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HomeMy WebLinkAbout20043-z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No Z-22229 Date MARCH 30, 1993 THIS CERTIFIES that the building NEW DWELLING Location of Property 650 EAST GILLETTE DRIVE EAST MARION, N.Y. House No. Street Hamlet County Tax Map No. 1000 Section 38 Block 3 Lot 7 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated JULY 17, 1991 pursuant to which Building Permit No. 20043-Z dated SUZY 24 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 AN ATTACHED C,ARn(;F. AS APPLIES} FQR The certificate is issued to EPAMINONDAS & ELENI T.AxxAR (owners) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL 41-SO-39- FEB. 1, 1993 UNDERWRITERS CERTIFICATE N0. PENDING - MARCH 29 1993 PLUMBERS CERTIFICATION DATED MARCH 10 1993 - DINOS ZERVOS f1,1.. CV+- ding Inspector Rev. 1/81 rosac 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) i N a ~ ~ i! ~ ~ Z Date .....1.~ ~ i9.~7" Permission is hereby granted to: ~ 0 34.5.:.. ta .~r..'.a~...-..`l/%ill~.C~.....Rr.........~...r.......~~.~.•`•T~~......r1.~~4.!:e(~.J.r1A~::...~!,1:4.fi....a~kl at premises located at ~P...`Jr..^~.. ..Pi....~,/f 1 .............................................~~"....7pp ~?..............................................~.77..................... County Tnx Map No. 1000 Section .........-.3.fJ..... Block .......ti~.......... Lot No..yl pursuant to application doted 19.~~, and opproved by the Building Inspector. Fee Bui g Inspector Rev. 6/30/80 i . / Tj 9 '7 Form No. 6 ~i~!t~~ ~r d~ TOWN OF SOUTHOLD , ,.•=.y~r.,...,,._ . . BUILDING DEPARTMENT t i I ~ ~ 'L; ' a , i~;ua 1 ~ , I~ TOWN HALL 76s-lsoz hp~lh I ~ 199;x# APPLICATION FOR CERTII'ICATE OF OCCUPANCY' A. 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 Fire Underwriters. 4, Sworn statement 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 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. Fees 1. Certificate of Occupancy - New dwelling $25.00, Additions to dwelling $26.00, Alterations to dwelling $2s.00, Swimming pool $2s.00, Accessory building $25.00, Additions to accessory building $25.00. Businesses $60.00. 2. Certificate of Occupancy on Pre-existing Building - $100.00 3. Copy, of Certificate of Occupancy - $s.00 over 5 years - $10.00 4.. Updated Certificate of Occupancy - $60.00 s. Temporary Certificate of Occupancy - Residential $15.00, Co pmmercial $is.00 Date z-: ~ l ~ ~ , J lew Construction... Old Or Pre-existing Building ocation of Property....I~~ao.........~:-:,5,~„~; j\\~~~~ t;,,,... ;~;,;(v~~S .c? House No. \ Street Hamlet nwer or Owners of Property......~:~::-:rc! , , , , , ;fir\4v::..~~V:~~ . ounty Tax Map No 1000, Section.....~~ ~u ..,Block.....~-'.........Lot....~,`~~~,,,,,,,,. ubdivision....~ :,,r,jv~Y•,.C;M.°;;ng.S,,..,.,,.,,,Filed Map.N~•~-~3$ ..Lot.....~1,,.,,., ermit No...