HomeMy WebLinkAbout19953-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
To~n Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No Z-21178
Date NOVEMBER 24, 1992
THIS CERTIFIES that the buildin~
Location of Property 770 VILLAGE LAiqE,
House No.
County Tax Map No. 1000 Section 114
Subdivision
ADDITIONS
MATTITUCK, N.Y.
Street Hamlet
Block 6 Lot I7
Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated JUNE 13, 1991 pursuant to which
Building Permit No. 19953-Z dated JUNE 18, 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 SUNROOM OVER EXISTING DECK AND DECK ADDITION TO AN EXISTING
ONE FAMILY DWELLING AS APPLIED FOR.
The certificate is issued to
NEIL J. & ALICE C. MacDONALD
(owners)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
UNDERWRITERS CERTIFICATE NO.
PLUMBERS CERTIFICATION DATED
N/A
N-256301 - NOVEMBER 9, 1992
Rev. 1/81
~0~ NO. ~
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~ 19953 Z
Permission is hereby~ranted to:
¥~,.~..z2'..~~~./.,. ....................
~ .... .xz~...zz. ~..~....~ ...................
· ....... , ,
,.o ~~....~.~.~..:..~....~_/~.'~....../....~.....~
at premises located at ....ZZ~;~, ...... .,~..../~... ,~-/;~. /~i ................................ ~ .............
co,,~ Tox Mop No. 7000 S,ction ..... /./..~ ....... mock ....... ~ .......... Lo, No ............./~ .......
~u.uo., to o,~,,c°,,o, d°,ed ..... ~./_../.~ ................................... , ,~..~/.., o.d op~ro~ed ~ ,~,
Building Inspector.
Fee O ~
Rev. 6/30/80
IrO~t, ar NO. ~
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
¢1'HI5 PEP, J~AIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N~- 19953 Z
County Tax Map No. 1000 Section ..... ../../[.....~'... ....... Block ........ ~.. ..........Lot No .......... ~.... .......
pursuant to application dated ..... .J~...~-./.~. ................................... ,
Building Inspector.
Rev. 6/30/80
Eo~m' N'of. 6
TOWN OF SOUTIIOLD
BUILDING DEPARTMENT
TOWN IiALL
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.
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 archiuect or engineer
responsible for the building.
6. Submi~ Planning Board Approval of completed site plan requirements.
;. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and
pre-existzng 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. C&rtificate 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
Constructio X
ew n ...... Old Or P existing B ildi
ocation of Property ~%Q ~ik!a~e ~ane~ Mattituck
Nouse No. Street Hamlet
nwer or Owners of Property ........ .. an~ Alice C. MacDonald
N~il J -. ..............................................
mnty Tax Map No i000, Section... j.l~..pp ..... Block .06.00 ...Lot. ~17
~bdivision .................................. Filed Map ................................
'' Lot
~rmit No ........... Date Of Permit .......... An~ - ~ Nell J MacDonald
· alth Dept Approval
' ' ....................... Underwriters Approval .........................
anning Board Approval ........................
quest for: Temporary Certificate. . . Final Certicate.. ~ ....
e Submitted: ~.~7~
...........................
770 U. Z2.&zge. £ccr~.
~, NY 11952
Nou~bo_.~.. 18, ~992
ATT:
~, ~Y 11952
Erw. io~e~ cute ,the
A.~o en.~, pu,,uu.,u~z.rut.~o you.,cJ.~on.,S,
AppEi..ca,,t~o~ ~o~ Poug.,~f,J~g pe.,'uT~i~,,~ ,i.n,C,~.u~¢~24.¢ d¢cJ~.
ge~tg ~
?OUNDATION
(1st)
FOUNDATION
2.
(2nd)
ROUGH FRAME &
PLUMBING
INSULATION PER N.
STATE ENERGY
CODE
FINAL
ADDITION[L COMMENTS:
THE NEW YORK BOARD OF FIRE UNDERWRITERS 1
BUREAU OF ELECTRICITY
F-- 85 JOHN STREET, NEW YORK, NEW YORK 10038
THIS CERTIFIES THAT
only the electrical equipment ~ ~scrlbed be~w a~ introduced by the applicant ~med on the a~ve application number in the premises of
~IL ~(H)O[~AL9, 770
in the following location; ~ ~asement ~ 1st FI. ~ 2nd Fl. OU~ Section Bilk Lot
) ~ ~ ~" ~ ~ and found to be in compliance with the requirements of ti is Board
SPECIAL REC'P TIMECLOCKS BELL ~ DIMMERS
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS
GAS H, P AMT. NO. A, W, G
SERVIC~ DISCONNECT S
OTHER APPARATUS:
METER
O~ECR~COND A W.G. NO OF HI-lEG
EQUIP. t~e'2W I~r3w 3,ff3w 3~/'4w , OF CC COND
UNIT HEATERS MULTI-OUTLET
SYSTEMS
NO. OF FEET
C
A, W G NO, OF NEUTRALS
OF HI-LEG
A. WG
OF NEUTRAL
GENERAL MANAGRR
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.
