HomeMy WebLinkAbout20313-z FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No Z-22126 Date JANUARY 27 1993
THIS CERTIFIES that the building NEW DWELLING
SOUTHOLD, N.Y.
Location of Property 1375 PRIVATE RD. Street Hamlet
House No.
County Tax Map No. 1000 Section 77 Block 3 Lot 18
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated DECEMBER 2 1991 pursuant to which
Building Permit No. 20313-Z dated DECEMBER 5 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 ONE FAMILY DWELLING WITH GARAGE IN CELLAR AS APPLIED FOA &
AS PER ZBA #3838
The certificate is issued to DAVID CICHANOWICZ & JOSEPH CAVANAGH
(owners)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL JAN. 22 1992 - 91-SO-12
UNDERWRITERS CERTIFICATE NO. N-258662 - NOV. 30, 1992
PLUMBERS CERTIFICATION DATED JAN. 26, 1993 - J. CAVANAGH
_---~<~=f~i~~ 1di q Inspector
Rev. 1/81
IPOBM NO. f
TOWN OP 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)
N o 2 0 31 3 Z Date ...1.~~ 19
Permission is hereby gra ted to; tL///~~~j~~~~~~ ~~7g~,~p
y/
.......Cif%~~~'.~s~Y....f..:~.~1.....~.. '
to .~a.~:..~
. . .
at premises located at ....1.~'r.~...~'.:..........r.........~.~
.............................................~~~r...'...4`T~.................................................................................
County Tox Map No. 1000 Section .....~.7.......... Block Lot No.........
pursuant to application dated ..~.Zf 19........, and approved by tfie
Building Inspector. '~'B ~ a
Fee S. ~1.~11..e.,r~J
i
uii I for
Rev. 6/30/80
i
U ~,11-fWl~ Form No. 6 ' p
(~~'T ~fSQ •CX~.~S `fir P,W,~ . ~ _
~j TOWN OF SOUTHOLD
lJ~~•o~~LCi r ~ • r 17S~' BUILDING DEPARTMENT ~ J~ ~ ~ J~ ~ •
' TOWN HALL i °
765-1802
,r`
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 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 17, 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
S. Temporary Certificate of Occupancy - Residential $ ~.OO, oo'mmercial $15.00
Date ~
few Const
ruction........... Old Pre-ex 'sting B ilding..
vocation of Property...........~~?o54~~c.'~FK~F1;^?~ ...........~;T,1.'fq/~
House No St ~ et Hamlet
)nwer or Owners of Property..~~:~(~(~(~G/~,,,,~,/~ F/,~I,/dOty/C,~~
:ounty Tax Map No 1000, Section...~..~ ,.,Block..... ~.~"......Lot....I.~
subdivision ....................................Filed Map...........
.Lot.
'ermit No~~~ ~~,,,Date Of Permit ................Applicant-~:~:.~s,'~~~~~,/?;,C/`./7~j~/~c.J/~7i
[ealth Dept. Approval........~.~ .........Underwriters Approval.......,,,,,,,,,,,,,,
Tanning Board Approval..... Y
.
equest for: Temporary Certificate..........: Final Certicate.~,
O--P-'
ee Submitted; 1
~ C. I o~ ~p APPLICANT • - ,
THE NEW YORK BOARD OF FIRE UNDERWRITERS z}~car z
104}zM71. BUREAU OF ELECTRICITY ~I
65 JOHN STREET, NEW YORK, NEW YORK 70038 ~yp C9 '"I
Date NOVBAtASR 30r59p`l. AppliraHonNmonfife 7bQOG792(N2 N "4J~f1V5.
~
THIS CERTIFIES THAT -
only the electrical equipment as described below and introduced 6y the applicant named on the above application number in the premises of s
s. cav~~a~Ge, ~afiosE eR~r.K I,f{NE (4tE"~Tjr ~z:z, 5~zr1•~tlz,n, ta,~.
in thefallawinq location; ~ Basement (zAR/i711h'
? /xt Ff. ~ 2nd F'l, .Sertion Bfork Lot
NO+fF<PdRGR 23 f.392
uqs examined on ' and found to be in conrplianre with the rrr{uirententx qF this /iaard.
