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HomeMy WebLinkAbout20013-z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Ha11 Southold, N.Y. CERTIFICATE OF OCCUPANCY No Z-20791 Date JUNE 16, 1992 THIS CERTIFIES that the building ADDITION & ALTERATLON Location of Property 1700 VILLAGE LANE ORIENT N.Y. House No. Street Hamlet County Tax Map No. 1000 Section 24 Block 2 Lat 17 Subdivision Filed Map Na. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated JULY 10, 1991 pursuant to which Building Permit No. 20013-Z dated JULY 11, 1991 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 ADDITIONS & ALTERATIONS TO EXISTING ONE FAMILY DWELLIPIG AS APPLIED FOR. The certificate is issued to PETER & CHARLOTTE DEUTSCA ' (owners) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A UNDERWRITERS CERTIFICATE NO. N-235815 - MAY 18, 1992 PLUMBERS CERTIFICATION DATED APRIL 30 1992 - K&K PLUMBIPIG & HEATING ---=r= Building Inspector Rev. 1/81 1'0811[ NO. A 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) t N°- ~ 0 Q 13 Z Date ....7~,~ 19.9.,1 r Permission is hereby grunted t I to L~a~. ..G~..I.A.?'.ik:.,~t.L,r.~.abAle°Rs.f.~7.?n~.r.....~. s sly..-.~ ~ ,,p®~_ ; ' ~ ~ J~~~ds¢,~~,irt2~....... ~•€>S,f~... ..t'e,~a.~~nG'`"~Y`G4~~'........~i r.....u j9~~..S-i .3~. f vv 4 of premises located at .....lf~.A... f ~ County Tox Map No. 1000 Section ..........,`~e'Z..T....... Block Lot No.. pursuant to application dated .....~r~~../.~~~ 19........, and approved by the ( Building Inspector. ~/~9/ Fee S.1~:3' Build~nspector t C Rev, 6/30/80 , . ~.G/.~.~-oa' Form No. 6 kk, r~.~ I~9'H"~{~ TOWN OF SOUTHOLD '9~1~~°~t~f.!_~~f~~~ t~~~ t~' BUILDING DEPARTMENT ~k d ~ ~ ~ ~k ~~s ~t,~.~~.,~ - TowN HALL ~ ~ ~ APR ~ Q l99~ ~ ~ 7A 76s-lsoz <<~ Lc~"T ~ ~ ~ . s. APPLICATION FOR CERTIFICATE OF OCCUPAN ~~7C3Va~f ~ ~ ~ k't3L~t 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 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 - Resident//d~ial $15.00, Commercial $15.00 Date .1.~.~?~~:. ~~y. ~~~.~L New Construction........... Old Or Pre-existing Building..... Location of Property.....~7a~...Vl~:'G'~~. ...D/L/~~+! House No. Street Hamlet Onwer or Owners of Property .Cr~~~~.~.~4'.~-..bE?.% ~.C~ County Tax Map No 1000, Section...2:¢.......Block......?:........Lot...... ~ 7 Subdivision ....................................Filed Map............Lot...................... Permit No.~: ~~(.~..~;Date Of Permit.Zl.(((.ln.~ ......Applicant. .%~:~?L--.:D~?!~~F/........ Health Dept. Approval ..........................Underwriters Approval......................... Planning Board Approval / Request for: Temporary Certificate........... Final ~Certicate....../. Fee Submitted: `$....~~.-~:Q C O~.P.C , ~ t~O9 q APPLICA~~. c~~FFO(/j~' TEL.7G5-]802 o~ol,,, o,~ TOWN Or SOriJTgOb,D ~ OFFICE OF BUILDIPIG INSPECTOR ' ° '~1 P.O. BOX 728 ~ ~ _,:""'~"°f.., - ~ \ ~i~ ~3 i ~..,,a~ -c TOVVNHALL `i~ ~~al`:~~~a~.~~~?~~"~! ~g Q~ SOUTHULD, N.Y. 11971 ~ ~_._w~..,,,~.-~x.,_ -•a~S~ t~~ ~l yb ~ APR 3 0 (99~ ~ ~to~,. s~K=~>r. C E R T I F I C A T I O N Dated Building Permit No. 2pp /3 Z Owner~,~-f, JYi~~` CH,4i~~ (please print) Plumber ~~k'PLl1AIRi~1~.