~d~`~ , ~ J ~..;1,~ .Applicant... •p..-,w.~v.Aw~a-. .Date O,fI/Permit... S ~alth Dept. Approval..........Y ...............Underwriters Approval......................... Canning Board Approval aquest for: Temporary Certificate..........: Final Certicate....~`:..... ~ ' ~e Submitted: $„...~;5...~0 . CQ ~ a ~a ~ APPLICANT ~ c~~FF~1/~'~, TEL. 7G5-1802 o~~N o~,~ ~co~rr or sooT~(~~.~ ~ a" 2' ~ OFFICE OF BUILDIt•IG INSPECTOR o ~ v. z,~ ';3~',v>; ~ P.O. BOX 1179 ,r; , TOWN HALL , %~Q.r SOUTHULD, N.Y. 11971 ~ ~RF' / ll 1.~~~ e a. C E R T I F I C A T I O N Date ~ ~ C7 ~ Building Permit No.~~ p ~ 2 Owner. Ln .~c.~ i~ C ~ t~~ /Y).) 1'VO ~..5 (phase print) Plumber \ N c9 \ ~ C~ ~ L < < - ~3~-t2 V~ (please print) I certify that the solder used in the water supply system contains less than 2/10 of to lead. (plumber's signature) sworn to before e this 19 ~ 3 • , i~,-to 6~.~..- NotaLy Public Notary Public, -County DOR13 AIARIE I14tREdI>Swpld EIet~; ~ Peablie, Ska4o ©1 New York la.,, ~?.•AG@5~08.8uf6olk Oa~e~ C,,:;:;ra~~rr3 ~yirae A~II 34, 9® 32" 3 _ 00 co ~ a THE' NEW YORK BOARD OF FIRE UNDERWRITERS lrnt;k, }-`fi't ILO' BUREAU OF ELECTRICITY 85 JOHN STREET, NEW YORK, NEW YORK 70038 Date 3l}}'18 ~1'Jr1993 ApplieationNo.onfUe ~1~~14f,29',ll91 P! 2.`781.8 THIS CERTIFIES THAT P~,I.tPiLl' Z~~r`~37 only the electrical equipment as described 6e/oar and introduced 6y the opplicont Homed on the obove opplication number in the premises of 17t'P,44iNOPA~ L~CC(CAS, GF16) };A:;'P GIGC7"CG ?li:LV~', ESA5'I' MAI;'Ct7k}~ BI,Y. in the folioECing locotion; ~ Basement 0 /st FL ? 2nd F'l. ~Il ,Sertion Block Lot 11 nos examined on I'{,~ f{ C :i 41 r 1 ~ 9 .t and found to be in compliance with the National Electrical Code. FIXTURE FIXTURES RANGES COOKING PECKS OVENS DISH WASHERS EXHAUST FANS OUTLETS ECEPTACLES SWITCHES INGANDESCENi FIVORESCENi OTHER AMT K W. AMT K.W PMT. NW, pMi K W AMT. H.P. ~1 ~ ~ fi e ~ } 4g . f! .L DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIME CLOCKS EELL UNIT HEATERS MULTI-OUTLET DIMMERS AMi K. W. Oll M. P. GAS H. P. AMI NO. A W. G. AMi qMP. AMT. AMPS TRANS, AMd R P SYSTEMS M1i WAiiS NO.OF FEET 1 L' 1 ;3p0U 2/P_~3 1 ~4; 1 SERVICE DISCONNECT NO.OF S E R V 1- C E AMT. AMP TYPE METER 1,e' ]W 1 ,9' 3W 9,e 3W S,e' 4W NO.OF CC. COND. A. W. G: ' - A. W G A. W G. EQUIP. PER B OF CC. COND. NO. OF HI~LFG OF HPIEG NO. OF NEUlRAIS Of NEUTRAL } 1h~r Ctl L } .!/0 1. 1/t3 OTNER AP?ARATUS: era~r,. WATF,N xk„~.~~;asll,_~~~~.5 x.~r, r,.rr.c.x:- SNQC(6 D},TECT'U[t I - 1, W,S,L', ELF.CTRLC L~Er,P~~ 8a~3 C~~~~ l it b~NACR6; 11G.. llLR IiI1':GSF NS', }1741G GENERAL MANAO@R Pe il`! ~ ~ ~~i yi 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 BE ALTERED IN ANY MANNER. r'lELD I;:S:`FC:iu,J ~~UAYc ~ COtYMENTS ~o J. X 9 9 9 H ~rr H W rOUNDAATION (1st) ~ .