FIXTURE FIXTURES RANGES COOKING DECK$ OVENS DISH WASHERS EXHAUST FANS
OUTLETS ECEPTACLE$ SWITCHES INCAN9ESCENT FIUOREECENi OTHER AMT. N W AMT. R.W AMi N.W AMT K.W AMT. H.P
zi. ?6 Z'I i F
DRYERS FURNACE MOTORS FUTURE APPLIANCE fEEDER$ SPECIAL REC'PT TIME CLOCN$ BELL UNIT HEATERS MULTI-OUTLET DIMMERS '
SYSTEMS 4
AMT. K. W Oll H. P. GAS H. P. PMT. N0. A W. G. AML AMP. AMT. AMPS TRANS. AMT N P NO. OF FEET AMT. WATTS
z 1? z - - a. z
I
SERVICE DISCONNECT NO.OF 5 E R V I C E Aj
AMT. AMP, TYPE ME}ER 1 q TN 1 AT 3W J B 3W 3,e' dW NO Oi CC COND A. W.G. NO OF HbLEG A W G NO OF NEUTRALS A' W.G.
EQUIP. PER B OF CC.COND. Of HbLEG OF NEUTRAL
Z ZFtO Cp 1 x 7 2/0 i 2l0 I
I
OTHER APPARA7U$:
6.3~.C.f:-4
SMOKE IlEi'Eti'POR:-1
9'42ACIi 1a[Gki't'7NG~-1Fi
~~~~~~f~~
~2~~~i~/~~~~~~~~~ ~
G & Gt)N5'RAGTOR f,S:C,#5iE1-Y;
tiOR 2'Lti
5015~'IiOhU, NYt z19"11 GENERAL MANAGER
z2
Per
This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by their credentials.
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT 8E ALTERED IN ANY MANNER.
S~FFOL,S'~, TEL. 7G5-1802
~a TORN OI' SOYJT~O~.D
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~ _t" x. .p : c OFFICE OF BUILDII•IG INSPECTOR ~ ~ t
can `•yj rn P.O. DOX 1'179
3 ,hk
/%~,Q~- SOUTHOLD, N.Y. 11971 JAN ~ 6
C E R T I F I C A T I O N
Date ~ ~ ~ ~
Building Permit No.~~~
Owner~_p~ 6PlF z~'/~?
/ (Please pr~t) .~6/~
Plumbe2~ a ~ _ < ~
(Please ~~L~'~Of
print)
I certify that the solder used in the water supply system
contains less than 2/10 of 10 lead.
r _
(pl,mber's signature)
Sworn to before me this
day of
19~,
Notary Pu i,
Notary Public, - County
EL9~At3ET&1 AN89 R1EbtlL£
• tVotaeY F'ubti~, eta&o oA t„w York
fVo. 52-~Y2;sF;S€~, ~asttclk bra gg~~33~$y
'!'arm iexiagrey. pctobar 39, 59;~
,INSPECTORS
Victor Lessard `~p~;~g>JFfI)(,~
Principal Building Inspector / ~ ~
'
Curtis Hoxton ~f ~ SCOTT L. HARRIS, Supervisar
Senior Building Inspector ~ o : c~ Southold Town Hall
Thomas Fisher ~ • ' ~ P.O. Box 1179, 53095 Main Road
Building Inspector ~ O~ t'
Gar Fish ~°;'9 Southold, New York 11971
Building Inspector x`21 •`-Y Fax (516) 765-1823
Telephone (516) 765-1800
Vincent R. Wieczorek
Ordinance Inspector
Robert Fisher
Assistant Fire Inspector OFFICE OF BUILDING INSPECTOR
Telephone (516) 765-1802 TOWN OF SOUTHOLD
DECEMBER 23, 1992
DAVID CICHANOWICZ 6 JOSEPH CAVANAGH
P . 0. BOR ~99~ f SO
MAIN ROAD
SOOTHOLD, NY 11971
To Whom This May Concern:
We are unable to complete your Certificate of Occupancy
because of the following reasons:
ffi An application for Certificate of Occupancy is
not on file. (Enclosed)
RX.Y No Underwriters Certificate on file.
xxx The check is not on file.)$25.00
RRR No Health Department Approval on file.
No final inspection has been made.
RRR No Plumber Solder Certificate on file.
(All permits involving plumbing being
issued after April 1, 1984).
BUILDING PERMIT # 20313-Z
Please contact our office on this matter. Thank you for
cooperation.
