] INSULATION
[ ] FRAMING [ ] FINAL
[ ] FIREPLACE & CHIMNEY
REMARKS:
DATE ~ INSPE
765-1802
BUILDING DEPT.
INSPECTION
[ ] F.OU~NDA~ION 1ST [ ] ROUGHPLBG,
[,~FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ ] FINAL
[ ] FIREPLA~(~CHIMNEY
DATE
765-1802
BUILDING DEPT.
I NSPECTp/ --
[ ] FOUNDATION 1ST [ ~ ROUGH PLBG.
[ ] FOUNDATION 2ND
[ ] FRAMING [
[ ] FIREPLACE & CHIMNEY
[ ] INSULATION
] FINAL
DATE~~~i INSPET~
September 26, 1996
Southold Building Department
P.O. Box 1179
Southold, New York 11971
To Whom It May Concern:
Our Building Permit, #22726Z, for 2850 Main Bayview Road, in Southold, is due to
expire on November 11, 1996. We would like to extend the permit for an additional
six months. Thank you for any consideration you can extend to us in this regard.
Sincerely,
Glenn and Ellen Smith
DIANE HEROLD, ARCHITECT
P.O. Box 884
Westhampton Beach, New York
June 15, 1995
11978
Mr. Gary Fish and Mr. Thomas Fisher
Town of Southold Building Department
Town Hall
Southold, New York 11971
RE: Building permit ~22726Z, May 5, 1995
Glenn Smith and Ellen Rosenbush Smith
2850 Main Bayview Road, Southold
Dear Mr. Fish and Mr. Fisher:
When the above permit was issued, your department included
a note that the permit would have to be amended and revised
plans submitted for any interior work. As Mr. Smith has asked
me to work with him, I need a clarification from your office.
I submitted the drawings showing a rebuilt stair from the first
floor to the second floor. Although the code was changed in
December for relocated buildings, the risers of the existing
stair were still too high to conform to code. In my discussion
with Mr. Fisher, he indicated the building department would
require the stairs to be rebuilt to conform to the building
code in all respects, eg. conforming width and size of treads
and risers. I submitted the plans accordingly and informed
Mr. Smith of this decision.
Subsequently, Mr. Smith had a conversation with Mr. Fish
who indicated that the stairs could remain as they exist.
Naturally it would save the Smiths money and would save an
attractive stair and rail if the stairs could remain.
I would like the building department to give a unanimous
final decision on this stair because I do not want an
inspector to arrive at the house at some future date and
require additional work.
Thank you for your attention to this request.
Sincerely,
Diane Herold
288-5049
APPEALS[ BOARD MEMBERS
Gerard P. Goehringer, Chairman
Serge Doyen, Jr.
James Dinizio, Jr.
Robert A. Villa
Lydia A. Tortora
Southold Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (516) 765-1823
Telephone (516) 765-1809
BOARD OF APPEALS
ACTIo~OoWyT(~FESi?gATRHDOoLFD Al'PEALS
DATE OF ACTION: March 1, 1995 APPL. #4~_ .
APPLICANT: GLENN SMITIt and ELLEN ROSENBUStt
LOCATION OF PROPERTY: 2850 Bayview Road, Southold~ NY
COUNTY TAX MAP DISTRICT 1000, SECTION 75, BLOCK 4, LOT 22.3
referred to as Lot #1 on the Minor Subdivision Map filed 8f3/92.
(This lot is also a portion of former CTM Lot 22.1.)
BASIS OF APPEAL: Notice of Disapproval issued by %he Building
Inspector dated December 19~ 1994, "In. an R-80 District accessory
buildings & structures shall be located in the required rear .yard.
Relocating the dwelling will create a nonconforming."
PROVISIONS APPEALED FROM: Article IH~ Sections 100-33.
RELIEF REQUESTED~ Approval of front yard location of existing barns,
which yard location results from the proposed relocation of an existing
dwelling, all as shown on survey prepared by Kenneth F. Abruzzo dated
September 21, 1994.