~1 FOUNDATION (2nd) _ - , 6 2. ~(1 O~ ~1 ROUGH FRAME & ~Q~ PLUMBING ~N~ ~~~P ~ ~ 3. m ra ~ H INSULATIOPJ PER N. Y. t STATE ENERGY CODE x t~ / ~ m 4 . 'j FIiJAL z~, ADDITIOPJAL COMMENTS: x~ 7~q 9~ ~ <re rt rt ~ t~ b ~ ~ H 77 (1 n\ ? ~.1 H~ H C•c~. ~ z~ ' ~ a • r \ _ H I T f- b Q C'7 l H / ro ``,~~y/ INSPECTORS PrincipaltBuilding Inspector O~pSVFFO~~COG Curtis Horton h~ SCOTT L. HARRIS, Supervisor Senior Building Inspector o - rra z Southold Town Hall Thomas Fisher u- P.O. Box 1179, 53095 Main Road Building Inspector ~ • ~ y p~ Southold, New York 11971 Bui ding Inspector ~Ol ~ ~a Fax (51b) 765-1823 Vincent R. Wieczorek Telephone (516) 765-1800 Ordinance Inspector Robert Fisher Assistant Fire Inspector OFFICE OF BUILDING INSPECTOR Telephone (516) 765-1802 TOWN OF SOUTHOLD STOP WORK ORDER TO• YOU ARE HEREBY NOTIFIED TO SUSPEND ALL WORK AT: 1435 GILLETTE DRIVE, EAST MARION, N.Y. 11939 TAX MAP NUMBER - Pursuant to section 100-281 of the Code of the Town of Southold, New York, you are notified to immediately suspend all work and building activities until this order has been rescinded BASIS OF STOP WORK ORDER: CONDITIONS UNDER WHICH WORK MAY BE RESUMED: Failure to remedy the conditions aforesaid and to comply with the applicable provisions of law may constitute an offense punishable by fine or imprisonment or both. DATED: INSPECTORS ~~gOfFO(,~-co (516) 765-1802 ~~O G,L SCOTT L.HARRIS,Supervisor VICTOR LESSARD, Principal ~ CURTIS HORTON, Senior r°ra x Southold Town Hall VINCENT R. WIECZOREK, Ordinance up P.O. Box 1179, 53095 Main Road ROBERT FISHER, Assistant Fire 9,~ ~ O!~ Southold, New York 11971 Oj ~ .1`a Fax (516) 765-1823 Building Inspectors Telephone (516) 765-1800 THOMAS FISHER GARY FISH OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD STOP WORK ORDER TO:EPAMMONDAS & ELENI LAKKOS, (OWNER) 2035 COYLE STREET BROOKLYN, N.Y. 11229 YOU ARE HEREBY NOTIFIED TO SUSPEND ALL WORK AT: 1435 GILLETTE DRIVE EAST MARION, N.Y. 11939 TAX MAP NUMBER -1000-38-03-07 Pursuant to section 100-281 of the Code of the Town of Southold, New York, you are notified to immediately suspend all work and building activities until this order has been rescinded BASIS OF STOP WORK ORDER:NO BUILDING PERMIT CONDITIONS UNDER WHICH WORK MAY BE RESUMED:WHEN A BUILDING PERMIT HAS BEEN ISSUED BY THE TOWN OF SOUTHOLD TOWN BUILDING INSPECTOR. Failure to remedy the conditions aforesaid and to comply with the applicable provisions of law may constitute an offense punishable by fine or imprisonment or both. DATED: MAY 24, 1991 VINCENT R. WIEC20REK ORDINANCE INSPECTOR TOWN OF SOUTIfOLD BUILDING DEPARTMENT • SOUTHOLD, NG1V YORK STOP WORK ORDER ~ TO: ~ l~I~~M.U/l0 {~aA'S ~-1..