SOUTHOLD TOWN BUILDING DEPT.
c'lELD Y::~: E:.: _J:i I~0%+- I~ :;i;:~(i9E.NTv
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FOUIJDATZON (1st)
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P,OUGH FRAi•fE &
PLUMBING
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S~FFnt~-~D~
~ ~ Southold Town Board of ~ eals
Ply
O`~~®~ ~~o~ MAIN ROAD -STATE ROAD 25 P.O. BOX 1179 SOUTHOLD, L.I., N.Y. 11971
.~_~p TELEPHONE (516) 765-1809
'~'C~ I^~-t.~ ~~,y~7 FAX No. (516) 765-1823
APPEALS BOARD ~V 'C _
MEMBERS `~ol-nJ
GERARD P. GOEHRING ER,OHAIRMAN
CHARLES GRIGONIS, JR. ~
SERGE DOYEN, JR. ACTION OF THE BOARD OF APPEALS y
JOSEPH H. SAWICKI ~ ~5,~ ~,.r ~~?f~,~''~"
JAMES DINIZIO, JR. _c V .
Appl. No. 3838: rO~~oF~~~ny:~~~~~~
Ty0~0
Matter of JOSEPH D. CAVANAGH and DAVID CICHANOWICZ for a
Variance to the Zoning Ordinance, Article XXIV, Section 100-244
and Article IIIA, Section 100-30A.3 (Article III, Section 100-31
as disapproved} for permission to locate proposed new dwelling
with an insufficient front yard setback from the northerly
property line and with an insufficient rear yard setback from
the southerly property line. Lot area is nonconforming at 8,417
sq. ft. in this R-40 Zone District. Location of Property: 1375
Private Road 1-A (said lot extending 1333.97 feet from the north
side of North Bayview Road), Southold, NY; County Tax Map
District 1000, Section 77, Block 3, Lot 18.
WHEREAS, a public hearing was held on June 29, 1989 under
Appeal No. 3838; and
WHEREAS, at said hearing all those who desired to be heard
were heard and their testimony recorded; and
WHEREAS, the Board has carefully considered all testimony
and documentation submitted concerning this application; and
WHEREAS, the Board Members have personally viewed and are
familiar with the premises in question, its present zoning, and
the surrounding areas; and
WHEREAS, the Board made the following findings of fact:
1. The premises in question is located along the easterly
side of a private right-of-way referred to as Private Road #1-A,
in the Hamlet and Town of Southold, and is identified on the
Suffolk County Tax Maps as District 1000, Section 77, Block 3,
Lot 18.
Page 2 - Appl. No. 3838
Matter of CAVANAGH AND CICHANOWICZ
Decision Rendered June 29, 1989
2. The property is vacant land consisting of an area of
8,4417 sq. ft. and is nonconforming in lot area, lot width and
lot depth.
3. For the record it is noted that a portion of the
subject right-of-way has been considered by the Board of Appeals
under Appl. Nos. 2627 and 2628 on October 11, 1979 (G. MacLean)
and was granted a conditioned approval under New York Town Law,
Section 280-A, subject to improvements to the right-of-way under
Board of Appeals specifications).
4. By this Board s letter dated June 9, 1989, the
applicants were advised that the right-of-way must be upgraded
by filling all potholes and depressions with medium-size gravel
(mixed with sand) for the entire length and existing width.
5. Article III-A, Section 100-32A and Column ii of the
Bulk Schedule of the Zoning Code requires a minimum rear yard
setback at 50 feet and minimum sideyard at 20 feet. Article
XXIV, Section 100-244(B) permits a rear yard reduction for a
principal structure to 35 feet in the front yard, 35 feet in the
rear yard, and 10 and 15 ft. for side yards, for lots containing
less than 20,000 sq. ft.
6. The relief requested by this application is for a
reduction of the most northerly front yard setback from 35 feet
to approximately 23 feet and from the most southerly yard
setback to not less than 10 feet.
7. It is the position of this Board in considering this
application that:
(a) the circumstances are unique to the property,
having frontage along three rights-of-way or roads;
(b) the relief, as alternatively granted, is the
minimal necessary under the circumstances;
(c) the relief, as alternatively granted, will not
alter the essential character of the neighborhood;
(d) there is no other method for appellant to pursue,
other than a variance;
(e} the variance will not in turn be adverse to the
safety, health, welfare, comfort, convenience, or order of the
town, or be adverse to neighboring properties.
Page 3 - Appl. No. 3838
Matter of CAVANAGH AND CICHANOWICZ
Decision Rendered June 29, 1989
Accordingly, on motion by Mr. Goehringer, seconded by
Mr. Grigonis, it was
RESOLVED, to GRANT alternative relief for the placement of
the newly proposed principal building under the Application of
JOSEPH D. CAVANAGH and DAVID CICHANOWICZ under Appeal No. 3838
at not less than it feet from the southerly property line along
land now or formerly of Westerbeke (Lot #1000-77-3-19) and at
not less than 22 feet from the northerly front property line, at
its closest points; and it was further
RESOLVED, that the legal right-of-way extending from the
north side of North Bayview Road to the subject lot be upgraded,
pursuant to New York Town Law Section 280-A, as follows:
All potholes and depressions shall be filled with
medium-size gravel (mixed with sand) for the entire
length and existing width. i
Vote of the Board: Ayes: Messrs. Goehringer, Grigonis,
Doyen, Sawicki and Dinizio. This resolution was duly adopted.