~ y/~~N~. (please print) I certify that the solder used in the water supply system contains less than 2/10 of to lead. (plumber's siynature)~ Sworn to before me this ~ day of otary Public Rotary Public, - County JQYCE NI. WILKINS 4952 48StSat~kNewYaft ' Term EKpiresJune 1$1~8~ 3 THE NEW YORK BOARD OF FIRE UNDERWRITERS eA~~ ~ !001.071 BUREAU OF ELECTRICITY 88 JOHN STREET, NEW YORK, NEW YORK 10036 Date NA°t 18,1992 gpplicatfonNo.enfile 75727891194 N 235845 THIS CERTIFIES THAT only the electrical equipment as deacri6ed 6elaw ¢nd introduced 6y the ¢pplicont homed on the ¢hove ¢pplic¢tion numher in the premises of E~EY'ER DEUTSCH, 17+30 VILLAUE LANK, QRZ{;Nt", N,Y. in theJollouinp loc¢tion: ®Basement ® lxt FL ®2nd F[. QU'1' 3ertion Block Lot w¢sexarninedon MAY 11,1'392 ¢ndfoundW6eincmnpli¢nreuiththerequirensentsq(this6o¢rd. FIXTURE ECEPTACLES SWITCHES FIXTURES RANGES COOKING DECKS OVENS DISHWASHERS EXHAUST FANS OUTLETS INCANDESCENT fIUORESCENi OTHER AMt K W, AMT. K.W PMT KW. PMt K W AMi. H.P. 27 22 'L1 1 17 DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIME CLOCKS BELL UNIT HEATERS MULTI.OUTLET DIMMERS SYSTEMS y AMT. K. W OIL H. P. GA$ H. P. AMT. N0. A W. G. AMT. AMP. AMi AMPS. TRANS. AMT. H P plQ, OF FEET AMT. WATiS $¢g 3 ~ 1 2 12 2 ! SERVICE DISCONNECT NO.OF 5 E R V I C E AMI. AMP LYPE EQUIP, I%9W 1%JW 3%JW 3%4W NO.OPER%COND OF CC.COND. NO OF HI-LEG OF M4LEG NO.OF NEUTRALS OF EUTRAL OTHER APPARATUS: a M4'PC7R5t3-F N, P. I G. F.C.It-5 SHURL~ DE;TPCTQRI-i .Po'l G & 5 CONTRACY'UR LIC.A57i1-CS DI]% 215 I 50U4'HOLO t NY. 11971 GENERAL MANAGlR 41 ~ Per This certificate must not be altered in any manner; return To the office of the Board if incorrect. Inspectors may be identified by their credentials. COPY FOR BUILDING DEPARTMENT. TH{S COPY OF CERT{F{CATE MUST NOT BE ALTERED IN ANY MANNER. OQ 3-~- co ~ THE NEW YORK BOARD OF FIRE UNDERWRITERS eAGR ~ to©e378 BUREAU OF ELECTRICITY 8S JOHN STREET. NEW YORK, NEW YORK 10038 Date ~UNfi 1~~'1992 APPlication No. on file 73129591(91 'N Z~972~ THIS CERTIFIES THAT only the elactricol equipment as described 6abw and introduced 6y the applicant named on the above application number in the premises of 4KTER ARUT3CR, 17e0 VT.C,LACrE C,A41Rt PO,fk17r URIRRT, R.X. fn the fallowing lacotion> ®Basement ® 1st Fl. ©2nd F'l. e(fT Serlinn Block Lot was examined on 3UNN (99,1992 and found w6e in conlplianre with the reyuirernents q(this Board• fIXTURE ECEPTACLES SWITCHES FIXTURES RANGES COOKING DECKS OVENS DISHWASHERS EXHAUST FANS OUTLETS INCANDESCENT fIUORESCFNi OTHER AMi K.W. AMT. K W AMT. K.W AML. K.W. AMT. H P z7 2z to z~. DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIME CLOCKS gEll UNIT NEATERS MULTI.OUTLET DIMMERS AMT. K W. OIL H. P. GA$ N. P. AMT. NO A. W. G. AMT. AMP. AMT. PMPS TRANS. AMT. H. P. SYSTEMS AML. WATTS NO.OF FEET ' 1 6ef9 SERVICE DISCONNECT NO.OF S E R V 1 C E AMT. AMP. TYPE METFR I LW I 3W 3 9 3W 3,R dW NO. OF CC. COND A. W. G. NO. OF NbIEG A. W. G. NO OF NEUTRALS A. W. G. EQUIP. PER B OF CG COND OF HbLEG OF NEUTRAL z tee ca z x 2 z 9 O7NER APPARA7UE: TRACK LSGHTIlIGe-12 I` I i I 'I i - / 9TEVL'fi EGFClS.ALRfSRT90N i,ZC.