~ ~ f 1, A~~K?JS (Owner, Uwner`s Agdni or Person Pertormmg tiVork) Aadress of above-named person) YOU ARE HEREBY NOTIFIED TO SUSPEND ALL WORK AT: l 3 G 1 t_ l~~~E D 2 ~ ul= 1 ts~?s a I~~•t~M Y, Aaaress where work is to be scoppea) TAX MAP NUMBER ~r~Qf~ 3 ^ fa ~ D Pursuant to section f D - 0~6' ~ of the Code of the Town of Southold, New York you are notified to immediately suspend all work and building activities until this order has been rescinded. BASIS OF STOP WORK ORDER: ~(Q ~ (,((f,. ~ ~ ~ C-, 1Z.I,lt, ( • CONDITIONS UNDER WHICH tVORK MAY BE RESUbIED: ~ kE l~ 1~ t,~ i ~3 d"P Ca 1' ~ ~L ~ l i " l-I ?4 S 13 sE~ 1~ ~ 1 s S u. ~ ~ i t~ ~ Sn ~e. °?°~l ~E~~ Failure to remedy the ctinditions aforesaid and to comply with the applicable provisions of law may conscitutc an offcruc punishable by fine or imprisonment or both. DATCD: ~j~ ,2 B NSPECTOI CODG ENFORCE\tENT OFFICER v i ~ (516) 765 802 O~pSUFFO(,~~oG VICTOR LESSARD, Principal 'yam SCOTT L.HARRIS,Supervisor CURTIS HORTON, Senior v°a Southold Town Hall VINCENT R. WIECZOREK, Ordinance p ^x+ P.O. Box 1179, 53095 Main Road ROBERT FISHER, Assistant Fire ~ Southold, New York 11971 'h0,~ .IO Fax (516) 765-1823 Building Inspectors ~ Telephone (516) 765-1800 THOMAS FISHER GARY FISH OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD STOP WORK ORDER, TO:EPAMMONDAS & ELENI LAKKOS (OWNER) 2035 COYLE STREET BROOKLYN, N.Y. 11229 YOU ARE HEREBY NOTIFIED TO SUSPEND ALL WORK AT: 1435 GILLETTE DRIVE EAST MARION N.Y. 11939 TAX MAP NUMBER -1000-38-03-07 Pursuant to section 100-281 of the Code of the Town of Southold, New York, you are notified to immediately suspend all work and building activities until this order has been rescinded BASIS OE STOP WORK ORDER:NO BUILDING PERMIT, CONDITIONS UNDER WHICH WORK MAY BE RESUMED:WHEN A BUILDING PERMIT HAS BEEN ISSUED BY THE TOWN'OF SOUTHOLD TOWN BUILDING INSPECTOR.. Failure to remedy the conditions aforesaid and to comply with the applicable provisions of law may constitute an offense punishable by fine or imprisonment or both. DATED: MAY 24 1991 ~'~''LQ''~ ~ VINCENT R. WIECZORE3t ORDINANCE INSPECTOR 3~zs~~Ql - ~.Q.. ~,1~c~. S1~.e c~~-e-p ~ yQ-g i IM- ~ l ©d./ T65-1802 ~o©o- 38'-03~ o "f BUILDING DEPT. INSPECTION [ ] OUND ON i5T [ ROUGH LBG. [ ] F DATION 2ND [ ] i CATION FRAMIN FINAL REMARKS: ~ j~ o ~ ~ ~V~(. ~ P CZ.®®~ ~D y~'~a~~~~ ~l D ~ V [ 1, ~c ~ ~ U t ~ ~ ~ ~ G-~ ~~IP~t~u. DATE I INSPECTOR~,~I,~~~GZO~-CS ~3 765-1802 BUILDING DEPT. INSPECTION [ ]FOUNDATION 1ST ~ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ]INSULATION [ ]FRAMING [ ]FINAL REMARKS: i DATE ~ fNSPECTOR 765-1802 BUILDING DEPT. INSPECTION [ ]FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ]INSULATION (]FRAMING FINAL REMARKS: ~ 4 ~ Y-~'~ DATE ~ INSPECTOR ~ ~ A r C~i'~~~J 765-1802 BUILDING DEPT. 1 NSPECTION [ ]FOUNDATION 1ST [ ] ROUGH LBG. [ ]FOUNDATION 2ND [ SULATION [ ]FRAMING [ ]FINAL REMARKS ~a~~ DATE ~ INSPECTOR a rss-isos BurLDING DEPT. IN~p~CTION [ ]FOUNDATION iST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ]INSULATION [ FRAMING [ ]FINAL REMARKS: /`~.