MOTION MADE BY: Robert A. Villa, Member
SECONDED BY: James Dinizio, Jr., Member
ACTION/RESOLUTION ADOPTED: (;ranted as applied, with location of
dwelling shown on the survey dated September 21, l~fi, .0n. this
.5, O001-acre parcel. ~
REASONS/FINDINGS: Single-family dwelling as exists is nonconforming
with a 23,6 ft. setback from Main Bayview Road and 13.4 ft.
nonconforming side yard setback from the northerly property line,
Accessory barn buildings will remain located greater than 75 feet from
the front yard principal setback line. Dwelling will be placed 60+-
feet from the northerly llne and 245+- feet from Main Bayview Road
wlfich also eliminates the present noncoifforming setbacks, The 'icon-
. servaHon easement area" on a large portion of ibis tract has also been
made available fer access and use incidental, to ihe principal dwelling,
VOTE OF TIlE BOARD: Ayes: Serge J: Doyen, Member
Jame~ Diuizio, Jr. ~ Member
Robert A. Villa~ Member
Lydia A. T'ort~ra, 'Member,
Gerard P. Goehringer, Chairman~Member
This resolution was unanimously adopted.
FOP, It NO. 3
TORN OF SOUTHOLD
BUILDING DEPARTHENT
SOUTHOLD, N.Y.
NOTICE OF DISAPPROVAL
December.)?
To
Diane Herold a/c Glenn Smith
P.O. Box 884
PLEASE TAKE NOTICE that your application aated
for permit to Relocate.a.n.e.x.i. sti. n.g.. ...d.w.e.l.l.l.n.g. ... .... at
2850 Bayview Road Southoid, N.Y.
Location of Property .......................... ...-' ......... . · .................... .
Douse No. Street, Hmnlet
O4
County Tax Nap No. 1000 - Section...........75 BLOCK .. ........ . LOT ...2.2,3... ......
Subdivision Filed Hap No ........ Lot No .......
is returned herewith and disapproved on the following grounds . IN AN ,R.-.80 DISTRICT
ACCRSSORY BUILDINGS & STRUCTURES SHALL BE LOCATED IN THE REQUIgED REAR YARD.
RELOCATING 'I'HE DWELLING WiLL CREATE A NON-COI~ORHING.
ARTICLE III CHAPT, 100-33
ACTION REQUIRED BY THE ZONING BOARD OF APPEALS.
RV 1/80
/]~J~,EDING INSPECTOR GARY J. FISN
" .......... ~" TOWN OF SOUTHOLD
t(¢ ·'BUILDING DEPARTMENT
I
~, ~ SOUTFIOLD N,Y. 11971
~'~-~7~;7~:';-'~ / TEL,: 765-1803
Disapproved. a/c ..............
LICATION FOR BUILDING PERMIT
]NSTRUCTZONS
3 SETS OF PLANS
CI1EcK
SEPTIC FORH
HAIL TO:
, .~tf~T .........
Tiffs application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3
ao
sets of plans, accurate plot plan to scale. Fee according to schedule.
b. Plot plan showing location of tot 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 y~hich is part of this appli-
cation. ' '
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 permit
shall be kept on the premises available for inspection throughout the work.
e. No building shall be occupied or used in whole q.r. in. part for any purpose whatever until a Certificate of Occupancy
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 the
Building Zone Ordinance of the Town of Southold, Suffolk County, New. York, and other applicable Laws, Ordinances or
Regulations, for the constraction of buildings, additions or alterations, or for removal o~' demolition, as herein described.
The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to
admit authorized inspectors on premises and in building for necessary ~ '~ ~ ,c~J
-- (Signature of applicant~ or name, if a~ corporation)
· ...........
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineeh general contractor, electrician, plumber or builder.
............ . ................... ................... : ..................................
Name of owner of premises .~..L, .~.~..~..V,:..~..t~. [7. g.. .~Lt.~ ................ ~...~.l"[l'{ .......................
' (as on the tax roll or latest deed)
If applicant is a borporation, signature of duly autl}orized officer.
(Name and title of corporate officer)
Builder's License No ..........................
Plunlber's License No .........................
