HomeMy WebLinkAbout20112-z
' FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No Z-20505 Date JANUARY 27, 1992
THIS CERTIFIES that the building NEW DWELLING
Location of Property 650 THE CROSS WAY EAST MARION N.Y.
House No. Street Hamlet
County Tax Map No. 1000 Section 30 Block 2 Lot 103
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated AUGUST 29, 1991 pursuant to which
Building Permit No._20112-Z dated AUGUST 30 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 2ND STORY DECK & ATTACHED GARAGE
AS APPLIED FOR.
The certificate is issued to CORINNE B. GARREN
(owner)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL 91-SO-75 - NOV. 22 1991
UNDERWRITERS CERTIFICATE N0. N-217756 - DECEMBER 23 1991
PLUMBERS CERTIFICATION DATED JAN. 6, 1992 - C. ZERVOS
Building Inspector
Rev. 1/Bl
I
rows xo. 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)
N o 2 01 12 Z Date .....c~t~Y'.... 19.91..
Permission is hereby granted to:
~~n/
of premises located at .......~.5~~~....r.1.Y..ld~ ..:s~aroD`....R:~.:.).3.14rt.:rv1......
G. ~,~,!!.l:I
County Tox Mop No. 1000 Sectio .......4r~. Block Z..... Lot No.....~ ~.3.........
pursuant to application dated ...r~..~'.,~4!:n.~.....~9 19.9.., and approved by the
BuildingJlnspecto`r.
Fee 5...:/.~~:..Y.
.....~4J..0:$:....
Bui ding Inspector
Rev. 6/30!80
i
Form No. 6
* • .,.r.
Y
TOSJN OF SOUTIIOLD
BUILDING DLPARTMGNT
TOWN HALL
765-1802
APPLICATION FOR CtiRTIFICATE OF OCCUPANCY
.1. This application must be filled in by typewriter OP, 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 Pire Underwriters.
4. Sworn sCatement from plumber certifying that the solder used in system contains
less than 2/10 of 17 lead.
S. Commercial building, industrial building, multiple residences and similar buildings
and installations, a certificate of Code Compliance from architecC or engineer
responsible for the building.
6. Submit Planning Board Approval of completed site plan requirements.
:3. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and
"pre-existing" land uses:
1. ,lc curate 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 $15.00, Commerci(a~l $15.00
Date *~C1uAr~:.. ~1.. ~ Q 7 .
::ew Construction....N...... Old Or Pre-existing rBuilding.
[.ocation of Property.....~..rJ.~..........~,~~.~r??~5..~~y........~~.~T...1,i,1,~(Z,l0h1
House No. Street Hamlet
Unwcr or Owners of Property...~~?r~r~~e..~?:,C>~r+-;er,
Cuunty Tax Map(~No 1000, SecCion..(.'.~~L~.......Block......~...I.....Lot.....~/~3,
Subdivision...l~~;~~~~.~~~..~C:W:m~o....Filed Map.:~~.(OCD..~~.IILILot...1~^.`~'
Permit No.. 2'~~~Z,,,,,,Date Of Permit...8.3~;,~,~,,.Applicant.~!Qr~SC ~nS-l-r-U~j-ip~
Health Dept. Approvall~l0~!..2z`~qQl„~,gI-50:.~5.Underwriters Approval~fc'z.~jiq~i....o'~~'7~c~(p
:'l:~niiing Board Approval
[:equcst for: Temporary Certificate........... Final Certicate..../.1~.
~'ce Submitted: $..~J~,_.,.C~
Qom. v3a~~
CO " O O_S APPLICANT -
0
5~FF0L~'CO~ TEL. 765-1802
TOt4~N OF SOY7~'E[Od,D
~
_ < OFFICE OF BUILDII~IG INSPECTOR
c ~~"Y'~ P.O. BOX 728
Wty' -e TOWN HALL
~ ~ ~~t- SOUTFiULD, N.Y. 11971
~fpl ~ y'U
C E R T I F I C A T I O N
Date J av. 6 iq ~ ~
Buildin/g~ Permit No/~. o~,(/,^~la
Owner ( ~Jy~~'t'I}~G~ (J C~~g,YY~y
(please print)
Plumber_CONS`tA-NTI 2E~~~DS -~I G, ~ ~3y~.. P
(please print)
I certify that the solder used i.n the water supply system
contains less than 2/10 of to lead.
1
(plumber's siynaturel~-
Sworn to before me this
day of
19~. -
/~otary Publ
Notary Public, IIC Coun v// P SHER y~
Rotary Pui~;tG 8?aRQ~ RJR York
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765-1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION 1ST [ ] ROUGH PLBG.