765-1802
BUILDING DEPT.
INSPECTION
FOUNDATION ~.ST [ ]' ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
FRAMING ~'~'INAL
DATE
765-1802
BUILDING DEPT.
INSPECTION
FOUNDATION 2ND [~*~ INSULATION
[ ] FRAMING
[ ] FINAL
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
FOUNDATION 2ND [ ] INSULATION
· ~'~MING [ ] FINAL
REMARKS:
DATE
765-1802
BUILDING DEPT.
INSPECTION
~FOUNDATION 1ST [ ] ROUGH
PLBG.
FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ ]FINAL
DATE
INSPECTOR ~~-~
3. N~ture of work (check wMch ely ~ ~able) New Buildi'ng ,. ,'. ...... Ad~i.~n~.~....D.e.c.k.... Alteration
Repair .............. Rem6~gi .............. Demolition .............. Other Work ............ ~...
' ~,~ (Description)
4 Estimated Cost ~,~.0.0. 0.0 0 $50.00
· (to be paid on filing this application)
$. If dwelling, numberofdwellingunits ............... 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 .......................................................
Dimensionsof same structure with alterations or additions: Front ................. Rear .................
Depth ...................... Height ...................... Number of Stories .....................
Dimensions of entire new construction: Front .......... ' ..... Rear ............... Depth ..............
Height ............... Number of Stories .......................................................
Size of lot: Front ...................... Rear ...................... Depth .....................
10. Date of Purchase ............................. Name of Former Owner ............................
11. Zone or use district in which premises are situated ....................................................
12. Does proposed construction violate any zoning law, ordinance or regulation: ...............................
13. Will lot'be regraded ......... , .................. Will excess fill be removed from premises: Yes No
14. Name of Owner of premises N..e.i.1. ,~....b!a..c.Dp.n.a..1.dAddress .7.7..0. y.i. 1..1.ag.e' ..LB... Phone No..2.9.8. T .4.4.2.0. .....
Name of Architect ... I~,A .................... Address ................... Phone No ................
Name of Contractor .. ~.~, .................... Address .... ' .............. Phone No ................
15. Is this property located within 300 feet of a tidal wetland? *Yes ..... No . ~...
*If yes, Southold Town Trustees Permit may be required.
PLOT DIAGRAM
Locate clearly and distinctly all build ngs, whether existing or proposed, and. indicate all set-back dimensions from
property lines. Give street and block numb:r or description according to deed, and show street names and indicate whether
interior or comer lot.
Planking 5/4x4
Fastened - 10D-Galv. H.d. Sprial Patio Deck Nails
Joists - 2x6-16" O.C.
Flashing - Aluminum on existing box beam
Girders 2 - double 2x8
Footings - concrete 3' belowgrade
Posts in ground supporting double 2x8 girders
8/4x4
Material - all CCA treated lumber
Ancored to existing dwelling - Teco fastening system
Railing around perimeter 2x6 Top rail
2x4 center rail, Height to top 32" 2
10/4x4 posts - spacing 4'8"
Stairs - box 2x12 tread (3)
2x12 stringer
8" rise
Handrail - 2x4 both sides
FORMNO. 4 <~='~
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
Certlfjcaf$ Of-OccUPancY' <
............ Date.. MA~ch. 2~5,. ,I&62. .............
THIS CERTIFIES that the building Ad d i t i on
~ 770 Village Lane' ~' Matt~ituck
Location of Property
· House No. ~ Street Ham/et
County Tax MaP No. 1000 Section .. I 1.4 ....... Block .... .0.6 ......... Lot .., .0.1.7 ...........
Subdivision , Filed Map No Lot No
conforms substantially to the Application for Building Permit heretofore filed in this office dated
· ~..M.a.r.e..h..ltl..)..I.~.8..7. ".,pursuant to which Building Permit No. ! ~.7.9.2. g.
dated . .~.a.r.qh...2.1.,.. ! .0.8.7. ........... was issued, and conforms to all or,he requirements
of the applicable PrOViSions of the law. The occupancy for which this certificate is issued is .........