@'d999P. GJj~~ P.G. BOX 1zf,S HOUT110Ler RYr J.1971 GENERAL MANAGER 1z , Per z - 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 6'UIL,DING DEPARTMENT. THIS COPY OF CERTIFICATE MUST'NQT BE ALTERED IN ANY MANNER. :1cLD i;:S:'c:.:iUti ~~U;,:B ~ :;vak~(tNT~ ~n O 1:. ~ t < ~ ~ - - H W FOUtJDATION (1st) ti FOUNDATIOtJ (2nd) - - 2 . ~ ~'7 p~ri °'E ~ o ROUGH FRAME & ~ r O PLUMBING L ~ y 3. ~ m r~ IIJSULATIOA! PER N. Y. STATE ENERGY CODE a 4 . ~ r H FINAL v ADDI OPJAL COMMENTS: ~ i - x \ ' ~ H ~ ~ H N O` p z ca A r~ _ H d X~ m "O H . _ a 4 Fireplaces 40 Clearances from Combustible Construction -4-•-° limit of combustible Linings capable of withstanding ~ construction 2000° F. temperature are clay 4.. mini 12" minimum to mantel brick other than shale, fire brick, 6" minimum 4o trim soapstone, cast iron. Where linings mm. fireplace lining to withstand 2000° F. are not provided, the thickness of s- curb required only when the back and side walls shall not inner outer hearth is not used be less than 12 inches. hearth 16" minimum width of Wood mantels acid trim should outer hearth when used be attached so that they cannot be 3 min- heated to temperatures in excess of '1` minimum 8" noncombustible 175° F., or be ignited by sparks = -C - outer hearth or embers. `outer hearth not required Fireplaces should be constructed when curb is used and so that, when they are in use, adja- surcounding floor surface cent or nearby combustible mate- I is of noncombustible rial shall not be heated to tempera- meterial [ores in excess of 175° F. or be ' exposed to sparks or embers. SECTION When fireplaces have openings on more than one side, the inner hearth should be depressed, or pro- f vided with a curb at least 3 inches 6 min.limit of combustible high. Such fireplaces should also r materiel or trim be provided with permanently at- ' i limit of fireplace I [ached screens to prevent sparks or opening curb when outer hearth embers from being scattered into ~ is not used; min. 3" the room. 6" min. ~ high inside, and min. 8" high outside Where the width of the fireplace opening is 6 feet or more, the ELEVATION outer hearth shall have a minimum width of 20 inches and shall ex- tend at least 12 inches beyond each side of the fireplace opening. Where it can be shown by tests .4^-inin. ~~limit of combustible made in conformity with generally ~~T'iiii7Tl777TT! construction accepted standards that prefabri• Gated fireplaces are designed and i I 2 min' built of materials that will not curb required only create a fire hazard or heat adja- inner when outer hearth cent material above 175° F., the hearth I is not used clearances illustrated on this page t - b" minimum to trim shall not be required. 8" minimum from edge minimum 16" when open ~ of fireplace opening or outer hearth is used limit of combustible material when outer PLAN hearth is used CODE MANUAL ~ 765-1802 BUILDING DEPT. INSPECTION C~~~, [ FOUNDATION i5T [ ] ROUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [ ]FRAMING [ ]FINAL, j REMARK8: ~E~°~n'( ~41ti.`~;~,,,~,~ i ~ DATE INSPECTOR i f ~~K .~-r r,' ~l3 ass-iso2 BUILDING DEPT. INSPECTION [ ]FOUNDATION i5T [ ] R GH PLBG. FOUNDATION 2ND [ INSULATION L] [ ]FRAMING [ ]FINAL I REMARKS: "~~~i `k k4{ pf[I IE _ { ` 4 4 VVV ` DATE 2 IJ INSPECTO _e,~~...~ _ _ ~3 rss-isoz BUILDING DEPT. INSPECTIt~N [ ]FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ]INSULATION 4 'E j ]FRAMING [ FINAL fi REMARKS: ~.I.~ _ ( 7 DATE ~ ~ INSPECTOR r 6 r,_ ~ r, 765°1SOZ BUILDING DEPT. INSPECTION [ ]FOUNDATION i5T ~ ROUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [~MING [ ]FINAL REMARKS:~~ G~ / ~ ~ .z 1 c ~ ~ ~ _ ~ .li ~ ~ e mws~ ~~,~2/~ DATE ~ ~ ~ INSPECT _ . e t ,F _ . L:~ a ~ i~ BOARD OF HEALER ~ ~ , . FORM rug. 1 ~ SETS OF PLANS • • - ~ ~ ~ - • v~rtie I ~ TOWN OF SURVEY . SOUTHOLD CII CR BUILDINGOFPl~1fi~T,IN~(ifzkT,t~~.E~~h'IC FORM•.