[ ]FOUNDATION 2ND I~NSULAT~ON
[)FRAMING ~ r~NAL
REMARKS:
~ DATE ~ ~Z ~ INSPECTOR
if L-°'~
i_
t
765-1802
BUILDING DEPT.
,INSPECTION
(]FOUNDATION 1ST [ ] ROUGH PLBG.
[ ]FOUNDATION 2ND [ ] INSULATION
[ ]FRAMING [ ~ NAL
REMARKS: r
~
DATE 1~ ~ INSPECTOR
765-1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION 1ST [ ~ ROUGH PLBG.
[ ] F NDATION 2ND [ ]INSULATION
[ FRAMING [ ]FINAL
REMARKS:
DATE ~ INSPECTO i2~1~~
~ UU
~ = t
C/~~~~ .
~t~~ . 765-1802
~UILDING DEPT.
INSPECTION
[ FOUNDATION 1ST [ ] ROUGH PLBG.
]FOUNDATION 2ND [ ]INSULATION
[ ]FRAMING [)FINAL
P
REMARKS: ~i~~ a-
e
~ ~
DATE ~ INSPECTOR
~~l?~ ~ ,.Q
765-1802
BUILDING DEPT.
1 NSPECTION
[ ] FO DATION 1ST [ ] ROUGH PLBG.
[ FOUNDATION 2ND [ ]INSULATION
[ ]FRAMING [ ]FINAL
REMARKS:
L~~ _
r
DATE INSPECTOR
_,L S~;S:'cC,iU:J ~~U6.E I ~Oh1MGNT° ,
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FOllN1jATI0N (1st)
o
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P.OUGH FRAME &
•PLUMBING r ~ ~
3 . ~ ~
m
IIJSULATION PER N. Y. a
STATE ENERGY ~ ~'YI
CODE ~
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FIiJAL
ADDITI JAL COMMENTS: ca
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765-1802
BUILDING DEPT.
1 NSPECTION
[)FOUNDATION 1ST [UGH PLBG.
[ ]FOUNDATION 2ND [ INSULATION
[ ]FRAMING [ ]FINAL
REMARKS:
L
DATE C ~ ~ INSPECTOR
.,ar.,r., r. ,,r.
,M' - - ,
R1T?del # G2$3/G282 ~ ~ ~>w~
i%~
1'F oduct Name: 60" wide - G280 Series
Medium buty Range II
' Gas Types ? Natural ? L.P.
r~
>~^wat,
specifications & Dimensions
:'„~,~x~ G.~s Input Information
. r.
- OASIC RANGE INPUTS _
MOUF.L 70TAL OTU HR.
/ fi0 mR+4el shlR view
~ r,7n2; 6292 RC 179,91a1
(:1MRf29J RC/ 233590 - I _ n:~ I - . a° e1
r @; OURNER INPUTS ~
- s
~,,"3. TYPE BURNER OTU/HR. ~•~"'1
pp ; O.nn ~ ,
;,.r
Lr. IRr or Standard 3~ flea. oven - - - - - - " - -
(9 pnr 1TW frcllan) J`__20,99fl ea. burner L°°'-~- -v "sue- - - ~u t:
t ~
.p • v- 11•n Topr(IneTlen nl 2 open burners) "I
^^^h a ~ ` _ . _ _ _ ,,.~1„ II
h s ,oM.. i r
~ .
r 1 x,
Eb~~ It n. 12" W sedlnn 1fl,000 ea. burner I ~I•^•' - - - - -
-
M -
FFq. r:,iddln (in Iku of 2 open bumera) - ~ ~ 1 , 1
-1~~~`-`~ (I per 12" W section) 1fl,1100 ea, burner ~ ~ I °i""' -
~;~yr .