D.e..c.k addition .t.q e.xi.s, tin.g, one family dwe. ll.i.n.g;
The certificate is issued ~o ~.I.L. J .~.a..c.D.ONA. LD, SR.
of the aforesaid building.
' N/A
Suffolk County Department of Health Appi'Oval ..........................................
UNDERWRITERS CERTIFIC,~TE NO ~. ,~ ...... N/A
PLUMBERS CERTIFICATION DATED:
Rev. 1/81
N/A
Nell J. and Alice C. MacDonald
770 Village Lane
Mattituck, NY 11952
298-4420
298-8353 (bus#)
13'9 x 15'4 Sunroom addition to be built onto existing deck, which deck was
approved by this Town on March 25, 1987 by Certificate of Occupancy No. Z15542,
see attached.
Sunroom to be constructed as follows:-
Deck Perimeter~
to be boxed in using 3/4" CCA plywood with 2" Dow Corning
foam insulation (foundation type) with 8x16 louvered vents.
Flooring:
3/4" CCA plywood over 5/4x4 existing planking with 3/8" ceramic
tile - glued on.
Framing/Sidewall
Construction:
2x6 wood frame; #15 felt underlay~ CD 5 Score 1/2" Sheathing
Siding:
Backerboard; 18" Cedar shakes - 14" exposure
Wall framing:
2x6 studs 16" o/cg R-19 insulation
Ceiling:
Cathedral type - 2x6 joists
Roof construction:
2x8 rafters 16" o/c; R-28 insulation; sheathing 1/2" CD plywood;
#15 felt; asphalt shingles; 2' soffit of 5/16" plywood with
4 8/16 soffit vents - continuous ridge vent
Interior walls:
lx6 T & G #2 V-joint cedar
Miscellaneous:
4 - 22 x 46 operable skylights
3 - 4' x 6' Anderson thermal casement windows (northside)
2 - 5' thermal aluminum sliding patio doors (eastside)
2 - 6' thermal aluminum sliding patio doors (southside)
Stairs:
Box 2x12 tred; 2x12 stringer; 8" rise; 4' landing
Electrical:
to existing Murray 100 amp service
Heating:
Plumbing: none
(See attached diagram of proposed addition)
APP.q~VF~ AS ~OTEg /'
765-1802 9 AM TO 4 PM FO~ THE
4. FI~AL CONSTF~UCTION
BE COMPLETE FOR C.O.
ALL CONSTRUCTION SHALL MEET
TH~ REQUIREMENTS OF THE N,Y,
STATE CONSTRUCTION & ENERGY
CODES, N~ RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS
Nell J.' and Alice C. MacDonald
770 Village Lane
Mattituck, NY 11952
298-4420
298-8353 (bus#)
13'9 x 15'4 Sunroom addition to be built onto existing deck, which deck was
approved by this Town on March 25, 1987 by Certificate of Occupancy No. Z15542,
see attached.
Sunroom to be constructed as follows:-
Deck Perimeter:
to be boxed in using 3/4" CCA plywood with 2" Dow Corning
foam insulation (foundation type) with 8x16 louvered vents.
Flooring:
3/4" CCA plywood over 5/4x4 existing planking with 3/8" ceramic
tile - glued on.
Framing/Sidewall
Construction:
2x6 wood frame; #15 felt underlay; CD 5 Score 1/2" Sheathing
Siding:
Backerboard; 18" Cedar shakes - 14" exposure
Wall framing:
2x6 studs 16" o/c; R-19 insulation
Ceiling,
Cathedral type - 2x6 joists
Roof construction:
2x8 rafters 16" o/c; R-28 insulation; sheathing 1/2" CD plywood;
#15 felt; asphalt shingles; 2' soffit of 5/16" plywood with
4 8/16 soffit vents - continuous ridge vent
Interior walls:
lx6 T & G #2 V-joint cedar
Miscellaneous:
4 - 22 x 46 operable skylights
3 - 4' x 6' Anderson thermal casement windows (northside)
2 - 5' thermal aluminum sliding patio doors (eastside)
2 - 6' thermal aluminum sliding patio doors (southside)
Stairs:
BOX 2x12 tred; 2x12 stringer; 8" rise; 4' landing
Electrical:
to existing Murray 100 amp service
Heating:
Plumbing: none
(See attached diagram of proposed addition)
UNDEi~VRITERS CERTIFICATE
REQUIRF.,D
OCCUPANCY OR
USE ]S UNLAWFUL
WITHOUT CERTIFICATE
OF OCCUPANCY
4. ~'"AL COMSTRUCTION MUST
THE REQUIREMENTS OF THE N.~
STATE CO~8T~U~ION & ENERGY
CODES. N~ RESPONSIB~ FOR
DESIGN OR CONSTRUC~ON ERRORS
Nell ~. and Alice C. MacDonald
770 Village Lane
Mattituck, NY 11952
298-4420
298-8353 (bus#)
and nc~ d~c~
~OH£ftO$ .40 Nf,AO.L
..... i rl
13'9 x 15'4 Sunroom addition/to be built onto existing deck, which deck was
approved by this Town on March 25, 1987 by Certificate of Occupancy No. Z15542,
see attached.