* ~
lk
GERARD P. GOEHRINGER, HAIRMAN
FORM N0.3
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TOWN OF SOUTIIOLD
BUILDING DEPARTbfENT
TOWN CLERK'S OFFICE
SOUTHOLD, N.Y.
NOTICE OF DISAPPROVAL
Date .~~CJ . 19 ~g.
~?:.:~3~. ga 9
yam,"..C~~, .~~~.r..~.~~~~,
PLEASE TAKE NOT~I~CEr
that your application dated , , , , , , , , , , , , , 19
for permit to ~ ' ~ ..4 +ryiG~~~!'- at
f
Location of Property 3 7?~, , , ,.4 I
House Na. .
Street ~~~~~~~~~~Hamlet
County Tax Map No. 1000 Section ,r~.7. Block Lot , , , . , ,
Subdivision Filed Map No. Lot No.
is returned Herewith and disapproved on the following grounds
as~~. o
• ' specto`r~~.
RV 1/80
x6s-isoz
BUILDING DEPT.
INSPECTION
[ ]FOUND ION 1ST [ ]ROUGH PLBG.
[ UNDATION 2ND [)INSULATION
FRAMfNG [)FINAL
' REMARKS: - ~
1
DATE / ~ INSPE ~
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,~~313 ~
~t~-isoz ~ y-~..,~"
BUILDING DEPT.
INSPECTtON
[ FOUNDATION 1ST [ ] ROUGH PLBG.
[ ]FOUNDATION 2ND [ ]INSULATION
[ ]FRAMING [ ]FINAL
,!I
REMARKS: ~i
l~
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DATE ~ INSPECTOR
765-1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION 1ST [ ) ROU °~PLBG.
FOUNDATION 2ND [ INSULATION
[ ]FRAMING [)FINAL
REMARKS: ~
DATE INSPECTOR
~l~
765-1802
BUILDING DEPT.
INSPECTI®N
[ ]FOUNDATION 1ST ; [ ROUGH PLBG.
]FOUNDATION 2ND [ ]INSULATION
' [~RAMING [ ]FINAL
REMARKS:
~ ~ ~ r
i
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f DATE ~ ~f ~ INSPECTOR
J
765-1802
BUILDING DEPT.
INSPECTION
[ )FOUNDATION iST [ ] ROUGH PLBG.
[ ]FOUNDATION 2ND [ ]INSULATION
[)FRAMING [ ]FINAL
REMARKS: ~ ~
~.,u., '
i
DATE 3 Z-. INSPECTOR
.
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BUILDING DEPT.'S
~
1 NSPECTION _
[ ]FOUNDATION i5T [ ] ROUGH PLBG. ~,L...~G/
[ ]FOUNDATION 2ND [ ] INSULATiON+ e~e~
[ ]FRAMING [ FINAL
REMARKS:
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DATE/L' ~f~9~ INSPECTOR
~ ~~3~~
765-1802
BUILDING DEPT.
INSPECTIt~N
[ ]FOUNDATION i5T t )ROUGH PLBG.
[)FOUNDATION 2ND [ ]INSULATION
[ ]FRAMING FINAL
REMARKS: G~~
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f
DATE ~ ~ INSPECTOR
°'~°""°"°"~arj~tP,Ai~~~~~ ~ BOARD OF HE.~LTA ~
glUHL00S,_•, 3 SETS OF PLANS ~ •
' ~ ~ FORM N0. 1 SURVEY _
~f ~ 0~ TOWN OF SOUTHOLD CHECK , ,
~ ~ BUILDING DEPARTMENT SEPTIC PORPf
e ~~I c TOWN HALL g, / •
~fl~l~~~ .,OUTHOLD, N.Y. 11971 ~OT~?
• IJ J TEL.: 7G5-1802 CALL
Examined . ! 19~! MAIL T0 .
Approved 19~~Penni[ No~~rS,(~ .