~:dddl./ernller mwrnxum•cn~inrnm ne...~, ~
in..mi,,,n nc n..~n
,g.,
t 1 humrn) 14,500 la. burner
' _ _ ~ Add A" Irv RI mndol
INSTALLATION NOTES NUII : Side Frain Option on 74" and Standard nn 3f" Griddle Adds A" In
:r `1 • ~ I I,.,„it r harartrristics eas h RC ovrn Width nl Rar+gr. ~ j
1``~~} , m ;r n,r Single phase, 2 Amps (6' power supply cord '
€ Miscellaneous Information:
r, pG Pm•ddnl)
(nn,busdble Wall Sldea Back UIRF.C710N5 rbR OROERINC
N`' r Inaranrrs i n Speclly Gas type (NA7/LP) and Elrvalion if Ovrr 7111X1 fi
.q' (125mm) 5 11T9nml
i~ retry Clearance tT9ld Uneralld NOT TOPS -it Not Specified 5717 on 1e0. Ilsr Su Rir -t, -2, rn -3
4' Rt' 41" (1041rnm) 3d'h" (e5lmrn) STORAGE RASE MObEI
sTn 35'h" (902mm) 32'h" i794mm) Oven Rase on left. Storage Base on Right.
y. ~ P. r nnm,rrdal cooking equipment requires an Use Model G292.
adrquate venUtatlon syystem. rot ddditlonal (Overall blmenslons Remain Sanw as 6293). Oi~
odnrmatirnt, reler to the National Rre 1'rotlcdon CONVECTION OVEN RASF MO[7FL
naorlatinn's Standard No. 96, "Vapor Removal In 1 ieu of std. Oven Rase
6.,. (ooking EqulpmenL"
tl) CO earl, Atld Su11iX ItC (Sid on lrtt)
P,, (7) LO Ra<r. A.IrI SufflX RC2
iMPORTANTs
fOR OPTIMUM PERFORMANCE
t)PF.hATING GAS PRESSUR~s
NATURAL 4.5"WC
t~ ~ PROPANE 10.0"WC
(4
r' ` Snppllnd with Oressme Regulator
Whrn ofdering, speclly type of gas to b! Used,
~
`y"# - napplr,g wdgM
k~ ~ Model-___- E°aw'°° ^
k 'z 2agf
i ~ lag 2~33f _ '
, 2nm(' 900/409 .
r'
a'~` Continuous product Improvement is a Garland policy.
.F,, i,` Therefore,lpedflcatlons find deslgn9 fire T12bjeN to change without notice.
I
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Minimuim Vlrad :3liield,lt+~i~ttitetnents for Some.' Cbtnmon Sequoia Installattona
4 ~ ~ ~ ~ ~ ~ '
j 'Eho shaded area iQnbt required f'Oy Yegt ex~i lnetCiiaddns vented direCdy int2t ihC Chimney
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Rear Wa111'rotecdt7t~ s'
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i Vlfa~t eht6W§ avay~ ~ tnprlt , tiidaias, watts, and ~iffi~~ta4 aYd 5h+td.
s~ z r ~ ~ 7fla ~w~1 ghiettl ~¢IiiWd ~iN~fii9ag~btln
- e~ i , , _ ' _ ~ . , ~ ~ 71~Y 5b f~tYEad&1 tg tlai'Mtn"i~ ,
~:~~~(i ~,te~a iu~~?mn~ti~ iafiu~~u~ti~~~(t~s m~f ~s~ wsrlo+wt c?~?i~sa i~ u ih ~b~~ one,
~ iil 6ht
~hCh ehs
Corner ~lall~ ~ra~t~~~t Nb St~vir ~i~ Coeir~ecttsr S~?iefd~ ,
~ lrr ~,(Vd~fl shf~l$„~'~t~~ exfentl to earner if tiesife~)
Hearth,~t~ ~t§~ofl~~~, ,e ,~'s ~'~i~~pl~,~e~~nsCal~ation t~lettrakte~'- ~
ut sr~
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pC~~J~ Direct Dave Upblast
Roof & Wald E~c,austers ,
- ~o„
- ~'d_ (Cg)
_ _
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f 1, ~ 111
c~5 _._(I
w+ f ~•a ...CI ~1
AGUC Centrifugal upblasl~ haunt models feature spun +y o
Hen i.un, n•...,. t rutr•am~nnu
.+ninum housings for maintenance frea perTormance.
