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Home My WebLink About20896-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No Z-21039 Date SEPTEMBER 23~ 1992 THIS CERTIFIES that the building ADDITION Location of Property 4350 CAMP MINEOLA ROAD MATTITUCK~ N.Y. House No. Street Hamlet County Tax Map No. 1000 Section 122 Block 09 Lot 08 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated AUGUST 17t 1992 pursuant to which Building Permit N.o. 20896-Z dated AUGUST 18'~ 1992 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 EXISTING ONE FAMILY DW~TJ.ING ~ APPLIED FOR The certificate is issued to RICHARD CURCIO (owner) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A UNDERWRITERS CERTIFICATE NO. N/A PLUMBERS CERTIFICATION DATED N/A Building Inspector Rev. 1/81 FOB. M NO. · TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING P ERA4,ffT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) NgN°. 208gSZ D~te ........... .~.~... ............................ , ,~.~..~.. Permission is hereby granted to: / · .._~!...~..~~...~.:......./..x~;../~;~/4~ ....... ~.~...(.~.~....~.~;4..~L..... .... ~ppremis~located at ........ ~ ........... ..~...~,.. ......... ~ ~"~" '""~ '"~'"'~'"~'"~ ......................................... (.....~..~...~..--~ x .~~.....j ................................................ County Tox Mop No. ]000 Section ....../..~;';...,,'~"=. ....... Block ....... ..~..g ...... Lot No ......... ..~....~... ...... pursuant to applica,ion dated ................... ~Z ....................... , 19.2.~T.., and approved by the Building Inspector. Rev. 6/30/80 Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 : APPLICATION FOR CERTIFICATE OF OCCUPANCY 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. 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, g certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. For existing buildings (prior to April 9, 1957) con-conforming uses, or buildings and "pre-existing" land uses: I. 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 I. 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 - $5.00 over 5 years - $10.00 4. Updated Certificate of Occupancy - $50.00 5.' Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 Date . . o.. . New Construction ........... Old Or Pre-existing Building..~ ............ .......... Location of .......... ..... ,, House No. Street Hamlet 0nwer or Owcers of Property...~ %C~.~L.~.O~.....~. County Tax Map No 1000, Section .............. Block ............... Lot ............. Fee Submitted: Subdivision ...................... ' .............. Filed Map .......... .. Lot ..................... Permit N~~ 08q~ .~. ~. .... Applicant ~.w~ ............. Date Of Permit .................. Health Dept. Approval ..... ~?/.-~- ............... Underwriters Approval....~./.~. ................. Planning Board Approval ·. Request for: Temporary Certificate ........... Final Certicate....~.. ...... PS'- o.o INSPECTORS ' Victor Lessard Principal Building Inspector Curtis Horton Senior Building Inspector Thomas Fisher Building Inspector Gary Fish Building Inspector Vincent R. Wieczorek Ordinance Inspector Robert Fisher Assistant Fire Inspector Telephone (516) 765-1802 SCOTT L. HARRIS, Supervisor Southold Town Hall P.O. Box 1179, 53095 Main Road Southold, New York 11971 Fax (516) 765-1823 Telephone (516) 765-1800 OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD SEFI~EM~ER 14, 1992 STAI~-.EY FLISS, 565 OLD HAIN ROAD HATTITUCK, lqY 11952 RE: RICHARD CUR(ilO 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 No Health Department Approval on file. No final inspection has been made. No Plumber Solder Certificate on file. {Ail permits involving plumbing being issued after April 1, 1984). BUILDING PEP~4IT ~ 20896-Z Please contact our office on this matterd Thank you for cooperation. SOUTHOLD TOWN BUILDING DEPT. (iC: RlCltklfl) glIR(llO ~0 ~ ' 50" ~1 ~ ~ :... L'..'~'i':'i :"~'.': ~' '. O~:LY TO TME PER~ON :C ~ '~,'~h .- ' -' '' TO THE ASSIgNeES OF 'THE "~.' T~ION/ GUA~ANT[~ A~[ NOT 1-4738-00530/0000126 iiU~ { 7 PERMIT Under the Environmental Conservation law (ECL) August 7, 1992 EXPIRATION DAlE August 31, 1995 -- Article 15, Title 5: __ Protection of Water -- Aflicle 15, Title 15: Water Supply Article 15, Title 15: Water Transport Article 15, Title 15: Long Island Wells Article 15, Title 27: Wild, Scenic and Recreational Rivers 6NYCRR 608: Water Quality Certification Article 17, Titles 7, 8: · SPDES -- Article 19: __ Air Pollution Control -- Article 23, Title 27: __ Mined Land Reclamation -- Article 24: __ Freshwater Wetlands Article 25: · Tidal Wetlands Article 27, Title 7; 6NYCRR 360: · Solid Waste Management -- Article 27, Title 9; 6NYCRR 373: __ Hazardous Waste Management [~---] Article 34: Coastal Erosion Management j----] Article 36: Floodplain Management j--]Articles 1, 3, 17, 19. 