Disapproved a/c • , ~ . • •
G P~ V c` r M1~ p 6':' ~ 7 ~
I.P B<`
9:
• • ri y,
~ d'~t~r DEC-21991 ,s;
( dding s ctor
a~ ~"u ~ ~ ,..z,.....a.. T :
APPLICA ION FOR BUILDING PERMIT I Y~A1~°3i.~Y~; adts`„`ffp''tSr_,r~
Date.: ~,,.v ....n. ~.:~,.,.,,.,.,Nr.~ C7~
INSTRUCTIONS
• a. Tltis application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3
sets of plans, accurate plot plan to scale. Fee according to schedule.
' or area sand giving a detailed descript on of layouttlof properPy mustsbeedrawn otn the diagram whi his part of hissappliS
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 avai]able 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 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 construction of buildings, additions or alterations, or for removal or 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 necessa 'nspections.
. ~.~~r~~~~.r~t. ~.111~~r~N.®~~C~......
(Signature of applicant, or napme/, if a corporatton)
(Mailing address of applicant)
State whether app]cant is owner, lessee, agent, azchitect, engineer, general contractor, electrician, plumber or builder.
....~cv Nc=l~,-.......~ .
Name of owner of premises ~ OS,,~„~,
t,([~ nj~~ v~~ ~ I C i~~9~~~~c ~
(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 . '
Plumber's License No . .
Electrician's License No . . .
Outer Trade's License No . .
1. Location of land on which proposed work will be done. l ~37u1 .
r
House Num bcr Street " " " " • • • • • • • • • • • •
\ Hamlet
County Tax Svtap No. 1000 Section U.~.~....1..... Block JJ
Lot...G~......
Subdivision filed t<1ap No. '
(Name) t Lot
State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. E. fisting use and occupancy ~/~CAlJ.1.. ~ ~ i.lA, , , , . , ~
~~.~--~~E~/~,/1~ G
b. I tended use and occupancy ..~/J~.J.~Qt.C.I.
• .1X4.~~•W ~~/~N
. - <«~.~,ufi~_I
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3. RNepaic of work (check which app'licable): New Building • , Addition Alteration .
• Removal Demolition Other IVork .
. . (Description) . .
4. Estimated Cost ~ • .Fee .
' (to be paid on Gling this application)
5. If s, s ~ .
dtvellin number of dwellin u'~nits Number of dwelling units on each floor .
If garage, number of cars .
6. If business, commercial or mixed'',occupancy, specify nature and extent of each type of use .
7. Dimensions of existing structures if any: Front . , , , , Rear Depth .
Height Number of Stories .
rmensions of same structure wit
Depth . , , , , ~ ~ alterations or additions: Front Rear .
8. Dimensions of entire new construe Height . • . Number of Stories .
ction: Front . Rear ,Depth .
Height ...............NumtjerofStories..........................................
9. Size of lot: Front .9:.........1,.......... Rear Depth ~ .
10. Date of Purchase . . . • .Name of Former Owner ,
11. Zone or use district in which prcrpises are situated .
oes ro osed construction viola
13, Hill lot be regraded , • , _ to any zoning law, ordinance or regulation : !~O........... .
14. Name of Owner of premrses , , ~ • ~ • ' ' ' ' ' ' Will excess fill be removed from premises: Yes
...............Address ...................Phone No......... .
Name of Architect ,II Address ...................Phone No... ~ ~ • ~ • •
Name of Contractor ..........i.. .Address ..Phone No..
P P Y
IS.Is this ro ert located with in,~00 feet of a tidal wetland? *YES... O
*If yes, Southold TowniiTrustees Permit may be required.
- _ . PLOT DIAGRAM
.
Locate clearly and distinctly all buildings, whether existing or proposed, and, indicate all set-back dimensions from
property lines. Give street and block n~rmber or description according to deed, and show street names and indicate whether
interior or corner lot. j
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STATE OF NE\V YORK, I
COUNTY OF 4S
..L.........• g Y P Y PP•
' ' ' ' ' ' ' ' ' ' ' ' ' ' ' • • • • • bein duI sworn do oses and sa s that he is the a Leant
(Name of individual signing contract)
above named. I
He is the .......................j.....
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is duly authorized to p5rform or have performed the said work and to make and file this
aPPlication; that alt statements contaiicd in this application arc true to the best of his knowledge and belief; and that the
work will be performed in the manner $ct forth in the application fled therewith.
Sworn to before me this ~ n
1
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Notary Public, ....i ~--:..~.'I~ii;.~: X. G/7.'~, County ,
NELEN R DE VAE
iNewYork (Signature of applicant)
NOIARYPIIBLIC,Stateo
No. 4707878,SuBolk,CountY Cp
Term Expires Match 30{ 19..~/
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