,urn's rugged construction consists of galvanized steel <„Nrr
rotor support plate, main brace assembly and vendun inlet _ - ~ ;
raase complete w{th integral flange to Pit over roof curbs. '
Standard F®at+ures-
• Non-overload+ng, ba•-:i<wardly inclined renttifucdalwheels
f~esigned specifically for Power Roof Exhausters to 6eggnd
provide maxirnwn eftic+encles at lowest possible sons ~ Mb+nr ?nms3 7 Mvlnr Supper, V'la+s
ratln(~5. 2 DrOCh3rge Apron fi pnnhnp Tiiha :=lift Y~.4 ,R .•r
s Mohr +s pr°' luk?~I';ated, directly connected tp fan wheel s spar, Inle+vomurr c:nwl
and `'he 31r StYea[Tl. J Maln Br: cv Fdslenuiy S An±,-V,bra6oa t~,xr~dy
Assembly +n Dremdy,t Area
~ PQSi+NB : ~ CUY111 ~i ilE3nl CGOiing W+tPI Clean O11t51de 5 Cunlufu~al FpP Wheel wrih ii Condwr Gwde
;:It fOr IO+ige( rr1+??O. +Iid. InldAe Fan 12 wedlher Rattle
'elacr'on of air volume as needed is obtainable with tha b Mnlor
v,an,,P,ia sr)cod oa)TraNer from Acorn Fan speed is
adjustai>le by t>Irning the deal tc permit air movement
down to 50% and on-tiff control. Controllers are designed
for use with 115V AC permanent split capacitor motor _ _
arTdior shaded pole motors. VariakYle speed controllers ~r,~.~ Acorn 'e. brp crr+lfies Ihai the Acorn
;:°n~:°
for single phase 230V operation are available for 1 HP uni+ssho+vn . =:I„ensed+cbear+hennacnseal
dual voltage 115/230V motors. 'The raunds' shown ar, based on tests mad+3 m
actor dance wdh AMCA Standard 21[7 and co+n{,ly wiN~
Dimensional 17ata ~ the reyuuements of the AMCA Cer+itiad Hating
CURB SHIP WT Proc7Yam
MOf7EL - I ~ 6 _ - LB$ l U AcornADUG models ate li5led with Underwutrr':,
E.._
L ' t dbGratOri4'S
C _ _ _
ApUCII 20h ?1Pe l6 20 _d6
AOI1C7T3 26 _ .'1'h i+l h6 1I;i 18 _ 20 5G__
A~UC745 46 ' 2Y'fz _°o'h 11S'z iF__ 20__ 58
~r7UC155 32 ~ 22~/a ~ 2414 I6!d _ 2a 24 70
All duuer,eion3 in rn:.,,~•%
~"e.rtormanoe Data
TIP SPU _ _ FAN CAPACITY IN CU8{C FEET PER MINUiE SPEE6 SONES to
MuoEl NP RPM {FPM) u°~ ~ P .375"$? son"SP ,b2 "$P~.750" SP r. o" ~ "Sp CONTROYrER 1 5" SP
C Q I/a 11a+i~5Ui1 1330 I?30 __7125_ r0Y0 S85 7-05 _ ~,<+5 _ ~ vSGJU 66
A000125 1/2 I;ao~ 57aJ 2180 _7080 _1sGb 1850 17;5 _1600_ 14GU +I40 ?IS ~ ~ v5Ca0 1?i
AOUCiaS _714 rr4~l r;r;0 2fi00 z5ea 2515 23is0 ?240 _ lass ty+0 153n 1n15 455 ( USCnn" 13n
APUCa55 + ~ v 6$33 3!25 ~ e035~ 2065 2855 ?7fi5 2fiGb 2565 ).3af1 212U ItSOn d;(,;4a' 13l
•tl zuUV~ use vSG35 : P figures ara u.lonml pn; rnu,ei fU S P mdutlu:: all uvr':rnal Ian los,r,y) TFu nr.ICA Seal aPPPiv, w.w pia lonnance only Pc, La inrmi ,~+°.bi,wn
8 ara 1~. I rr~ wd0°~I dna~ yy
~r : SN yif ~-0 t
T82 Lafr~}:~:.:..: ireet, NY, New York ip013 Tet' (212) 431-5885 ~ FAX: 212 43T-4514
r,~i;~'nri '=+~~'~i 'i=,'T? '-+~'C 3b~'g~3S~';3ti5`~N 1~1 ~b(n 3N
~ ~.a...,
r' BOAFD OF HEALTH
Ili FORMN0.1 3 SETS OF PLdvS~.......
TOWN OF SOUTHOLD SURVEY
2 9 ~99~ i~~ BUILDING DEPARTMENT CHEC1: • • • • • = -~/-g~O•T• • • -
f.s TOWN HALL SEPTIC- FoRrl _
BLpG. ~~t;'r; `¢.~~i..'•`~ SOUTHOLD, N.Y. 11971
TOWN OFSO~tTrtc~tt7 TEL.: 765-1802 t.O'"` pp
• ....e.„...,,s..,.,u,.~,,.,., CALL ~ .~9.......
Examin ~R..b'.c~4.,,19q~ P1AIL TO: .
Appro~~~..~ 19.1. Permit Noa~.0.// 1-.~, . .