Electrician's License No .......................
Other Trade's License No ......................
1. Location of land on which proposed work will be done ...................................................
llouse Number . Street Hamlet
Cotmty Tax Map No. lO00 Section ; Block ..... Lot, * ....
(Name)
!. Slate existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing useland occupaucy ....%~tOO/.~.'; EY'X133[I~Y..~.t~.t.t¢6 .................... .. ...........
b. Intended use and occupancy .., .~it~6t.~..'7 .U-7'~i't, ttc,~ ,B. t4,f6¢M,~6 ........... . ........................
· ~phcable); New ' Ad
k (check wblch Building ' lition Alteration
3 Natt re ofwo a
Repair .............. Remloval .............. Demolition .... ¥...: ..... Other Work ~ .....
~v og m~t ~ 9,,o0o ' ] (Description)
4. Estimated Cost . ~*Y~.~q~.~tOg.. ~. 1~.~ .......... Fee .............. ~t... ~ ...........
(to be paid on filing this application)
5. If dwelling, number of dwellin~ units ..... ~ ....... . Number of dwelling units on each floor.. ~ ..........
If~arage number of ears .... . .....
mt a' ......................................... .............
, specify nature and ext~nt of each type of nsc ......................
7. Dimensions of existing structures, if any: Front..~.,~ ........ Rear ,,/.~ ~ ~.; .... ~ Depth . ~ ~ ........
Height ............... Nut~lber of Stories .... ~ ................................................
Dimensions of sfime structure with alterations or additions: Front ~. ' Rear
Depth ..... ~ ........... .... tleight ......... ~f ........ ... Number of Stories .... ~ ..... '..
8. Dimensions of entire new construction: Front . .~ ......... ~ Rear ..... ~ ....... Depth . ~ ..........
Height ..... ~ ...... Nmhber of Stories ~ ~ ....................................
s, oCiot: .......... '.. m "
Date of Purchase . ~0p~6%~.. ~ ~ .... . ...... Name of Former Owner ~P/~ ~..
Zone or use district in which p(emises are situated .............................................
Does proposed constrnction vidlate, any zoning law, ordinance or regulation: .... ~ ..........................
Will lot be regrad~d .'...... ~.d h~ g~' '" '" Will excess f~l be rem~yo~rom premises: Yes
N~e of Owner of pre roses . .~ .. t~t~... Address ~~. ~., Phone No.
Name of Architect ~l~.. ~ ............ Address ~.~. ~g~. ~t~y.~. Phone No.~:~q~.; ...
Name of Con~ractor . O.~O~li .................. Address ...~ ........... Phon~ No...
~ th~ proper~y wtCM_n ,300 fee~ of a ~dal Wetland7 *Ye~ ........ ffo,.~. ......
~f ye~ Sou~ho~d :Town ~ru~t~ea P~mit may be required.
PLOT DIAG~
Locate deafly and distinctly all buildings, whethe'r existing or proposed, ~d. indicate ~1 ~et-baek dimensions from
or description acaord~g to deed, and show street n~es and indicate whether
10.
I1.
12.
'13.
14.
15.
property lines. Give street and block number
interior or corner lot.
~OUNTY OF..~.?..~V~. j .~. ......
.......... '. ~.~ · · ~ ~0.~ ............... being duly sworn, deposes m~d ~y~ that he is the ~ppli~nt
(N~me of individual sighin~ contract)
hove named.
the i ~ '
is .................... , .... , · . .....................................
(Contractor, agent, corporate offieer~ etc.)
said owner or owners, and ~s dqly a lthonzed to perform or have performed the said work and to m~e and file this
~pl cat on; that all statements contained in this application are true to the best of his ~owlgdge and belief; and that the
ork w~l be perfo~ned in the mann,er set forth in the application filed therewith.
xvom to before me ti '
us
....................... day Of ..................... ,
otary Public,
D~ORAh'
JI~OYARY P(JBLIC, Stale of No~
~. 4957775, Suffolk Cou~
~erm Expires Octo~r
.. .tO. Corm y
' (Signature of aplqiC:-"'