-~~~~-~C~ ' DATE ~ INSPECTOR c 765-1802 BUILDING DEPT. INSPECTION [ ]FOUNDATION 1ST ( ROUGH PLBG. [)FOUNDATION 2ND [ ]INSULATION [ ]FRAMING [ ]FINAL REMARKS: DATE INSPECTO v~~ a ~ , r- ~ 765-1802 BUILDING DEPT. INSPECTION [ ] FO TION 1ST [ ] ROUGH PLBG. FOUNDATION 2ND [ ]INSULATION [ ]FRAMING [ ]FINAL REMARKS: _ (,1 a DATE D" ~ INSPECTOR 1 D ~ 60nF0 OF HEALT7i FORM N0.1 `~J SETS OF P \:7S TOWN OF SOUTHOLD -'--SURVEY ~ (7~ BUILDING DEPARTMENT ---'OIIEEh • • • • 3a~~••• _ TOWN HALL SEPTIC CORN 741.i1Ta, tD SOUTHOLD, N. Y. 11971 _.„,,;,,'1j',;~! ~?F$ i7 TEL.: 765-1802 t:OT`I FY ; cnLL .33::5/^.7.1 Examined , , , , , , , , lg~, CIA I L TO :approved 19~~Pennit No.. ~9.~.~`"~~ . Disapproved a/c _ . ~ ~ F ( ilding Inspector) APPLI ATION FOR BUILDING PERMIT Date 19 . ~ INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 its 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 r areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- ation. c. The work covered by this application may not be commenced before issuance of Buildin; Permit. d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such permit call 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 Occupancy tall 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 wilding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or egulations, for the construction of bu+ldings, additions or alterations, or for removal or demolition, as herein described. he applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to lmit Suthorized inspectors on premises and in building for necessary inspection (Signature of applicant,, or~nante, if a corporation) (Mailing address of applicant) tate whether applicant is owner, lessee, agent, architect, engineer, genera] contractor, electrician, plumber or builder. "ame of owner of premises ~J°~!~1,~IUD ~ 5, . L~ k X f'j,5 (as on the tai roll or latest deed) applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) s Builder's License No. ..:T~~;,,,,,,,,,,,,,,,, C,~~ ~ a Plumber's License No. ..7Q3.Q ; , , , , , , , , , , y Electrician s License No. ~ , ~`~~-6C/ Other Trade's License No. 1nJ,~k,~,pt~x,., ~,Q1.q~, „ ~ • r Location of land on which proposed work will be done. . House Nwnber Street fIantlct County Tax Map No. 1000 Section ...-3. Block ...:3, , , , , , , , , , , Lot 7 . r Subdivision . ~+11:e-9)y , ~~I(A.(1 Piled Map No. ~ 0. j, Lot . (Name) State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy . //~~y~ b. Intended use and occupancy ..U~~.. ~~~.1.. ~....~U ~"`~''~i'a~f;~,otktlugy~gfA~N vts~ ~v~ 71+1g ~~?~fis ~ •~1~ . r 4 r Rem b~~-~ 3. Napure of work (check which ap,p(icable : Ncw Buildin , Re air ) g Addition Ie , val Demolition ~6 ; a bytl#~~ Work , ~ ; 4. Estimated Costi~.(~•~/~~~. Fce il~ ~~(I~es~~iptionj (to be aid on fl 5. If dwelling, number of dwelling ,III. • . • • . • • • , , . Number of dwcllm unitps on cachhrig,this,`5ppljcation) units . g floor. ~~e:......... If garage, number of cars , . ,?1 ~ . 