Sunroom to be constructed as follows:-
Deck Perimeter:
to be boxed in using 3/4" CCA plywood with 2" Dow Corning
foam insulation (foundation type) with 8x16 louvered vents.
Flooring:
3/4" CCA plywood over 5/4x4 existing planking with 3/8" ceramic
tile - glued on.
Framing/Sidewall
Construction:
2x6 wood frame; #15 felt underlay; CD 5 Score 1/2" Sheathing
Siding:
Backerboard; 18" Cedar shakes - 14" exposure
Wall framing:
2x6 studs 16" o/c; R-19 insulation
Ceiling:
Cathedral type - 2x6 joists
Roof construction:
2x8 rafters 16" o/c; R-28 insulation; sheathing 1/2" CD plywood;
#15 felt; asphalt shingles; 2' soffit of 5/16" plywood with
4 8/16 soffit vents - continuous ridge vent
Interior walls:
lx6 T & G #2 V-joint cedar
Miscellaneous:
4 - 22 x 46 operable skylights
3 - 4' x 6' Anderson thermal casement windows (northside)
2 - 5' thermal aluminum sliding patio doors (eastside)
2 - 6' thermal aluminum sliding patio doors (southside)
Stairs:
Box 2x12 tred; 2x12 striuger; 8" rise; 4' landing
Electrical:
to existing Murray 100 amp service
Heating:
Plumbing: none
(See attached diagram of proposed addition)
UNO~IT~RS CE~IFICATE
R£QUII~ED
APP..ROVEO AS NOTED
NOTIFY B(JIL'DI~IG DEPARTM~ A~
765-1802 9 AM ~ 4 PM FOR ~E
C~L LOWIN~ IN~PECTIONS'
~ F(~H~f~AT~C)f,~ ~*0 REQUIRED
F~R POHRED CONCRETE
2 ROUGH ~ FRAMING & PLUMBING
3 ~NSULAT~f)N
4, FiMAL CONSTRUCTION MUST
B~ COMPLETE FO~
ALL CONSTRUCTION SHALL ME~
THE REQUIREMENTS OF THE N.Y.
STATE CONSTRU~ION & ENERGY
CODES. NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS
JUN t 4 [99I
xammed
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-18021
BOAC. D OF H£,,\LI"II .........
3 SC-TS OF PLANs ..........
SURVEY ....................
ClI~cK ....................
gEPTIC FOR:I
CALL
pproved ..~' ...... 19 ermlt No.. . . ~ ........ ,.._ o .
APPLICATION FOR BUILDING PER~I~ ............................ ~';"" ': ' ~
.,, ; /
....... 97/.
INSTRUCTIONS "'
a. ~fis application must be completely filled ~n by typewriter or ~n ink and submitted to the Bu~ld~ng ~nspector, w~th 3
s of plans, accurate plot plan to scale. Fee according to schedule.
b. Plot plan show~g Iocation of lot and of btdld~gs on premises, relat~onstdp to adjoining premises or public streets
areas, and giv~g 8 detMled description of layout of property must be drawn on the diagram which ~s pan of th~s app~-
ion.
¢. The work covered by t~s application may not be ebmmenced before issuance of ~tdld~ng Pe~ft.
;d. Upon approval of th~s application, the Building Inspector will ~ssued a Build~ng Pe~it to the applicant. Such pe~it
!~ be kept on th~ premises available for inspection throughout the work.
.e. No build~ng shall be occupied or used ~n whole or ~n p~t for any purpose whatever until a Certificate of Occup~cy
J ha~e been granted by the Buildlng Inspector.
APPLICATION IS HgREBY MADE to the BulldOg Dep~ment for the ~ssuance of a Building Pe~it pursuant to the
!d~ng Zone Ordinance of the Town of Southold, Suffolk County, N~w York. and other applicable ~ws, OrdM~ees or
~ulations, for the const~ction of bu~ldMgs, addR~ons or alterations, or for removal or demolition, am here~ described.