••~~-~~•••••' TOWN OF SOUTHOLD TOWN HALL ' ' ' ' ' • • • • • • • . • SOUTHCtLQ.pi.~_11ff71 t:t)TIFY: ~y TEL.:7G5.1'Ff~~%' CALL Exanr•incd . ! l99/ 3TM.xt~, . MAIL T0: Approv¢'d C~: 7 ~ fi • r~ 194,• Permit No.. +F~Yi;~':s~ , . . DisapprovccJ a/c y.}''~. ..`t".~ . . . j ...............~il• • a'+''' . ' ~.~•Z•' amt f\ • l.`l~s } ~ • ~ d ~ ~ , •ildi nspector) ' ~ ~^ti ~ • .'~""`~:~~.~`+`;'14~R,L1~~lT~,ON'~Fi BUILDING PERMIT /~I1~Iff~~.(p. ~/1/`/7y ~"S t • . t:;"',}a 5:. '~0 '.fit ~l'.`I.1[ . r + I l ~~ih.."a~:'it.4:.°_:t .~~L$`a''~:i'!""t '.:ry'l:%`~1•~., Date .~.(_..1....IS. a ` ~ ~ INSTRU t: ;4•''"t 'V.Til'n,~r„~e~, ,1.a~ c(~ .'.~.t ?,y")+".,ta ;'q!!S:!1".,ia~'•: IU~• j tira ' a. Tlu`s application must be completely filled in b ` j . setg;of plans, accurate plot plan to scale. Fee a y typewriter or in ink and submitted to the Building Iiupectnr, witY 6. Plot plan showing location of lot and f bu~ldino schedule. or areas, and giving a detailed description of ]ayout of ooerPremises, relationship to adjoining premises or public stye: i cation. P P y must be drawn on the diagram which is parz of this apF c. The work covered by this application may not be commenced before issuance of Building permit. -d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such perry shall be kept on the premises available for inspection throu;hout the work. e. No building shall be occupied or used in whole or in part fora{7y purpose whatever until a Certificate of Occupan~ shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to.(ht ui d' Building Zone Ordinance of the Town of Sotifli~d~~S~(i~pCa~~L ~,~q~.t~i~`essuanc~tof a Building Permit pursuant to tl Regulations, for the construction of buildin s, d' ' ' Y New Y°fk, a~i'a` other applicable Laws, Ordinances < The applicant aerees to comply with ajl. ~ r b~~f~~'~~~~ltei`~{ons}~ry~`o;~,rerrt~4a~1or demolition, as herein describe admit authorized inspectors on re ~PI~~~~• ws narac s• 'b ild ` P mrses a . ~ s,r. ~ b1~~c~~PS.1'Ifiousin~ code, a -----._n_. ___fl-~~orns~ss'~n,knapeetians. y~ nd3Spulations~znd; • • ~+P. L . (Signs re of applicant, or name, rf a corporation) • (Mailing address of applicant) • ~ ' State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder W/1/$'~Q } g..... ' DlameoCowneroCpremises ..Pt~,~tjt~•.~/~~{jl't"~".:~tC(~r~y?E,j (as on the tax roll or (latest deed j • • • ~ • - • ~ • • ' ' ' ' IC applicant is a corporatio~,n/, signature of duly authorized officer. - .Name and J!~ , • • ( title of corporate ofrccr) Builder's Liccnsc No.......... . ~Od'E1V = Gt~LG ~pG~ Plurnber's Liccnsc No . . ~//~p~CJ~/y~/•~/.~~e~tyss0 ,d fb•~~.~uL•rC,,.y/ Electrician's Liccnsc No. • , , - • , , • • • • • • • • • • • ~ lad,.,, ~ t~. ~ ,yti+ t Outer Trade's Liccnsc No . ~1. Locat/tJi`yon of land on which proposed work w~ill/bc d,/or.~e,',Ctf~;a~,?.,,+, •,;~a llouSLNOa' ...................v`L~!/arls~..'1,~/-'vc ~`1~~/• . umber StrccL • ~ ' • • , • Hamlet County Tax ~\1ap No. 1000 Section • O p7•~ , • . Block ttG Lot • ~7 Subdivision M.t . . Fl1cd tap No. ~liQ State c~istin•. .......(Name) Lot o use and occupancy of premises atn~d~i/n tended ursde and occupancy of proposed construction: A• tixisting use and occupancy....