27, 37; 6NYCRR 380: Radiation Control [--~ Other: Pt R~tlT ISSUED TO TELEPHONE NUMBER Richard A. Curcio ( } ADDRESS OF PERMITTEE BOx 522 Mattituck, NY 11952 CONTACT PERSON FOR PERMITTED WORK J TELEPHON£ NUMBER b~rietta Fogerty 1375 Pourth St., New Suffolk, I~f 11956 I ( ~ C~rcio Property 4350 Camp M~neola LOCATION OF PROIECT/EACILITY ~ttituck COUNTY TOWN/~ WAtERCOURSE/WETLAND NO Suffolk Southold DESCRIPTION OF AUTHORIZED ACTIVITY F~place an existing (7'x 24~ deck and add a n~ (14'x 1~ portion. second story deck (15' x 14 1/2'). Constrict a Place a (10' x 10') utility shed. g2.1 work shall be in accordance witJ~ the attached NYSDEC approved plan. By acceptance of this permit, the permittee agrees that the permit is contingent upon strict compliance with the ECL, all applicable regulations, the General Conditions specified (See Reverse Side) and any Special [~o~nditionsigcJu~ed as pa~t ofthis permit. uty Req~ona± PERMITADMINISTRATOR ADDRESS David DeRidder AUTHORIZE D SIGNATUR[j~ ~ DATE g~ 7, lqq? Page1 of 4 r 1-4738-00530/00001=0 AUG '{' !?:~, PERMIT Under the Env ronmental Conserva! on Law (ECl-) August 7, 1992 August 31, 1995 TYPE OF P£RMIT [Check All Applicable Boxesl ] []]New [] Renewal []MOdlhCat,on [:3Permit to Con,true, J-]Permit to Opera,e -- Article 15, Title 5: __ Protection of Water -- Article 15, Title 15: __ Water Supply F------] Article 15, Title 15: Water Transport {--~ Article 15, Title 15: Long island Wells -- Article 15, Title 27: __ Wild, Scenic and Recreational Rivers -- 6NYCRR 608: __ Water Quality Certification -- Article 17, Titles 7, 8: __ SPDES Article 19: Air Pollution Control -- Article 23, Title 27: __ Mined Land Reclamation -- Article 24: __ Freshwater Wetlands Article 25: Tidal Wetlands Article 27, Title 7; 6NYCRR 360: Solid Waste Management -- Article 27, Title 9; 6NYCRR 373: Hazardous Waste Management ['~'--] Article 34: Coastal Erosion Management -- Article 36: Floodplain Management r--.-~ Articles 1, 3, 17, 19, 27, 37; 6NYCRR 380: Radiation Control Other: Richard A. Curcio ADDRESS OF PER,N~ITTEE 5OX 522 Mattituck, NY 11952 CONTACT PERSON FOR PERMITTED WORK TELEPHONE NUMBER [~rietta Fogerty 1375 Fourth St., N~ Suffolk, NY 11956 ( C~rcio Property 4350 Camp Mineola toc^no~ OF Matt±tuck COUNTY TOWNJ~ WAE[RCOURSE/WETLAND NO NYTM COORDINATES Suffolk Southold ~ N4 DESCRIPTION OF AUTHORIZ[D ACTIVITY Replace an existing (7'x 24~ deck and add a n~{ (14'x 1~ ~ortion. Construct a second story deck (15' x 14 1/2'). Place a (10' x 10') utility shed. All work shall be in accordance wit2~ the attached NYSDEC approved plan. By acceptance of this permit, the permittee agrees that the permit is contingent upon strict compliance with the ECL, all applicable regulations, the General Conditions specified (See Reverse Side) and any Special %nditions iocluc[ed as part of this permit. ut¥ Req~ona± PERMIT ADMINISTRATOR ADDRESS David DeRidder AUT H ORIZ E D S ,CNAT U RE/~/~,,,.~._.~ ~ Pase I of 4 GENERAL CONDITIONS Inspections The permitted site or facility, including relevant records, is subject to inspection at reasonable hours and intervals by an authorized representative of the Department of Environmental Conservation (the Department) to determine whether the permittee is complying with this permit and the ECL. Such representative may order the work suspended pursuant to ECL 71-0301 and SAPA 401(3). A copy of this permit, including all referenced maps, drawings and special conditions, must be available for inspection by the Department at ali times at the project site. Failure to produce a copy of the permit upon request by a Department representative is a violation of this permit. Permit Changes and Rer~ewals 2. The Department reserves the right to modify, suspend or revoke this permit when: a) the scope of the permitted activity is exceeded or a violation of any condition of the permit or provisions of the ECL and pertinent regulations is found; b) the permit was obtained by misrepresentation or failure to disclose relevant facts; c) new material information is discovered; or d) environmental conditions, relevant technology, or applicable law or regulation have materially changed since the permit was issued. 3. The permittee must submit a separate written application to the Department for renewal, modifica- tion or transfer of this permit. Such application must include any forms, fees or supplemental infor- mation the Department requires. Any renewal, modification or transfer granted by the Department must be in writing. 