Disapproved a/c
a.L
(Building Inspector)
APPLICATION FOR BUILDING PERMIT ' ^ l,p, `
Date ! `~!~t~:~i S.P..., 194 l
• INSTRUCTIONS 111 `
a. This 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.
b. Plot plan showing location of lot 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 which 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 or in pazt 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 neces ary inspections. _
(Signature of applicant, or name, if a corporation)
?3os PG.rk. Ave:,. Soy:-~:~.~d. ~..y....
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
......~:ear.~-~:~ ~-~:c~f-4.r .
Name of owner of premises . ~ r.l:nne:...B C-~.Q.rr.~ ~ .
(as on the tax roll or latest deed)
If applica t is a corpo ation, si ly authorized officer.
(Name and title of corporate officer
Builder's License No. Nf A use
N/ ~-7
Plumber's License No. A
Electrician's License No. N+/~ .
Other Trade's License No. !Y~!~.
1. Location of land on which proposed work will be done. ~
~~12C
..............1-~+3~ ~ Q`~ `..~ebb.le . -h .~t~r.'m.,s.r .fem. t~1~r.'~.<m.
Flouse Number ~ Street ~ Hamlet
2 f
County Tax Map No. 10Q00~,S,e~ct~ion 3~ • . • • • • • Block Lot 2/_.....~. .
Subdivision ~!~4!~-.. Filed Map No. ....3 Lot ~?~f1 • • • • • . .
(Name)
2. State existing use and occupancy of pnrem~is~es,a,~nd intenld/e~duse and occupancy of proposed construction:
a. Existing use and occupancy v~4?.~-I • •
•{~4.4+M.
I ~I .......~y.~..o .
b. Intended use and occupancy ~ p,~j.~.~....l.H-1 ~ i~...~U1. 4k4-~ .
, ~J
3. RNepuuri of work (check which applicable): New Building Addition Alteration .
Removal Demolition Other Work .
4. Estimated Cost KJ~E~Q Fee
g (to be paid on filing this app~l/icatnnion)
5. If dwelling, number of dwellin un•ts Number of dwelling units on each floor N~/'r
If garage, number of cars /1/ •
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use .
7. Dimensions of existing structures, i~' any: Front .........:..::.Rear , r Depth , , , .
g ...............Number
Dimensions of same structure with of Stories .
alterations or additions: Front Rear . . . . . .
Depth $eight Number of Stories .
8. Dimgensions of entire new construct,,` ~
ion: Front y~ Rear ~ ~ ......Depth .....'-E.? .
Hei ht
um eri
, ~ofStories....,..~.•
9. Size of lot: Front h~ ~ Reef ......1:7 ~ Depth ...,~.(t+~ ~ .
10. Date of Purchase 'I •
11. Zone or use district m which remi 9 ~ I • Name of Forme; Owner ZR~11A~T°1.~141.i s~ .
p •~es are situated ...)'"~.I,C{,P,(') ;h ~ , • , ,
12. Does proposed construction violate',any zoning law, ordinance or regulation: ..n
13. Will lot be regraded ,1"l, d
14. Name of Owner of premises C.O('J11 ' ' • • • Will excess fill be removed from premises: Yes No
• • • • • • • , • ne .~7•. ~t:)?"1"Eh Address !~4.1S.8Ytx~w~ S1'.. (x f?f':.. Phone No..y. ll:-,4~O 1, •
Name of Architect ~
C ..Address ...................Phone No. .
Name of ContractorJUflfiSir. .~51"f~C12PC1 Address 13n5 94?I4~4,.Sh1~1., Phone No.Z~-.~4
15. Is this property within 300'feet of a tidal wetland? ~yes,•,,,,,, No..,~.....
*If yes, Southold Tow Trustees 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 number or description according to deed, and show street names and indicate whether
interior or corner lot. ~ I r-~l~' SI,~Je~./
a
I~
STATE OF NEW YORK, S S
COUNTY OF .
• • • • • • • • • • • • • • • • • • • • • • • being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
above named.
He is the
• (Contractor, agent,.corporate officer, etc.) • • • ~ • •
of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this
application; that all statements contained in this application are true to the best of his knowledge and belief; and that the
work will be performed in the manner set!i forth in the application filed therewith.
Sworn to before me this
day of 19
Notary Public, ~...h!:,R County
i ~
1t~y (Signature of applicant)
NOTARY PUBLIC
StOaLe
n~ New Y~?ork,, • . • .
TerNm~•E
p~es March
80,19.=L.Y
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