-Ya~t,/C~6l!C~• fi¢'I~GY B~~MCY•--.•. B. Intended use and occupancy.:..r~!YB~..(,~~'{i~~: ~(~jlfs,~~?~/••.••••• t.~rxssa..,. _ _ V 3. Nature of work (check which applicable): New building Ad•'~ticn . ~ • • • • • Nteration Repair RFinaval Demolition J .5~~ Tennis~Court•...... ~~Accesppsory Building.... , , , , , , Fence y. t er Work:. 4. Estimated Cast ~ 0. Y.F V.~.~.'. 4p Fee ; ~ ~ . . 4tn be oatd'on liling.lR~is`aDphcation) 5. If dwelling, number of dwelling;units dNY , , , , , , , Number oC dwelling units on each floor . , Ifgaragc,numbcrafcars ..JM~...... 6. If business, commercial or mix¢~1 occupancy, specify tt),re,and extent oC ea t t p,,c,,4C use /y~ 7. Dimensions offxis tng structures, if any: Front p?~j;(; , ,Rcar ..~~YC:!•..... Depth . ,,~;(Q E;T.•. Height •,~,(~„~j;,,„Nun}bcroC Stories. ,'z't!fIQ„ Dimensions of same structure wjth alterations o • ditions: Front ~.~s Rcar 44 , ~ • • Depth , . ~Q„ F7; ; „ I[cight . . ~CR . FT : j • . ~rt~,ycr oC St cs a . • . 8. Dimensions of entire new construction: Front . , ,~f{-~~r , f'007. p~ • • ~ • • Hci;ltt ...~4.F7: tp,~er of Stories • • • . 9. Size of let: Front r'........ P.car , . ,t~-Q„~; Depth • . 10. Date of Purchase , ..S : • (j,, ~ ~URCK . Name of Po c Owner 11. Zone or use district in which prCmiscs arc situated ,~NEr.,~}['i/,CtEr _ ~iy~l~'/~/~(~'~~~ I2. Does proposed construction vioja[c an zoning law, ordinance or regulation: Y ~b• , 13. 1Vill;,lohbe•r8graddd' ; , , , , , , , ,1Vill excess tll be r ovgqd,~,f~~rom premisesy~~,~ 14. Narxve•ofO~4nerbfpremises .Address./,~~~~~,,,/Y.'I:,PhoneNol~JxnS+.`.~~~ Name of Architect ,1r.~1~(~?;.~ .~;TF6G,/~'/;Q4~I ,Address .4'~.~,~P.~!6, , ...Phone No..~r .~.`.~P. Name of Contractor . ;/,~;'~Q, , , , ; , , , , , , ,Address . .Phone No. . 15.Ls this property•Loc~ted within.3pp feet of•a•tidal•wetland? =YES....NO..~•. . *If yes, Southold Town Trustees Permit may be required. PLOT DIAGRAS4 Locate cleazly and distinctly ally, buildings, whether existing or proposed, and indicate all set-back dime..^sior:; is property lines. Give street and blocknumber or description according to deed, and show street names and indicate w::.::. interior or corner ]ot. Iil , ~"6~- ~'r7"lledf~'b 0~7rtW~s. - . !flat/ Wo7C'1Y la` .~~/'l"</Z~Z~-/ • !N' Z6fZN • ~7C1 SrG~lf! ~Z"~'~ClN7'. , , •~MS ~M1!.v `~ui fs`L~t~~•itJV it a_,~J1V 1'A a .,51 v ~ , , STA TC OT`! fi'E5b'~'YCJ (Z t, "~A., t.;.? } ~ °`~r R~; ; COUNTY (SF . • Jt ~ [ AL~~if' (Name oCindividual si,n" • • • • ' ' ' ' • • • • being duly sworn, deposes and says that he is the applica: • tttg contract) about named. ~ ' 1-Fc is tltc HGU •+VI ~.~,.......Lq.~•..~.N, • r., ~,a~hl., (Contractor, ageti't; rpbrat~"'o°tY'iticr,'ctc.) • of said owner or owners, and iS~d'uIU :{uthorizcd to perform or have performed the said work and to make and Glc tl: application; that all statements cont~incd in this application arc true to ~~~t>'yst of his knowledge and belief; and that L': work will be pcrl'p tltc mannej~ set forth in the application filed the ct0lth. Swom to bciorc ~dhis / ~ + a' Notary Public. LLIA i ' MITdg070Pfp y h ~-,,,~~,t, Otety Pu IC, $t4t' Ico~f~,[.t a~s i ! .ir+R~\%.: 1 .`r •y . otMIg7~1'aH9" _ (Signature oC applicu!' Qu ed In Suffdlk (`punts .a ' • salon Expires ~~~L ,