4. The permittee must submit a renewal application at least: a) 180 days before expiration of permits for State Pollutant Discharge Elimination System (SPDES), Hazardous Waste Management Facilities (HWMF), major Air Pollution Control (APC) and Solid Waste Management Facilities (SWMF); and b) 30 days before expiration of all other permit types. 5. Unless expressly prcvided for by the Department, issuance of this permit does not modify, supersede or rescind any order or determination previously issued by the Department or any of the terms, con- ditions or requirements contained in such order or determination. Other Legal Obligations of Permittee 6. The permittee has accepted expressly, by the execution of the application, the full legal responsibili- ty for all damages, direct or indirect, of whatever nature and by whomever suffered, arising out of the project described in this permit and has agreed to indemnify and save harmless the State from suits, actions, damages and costs of every name and description resulting from this project. 7. This permit does no~; convey to the permittee any right to trespass upon the lands or interfere with the riparian rights o! others in order to perform the permitted work nor does it authorize the impair- ment of any' rights, title, or interest in real or personal property held or vested in a person not a party to the permit. 8. The permittee is responsible for obtaining any other permits, approvals, lands, easements and rights- of-way that may be required for this project. Page 2 of 95-20-6a (10/90] -- ~'5c ADDITIONAL GENERAL CONDITIONS FOR ARTICLES 1S (Title 5), 24, 25, 34, 36 and 6 NYCRR Part 608 ( 9. That if future operations by the State of New York require an if. in the opinion of the Department of Environmental Conservation 13 it shall cause unreasonable obstruction to the free navigation of said waters or flood flows or endanger the health, safety or welfare of thereby without expense to the State, and if, upon the expiration or 10 That the State of N~.w York shaft ~n no case be liable for any damage the U S. Army Corps of Engineers, U.S. Coast Guard, New York State Office of General Services or local government which may be required ) other environmentally deleterious materials associated with the project. Any material dredged in the prosecution of the work herein permitted shall be removed evenly, without leaving large refuse piles, ridges across the bed of a waterway or floodplain or deep holes that may have a tendency to cause damage to navigable channels or to the banks of a waterway. There shall be no unreasonable interference with navigation by the work on 8/6/92 . SPECIAL CONDITIONS Any debris or excess material frc~ construction of this project shall be completely r~noved from the adjacent area (upland) and removed to an approved upland area for disposal. No debris is permitted in tidal wetlands. No decks, accessory structures, or additions will be permitted without further approval from the Department. Supplementary Special Conditions (A) thru (J) attached. DEC PERMIT NUMBER 1-4738-00530/00001-0 Page 3 of 4 'C 'P /nod '.3 Uall~'' '3 'D New York State Department of Environmental Conservation Building 40--SLINY, Stony Brook, New York 11790-2356 (516) 751-1389 Thomas C. Jorling Commissioner Richard Curcio Box 522 Mattituck, NY 11952 August 7, 1992 RE: 1-4738-00530/00001-0 Dear Mr. Curcio: In conformance with the requirements of the State Uniform Procedures Act (Article 70,ECL) and its implementing regulations (6NYCRR, Part 621) we are enclosing your permit. Please read all conditions carefully. If you are unable to comply with any conditions, please contact us at the above address. Also enclosed is a permit sign which is to be conspicuously posted at the project site and protected from the weather. Very truly yours,' Marily~ Peterson Environmental Analyst HE~/nw enclosure CHARLES T. HAMILTON Chief, Marine Regulatory Sectio~l NYSDEC, Bureau of Marine Habitat Bldg. 40, SUNY, Room 228 Stony Brook, NY 11790-2356 Re: Permit No. Protectio~ Issued To: Contractor's Name: Contractor's Address: Contractor's Phone No. Dear Sir: Pursuant to General Condition Number 1 of the above referenced permit you are hereby notified that the authorized activity shall commence on This notice is to be sent at least two days in advance of commencement of the project. The permit sign will be posted at the site and copy of permit will be available at site for inspection. Submitted By: Date: FAILURE TO NOTIFY OR POST SIGN WILL LEAVE OWNER AND/OR CONTRJkCTOR SUBJECT TO APPLICABLE PENALTIES FOR NON-COMPLIANCE WITH PERMIT CONDITION. CHARLES T. HAMILTON Chief, Marine Regulatory Section NYSDEC, Bureau of Marine Habitat Protection Bldg. 40, SUNY, Room 228 Stony Brook, NY 11790-2356 Re: Permit No. Issued To: Contractor's Name: Contractor's Address: Contractor's Phone NO. Dear Sir: Pursuant to General Condition Number 1 of the above referenced permit you are hereby notified that the authorized activity was completed on Submitted By: Date: THIS NOTICE, WITH PHOTOS OF COMPLETED WORK AND/OR COMPLETED SURVEY, TO BE SENT TO ABOVE ADDRESS PROMPTLY UPON COMPLETION OF PROJECT. FAILURE TO NOTIFY WILL LEAVE OWNER AND/OR CONTRACTOR SUBJECT TO APPLICABLE PENALTIES FOR NON-COMPLiANCE WITH PERMIT CONDITIONS. IS ref: BMIIP The A. following SUPPLEMENTARY SPECIAL CONDITIONS conditions apply to all permits: If any of the permit conditions are unclear,the permittee shall con- tact the Division of Regulatory Affairs at the address and telephone noted below. A copy of this permit with supplementary conditions and approved plans shall be available at the project site whenever authorized work is in progress. The permit sign enclosed with the permit or a copy of letter of approval shall be protected from the weather and posted in a con- spicuous location at the work site until completion of authorized work. At least 48 hours prior to commencement of the project, the permittee shall complete and return the top portion of the enclosed receipt form certifying that he is fully aware of and understands all provisions and conditions of this permit. Within one week of completion of the permitted work, the bottom portion of that form shall also be com- pleted and returned. For projects involving activities to be accomplished over a period of more than one year, the permittee shall notify the Regional Permit Administrator in writing at least 48 hours prior to the commencement of resumption of work each year. If project design modifications take place after permit issuance, the permittee shall submit the appropriate plan changes for approval by the Regional Permit Administrator prior to undertaking any such modi- fications. The permittee is advised that substantial modification may require submission of a new application for permit. Ail necessary precautions shall be taken to preclude contamination of any wetlands or waterway by suspended solids, sediment, fuels, solvents, lubricants, epoxy coatings, paints, concrete, leachate or any other environmentally deleterious materials associated with the project work. Any failure to comply precisely with all of the terms and conditions of this permit, unless authorized in writing, shall be treated as a violation of the Environmental Conservation Law. The permittee is advised to obtain any permits or approvals that may be required from the U.S. Department of Army Corps of Engineers, NY District, 26 Federal Plaza, New York, NY 10278, (Attention: Regulatory Functions Branch}, prior to commencement of work authorized herein. The granting of this permit does not relieve the permittee.of the .responsibility of obtaining a grant, easement, or other necessary approval from the Division of Land Utilization, Office of Gemeral Services, Tower Building, Empire State Plaza, Albany, NY 12242, which may be required for any encroachment upon State-owned lands underwater. Regional Permit Administrator NYS Dept. of Environmental Conservation Bldg. 40, SUNY-Room 219 Stony Brook, NY 11790-2356 (516) 751-?~389 Page eof ¥ $ NOTE . I · MONUMENT 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ .~NDATION 2ND [ ] INSULATION FRAMING [ r..~NAL DATE INSPECTOR OUNDA~ION ( ~ st) OUNDAT!ON (2nd) OUGH FRAME .PLUMBING iNSULATION PER N. Y. STATE ENERGY CODE FINAL ADDITIONAL COMMENTS: FORM NO. t TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-180:3 , ppro,cd ....... Pc=i, Disapproved ale ..................................... BOARD OF HEALTH ......... 3 SETS OF PLANS ......... SURVEY .................. CHECK ................... SEPTIC FORM ............. NOTIFY CALL .................. MA=IL I 't' 199'2 /~Buildin= Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Date ~/ws-~. ~.~.. ..... Ic. a, 'rids application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, ~v 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 st or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this 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 appticant. Such pe ,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 Occup; shall have been granted by the Building lnspectdr. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pumuant Building Zone Ordinance of the Town of Southold. Suffolk County, New York, and other applicable Laws, Ordin:mc~ Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein descri The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, an admit authorized inspectors on premises and in building for necessary i~ections. ~ , , ~ ~ a c ' · . (Mailing address of applicant) State whether applicant is owner, lessee, agent, archftect, engineer, general contractor, electrician, plumber or bull ................ ! ......................................................Co .Tm ro ' , .... Name of owner of premises . qr. . .~. F~, ~ .~ .................................. (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', License NO / R.}.~ .~..~..'7...~. ,~ .... Plumber's License No ......................... EIcctncmn s L~cense No ....................... Other Trade's License No ...................... 1. Location of land on which proposed work will be done..~ 3.~..~..,,.~a, ff'l/.~.t"'r~ n . .~..i..D.CO. Lc&. ....... House Nun bet : Streets, Hamlet County Tax Map No. 1000 Section Block Lot... ................ Eiled Map No ............... Lot ............. Subdivision ................ (~q'n]l~) 2. State existing use and occupan:y of premises and intended use and occupancy of proposed construction: Existing use and occupancy b. Imended use and occupancy ~ ~ $ i C . . . : .............. 7~ fL" ,' '': .... ' ' '.~' .......... 3, Nature of work (check which applicable): Nesv Building .......... Addition .......... Alteration ........ Repair ...... Removal ............ Demolition .............. Other Work ~ ~C.~,- ~.~/oiO..~r,~X "~ ¢,n [C~rc,[a~"- (Description) 4. Estimatdd Cost ~.-5~-'0.O. ........ .~ .............. Fee .................... (to be paid on filing this application) $. If dwelling, number of dwelling units .... .] .......... Number of dwelling units on each floor.., t". ' If garage,, number of cars ...................................................................... 6. If business, commercial or mixed occupancy, specify nature and extent of eaclLtype of use ............. 7. . .... . ~, ........... . ~ .'A'''' Dtmenslons of exzstmg structurcs, If any: Front . ~ Rear ....-.-.-~1~ ......... Depth .J.~.. ~... Hci2ht':' ............. Numbcr of Stories ..... ~. ............................. ' Dimensions of same structure with alterations or additions: Front . ..~ ............. Rear ... 0~ ......... Depth . .~/o) '..~.': ............ Ilcight ......... , ............. Numbcr of Stories . . ,b""""""""~ .... S. Dimensions of entire ncw construction: Front...Z~, .......... Rear..{¢~/ .......... Depth ]).~.]']]]2]]]] Height ............... Number of Stories. ' ~;;~t~ ' ~ .)]j~ .~i' ........... 10. Date of Purchase .~t~la. ¢~..8.to ................... Name of.Former ~wner ~.ezn. lZ,../~.o ~ .'r, .o. .......... 11. Zone or use district in which premises are situated ..... j~ .e.%~.'4 .~'?.~..<-,4. ................................. 12. Does proposed construction violate any zoning law. ordinance or regulation: ..... /~. 0 ...................... 13. Will lot be regraded ...... .~.0. .................. XVill excess fill be removed from premises: Yes ,~ Ix 14. Name of Owner of prcmisesl~r.c~. Goc .,.o. .... Address ':/tS~F,-O~/)~bo:'¢/.q .~.. Phone No..'/dj~ ........ Name of Architect ........................... Address ................... Phone No .............. Name of Contractor STer~.~.¥..F.b. ~ ~. ~£.... ........ AddressOTd~,t~. Pt'{..~.~.a.~... Phone No~. ff.'.~. ,7.~. ~ :. 15.Is this property located withiuqO0-feet of a tidal wetland.* ~¥gS~iJ..NO .... ' *If yes, $outhold Town Trustees Permit may be required, PLOT DIAGRAM Locate clearly and distinctly fll buildings, whether existing or proposed, mad. indicate ali set-back dimensions fro property lines. Give street and block number or description according to deed, and show street names and indicate wroth interior or comer lot. STATE OF NEX~gF)'RK /'ND_ /// COUNTY OF.~~(./~ S.S ... O.{~.~. ........ being duly sworn, deposes ~d says that he is the applied (Name of individual s~gning contract) above named. (Contractor, 5gent~ corporate officer, etc.) of said owner or owners, ~d is duty authorized to perform or,have perfo~ed tko said work and to m~e and file t] application: that alt statements contained in this application are trne to the best of his knowledge and belief; and that t work w~l be perfomed in the m~ner set forth in the application t~lcd therewith. .... , ........ .......... ./ wv ......... ~. ~t~* (Signature of ) 7 ~ )