6. If business, commercial or mixca occupancy, specify nature and extent of each type of use . . y~ imenstons of existing structure , if any: Front , , , , , , ; , , ; ,Rear , Depth , Height Number of Stories . . . ' ' ' ' ' ' ' ' ' ' ' tmenstons of same structure wi P th alterations or additions: Front , , , , , , , , , , , , , , , , , Rear . De th ~ .Height Number o Stones . . 8. Dimensions of eqq~ire new construction: Front . ,ag~~•, , , , , , , Rear f, . Height ~i'~O(d(R41I1 I~ Iq$.. Nu a~ • .......Depth .S`~:f'f ; , , , , , , , , 0 tuber of Stories ,QY,IQ, f p(L~; , 9. Size of lot: Front . , ~r'~O.,Q,3 , Rear . ,/,O,Q , Depth ~ y~• ~ 7 ~ /L/(,. ~1,~,~', 10. Date of Purchase . , ~IPt ~ A ~h { ~Igq,l ...............Name of Former Owner ~Cs°°.r.1C~ r ~U C / 1. Zone or use district in which pre to any zoning law, ordinance or regulation: 13. Will lot be r~~raded miles are situated . . . . . . . . . . 12. Does proposed construction viola' yy~~ I .1Y.v 14. Name of Owner of rQ~miles ,~f ' LAKE $ • • Will excesses be rem~gQvcd from premises•/~ Yes N~ P]Iq 'I~/ LQ~mlRa'IC~A-S.....R. Addressaf73`~... /2 ST...... Phone No.l/!~.~,~: 5, t Name of Architect . l `It~K3 „ ~,IJN, f , , , , , , , • AddressAlF.1((U K U~{p /~~~,~Phone No..~,7, ;Q,z{~, , ~ Name of Contractor . l5. Is this ro ert withan 3 ~ • • • • " " • ' • Address Phone No....... . P P Y 40 feet of a tidal wetland? ~ ~ u " " If yes, Southold Town Trustees PermiE may be required. NO.,~,,,,, PLOT DIAGRAM Locate clearly and distinctly al( buildings, whether existing or proposed, and, indicate all set-back dimensions from property lines. Give street and block number or description according to dead, and show street names and indicate whether interior or corner lot. I ~ r _ I , III ~~I K I I I I •ATE OF NS~V YORK, - ~~(~m~~d~ual signing~~~ / ~ ' ' ' ' being duly sworn, deposes and says that Ite is the applicant ~ (contract) ove named. isthc I (Contractor, agent, corporate officer, etc.) • • ~ • • • ' ' ' ' ' ' ' ' ' ' said owner or owners, and is duly at thorized to perform or have performed the said work and to make and file this >lication; that all statements containc~l in this application arc true to the best of ]tis knowledge and belief; and that the rk will be performed in the manner set forth in tltc application filed therewith. om to before me fhis ~ ........day of.. 19.~.~ ary Public, , , , I~L!~~;-a , , , County ~j ~ pdZy~'p'4'up~`~u~ • • • . • . • • . • • . ~ ~ (Signature of applicant) Twm R.~plraJun~ 1~,1~ A is ° ~ o\„° ` ~ n \ o ~o O ~w~ T M ~ ~ ~O N A '~O U o5a Z 'O ~ ` M t e >o o0 00~ ~ 0 1 ~ ~ ~ ° o N ~ ~ \ ~Z i 215 ~ : ~ N ~ ~ \ ••~s, o dg2 .'Z O2 a9 ~ z .~L ~ o i ~ v Qy o dno~ p7 0 ~ . 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