~.appHcant ag[ee~, to comply w t~ aH applicable laws, ordinances, build~n~ co · ' ~ .
ut authomzed mspectom on premises and m buildin- for necessa ' .~ de. housm~ code. and r~gulat~ons, and to
(Mailing address of applicant)
:e whether applicant ~s owner, lessee, agent, architect, engineer general contractor, electrfc~an, plumber or builder.
Owner
~eofowncrofpremJses Neil J MacDonald and Alice C MacDonald
(aS on the t~ roil or latest deed)
2pi[cant ~s a corporation, s~gnature ofdtdy authorized officer. ,'
(Name and .............................
title of co~orato officer)
Buflder's L~cense No ...... ~~ ........
Plumber's Lfcense No ........... : .............
Electrician's L~ccnse No .......................
Other Tr~de's Lfccnse No ......................
ocat~onoflandon whJch proposed workwNlbcdouc. 770 Village Lane, Mattituck
ous~ Number
Street ......................................
Hamlet
runty Tax M~p No. 1000 Section .... ........ Block .. 06.00
· · tot 2zT..p0
',bd[v~s~on ........... Filed Map No.
(Name) .............. Lot .............. ..
~Ic cx~$I~ng use and occupancy of prcmJscs ~nd b~tcndcd usc amd occupancy of proposed cons[ruction:
Ex~sI~ng use ~nd occupancy Residential , ·
3. aiwa c eckwh~ a plicable):Ncw Building .......... Addition Sunroom ,\lteranon
' ' .......... m0val Demolition
.............. Other W.rk ...............
4. Estimated Cost...~.5.,.0.0.0...0.0 i - (Description)
5. I~dwelling, number of dwelling Un t~ N (to be paid on filing this applicatmn)
· h garage, number of cars .... i .................. tuber of dwelling umts on each floor...
6. If business, commercial or mixed[ occt panty, st)coif
Dimensions of ex stin,-,st ...... , i .~ ., y nature and extent of each type of u,,e
· o ~u~.~ures, llally; Front ............... Rear .....................
H'
~21~[lt .........
Db ...... Number of £tor/es ...... ' ............. Depth ...
ddi~i .................... ' ....
nensions o same structure with alterations or a OhS: Front ......................
Depth i Hei~d~t ................. Rear
3. DimensionsofentireneWconstru!etion: Fr~t .................... NumberofStories .... ' ..........
Height ~ · ................ P, ear .............
............ ;..tNBmlier of Stories ............... Depth
9 Size allot: Front ...............
0 Date of Purchase ............. · · ·. Rea .........
....................... Depth
............ i ................. Name of Former O ......................
I. Zone or use district in xvhich prcniises are situated ..... . . ..
Does proposed Construction Vmlat,e any zoning law, ordinanc
3. Will lot be r~graded .......... i ~' or regulatio'n. % ' ....... .:,' ........... j'
4. Name of Ow/her of premises S. ame 'f .... ;'. ......... Will excess fill be removed from )rem scs- v~¢
.... ~s..a.p.p.z.z.c~.n.t... Address 770 Village Ln ~' "one ,5~~. ,, No
Name of, Affchitect ...... n/.a...! . . ~,~ ' ......... ~ ........ ~ I~one No p?p-?.%z.0 ......
Name of ContraCtor ..... q/.q · · .iJ ........... ~xoaress ................... Phone No .
.............. Address .....
5. Is this property within 300 feet of a tidal wetland? *Yes ........ No...x ...... ''
.............. Phone No ..............
· If yes, Southoid ToWn Trustees Permit may be required.
· .-. , PLOT DIAGRAM
Locate clearly and distinctly all bdild~ngs, whether existing or proposed, and. indicate rill set-back dimensions from
:nperty lines. Give street and block number or descriptioh according to deed, and show street names and indicate whether
tartar or comer lot.
SEE ATTACHED
TE OF NEW YORK,!
'NTy OF . . $IJFFOIA( ......
· · · ~I[. 4 · .MAq~0~AhD. .......... ! ..........
(Name of individual signing col!tract) ..... being duly sworn, deposes and says that he is the applicant
named.
i(Contractor agent corporate officer ...........
' ' , , etc.)
d OWner or owners, and is dtdy auth(rizcd to perform or have performed the saki work and to make anti file this
at/on; that all statements contained inl this application are true to thc best of his knowledge and belief;and that the
will be perforated in the manner set for~t ~ in thc application filed therewith.
to before me this
L[ Commission Exp,res June ~0. 1 ~ ' ~ (Signa~rc of applicant)