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" FORM NO. 4 TOWN OF SOUTHOLD BUILDING BEPARTMENT Office of the Building Inspector Town Ha11 Southold, N.Y. CERTIFICATE OF OCCUPANCY No Z-22602 Date SEPTEMBER 22, 1993 THIS CERTIFIES that the building ADDITION Location of Property 670 NORTHFIELD LANE SOUTHOLD N.Y. House No. Street Hamlet County Tax Map No. 1000 Section 79 Block 3 Lot 5 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated AUGUST 6, 1990 pursuant to which Building Permit No. 19311-Z dated AUGUST 7, 1990 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 GARAGE & DECK ADDITION TO EXISTING ONE FAMILY DWELLING AS APPLIED FOR. The certificate is issued to ARTHUR J. & RITA J. HAMILTON (owners) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A UNDERWRITERS CERTIFICATE N0. N-241124 - JULY I, 1992 PLUMBERS CERTIFICATION DATED N/A J - • ,iP~ ilding Inspector Rev. 1/81 i I 1013ffi NO. f TOWN OP SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHALD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) f i N~ .E ~ ~ 1 1 Z Date ..........~~...~..:7....., 19.~.~? Permission is hereby grant(e~dlt~o~:-Q ~ _t 1 c~ ^ _ A t ~ ~r,,~~~ , ~ .....K.:.Y?5.... L~t~. ~.~t.~.Y.~ .rri,:~iJ.... f of premises hated at ........,7,C?..........~:~,~:~:l...... ..~X-.... .~4^:4~i.........4? County Tax Map No. 1000 Section Block .......~..t1~...... Lot No.....~l.aS............ pursuant to application dated ..r~:S4~....~ 19%.°., and approved by the Building Inspector. Fee 5...~J.~....../ Building Inspector Rev. b130/80 i ,D,a~,~ ~ ; ~ U~ ~-rz~rO3o~. N Form No. 6 ~ 9 7, TOWN OF SOUTHOLD =?5 ~i;'; ~~~9i E~~Y~ ~ ~.......:.:.o..~:.,,e 7 BUILDING DEPARTMENT j';~ 765N1802L .3 Q z.j APPLICATION FOR CERTIFICATE OF OCCUPA TC1Wl~ t~)F ~+OsJTE~~i'ars"~ 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 plumbez 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. Accuzate 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 5ha11 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 - Residential $15.00, Commercial $15.00 Date ~~..7-~./9 ~ New Construction.. x....... Old Or Pre-existing Building Location of Property....... .1?.~~ ............./1/.:'.2T~f F:~~-.~~. L .~!U.~............ Sgv~o L.l House No. Street Hamlet Onwer or Owners of Property../b2~.rh.U~..J...Y...~1~~~•. :~.:..~+~r!~f~/`~.•.•.....•••..••. cc~~ County Tax Map No 1000, Section... .V.7.1.....Block...~...........Lot Subdivision ....................................Filed Map........... .Lot....... . ~ l ( gg,, ~ Permit No. .......Date Of Permit... rSj7. ...Applicant. ctl~:~:~~"... 2~r~ :(:^M!L,~'~N, , , Health Dept. Approval ..........................Underwriters Approval......................... Planning Board Approval Request for: Temporary Certificate........... Final Certicate...~...... Fee Submitted: $,Zi~ ~ `~„Q~s lt ~K~~oC,~ .PLICANT Cb ~ oho', f~ 02~ - - s~ 14311 _ . THE NEW YORK BOARD OF FIRE UNDERWRITERS P:~c~: ~ 119) 112 BUREAU OF ELECTRICITY 85 JOHN STREET, NEW YORK, NEW YORK 10038 ' Date `7 t11'~ ~1 t~'i'~g2 APPlicotion No. an file 03197. "a92l92 ~ ~411~~ THIS CERTIFIES THAT l' only the electrical equipment os deacrihed 6ebw artd introduced 6y the opplicont homed on the ohove application numher in the premiaea of I MR, HAtdZ1',TQN, 670 1tOR1`HPTFLi? LANE, NYT~3, Sf1U1'HpLI?r N.Y„ in the foUowinK location; ? Basement ~ 1st FI. ? 2nd F'1. C1UT Section Blcek Lot was examined on J UN fl ° ~ , 1 ~ y? and found to be in cuntpliance uirh the regniremenis o(thia Board. FIXTURE FCEPTAClES SWITCHES FIXTURES RANGES COOKING DECKS OVENS DISHWASHERS EXHAUST FANS OUTLETS INCANDESCENT FWOREECENi OTHER AMT. K. W. AMT. N. W. AMl K W AMT K W AMT. H P. 6 4 A E DRYERS FURNACE MOTORS pUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIME CLOCKS BELL UNIT HEATERS MULTI.OUTLET DIMMERS SYSTEMS AMT K. W Oll H. P. GAS H. P. AMT NO. A W. G. AMi. AMP PMi AMPS TRANS. AMT. H P. NO. OF FEET AMT. WATrS 1 30 SERVICE DISCONNECT NO.OF 5 E R V I C E MIT. AMP. LYPE METER I 4W T % BW 9 ~ ~W J~ AW NO. OF CC. COND A W, G NO OF HIAFG A. W C' NO OF NEUiRAlS A W G. EQUIP. PEP B OF CG COND. OF H4lEG OF NEUTRAL OTHER APPARATUS: PAtiEI,T30ARt}St1 G (;IR. 100 ~I . ~ SAGE &GUDEtdARN ):ilCl;J,S14GE LLC.f#3G3"i°E P.q.BpR 17E3 SQU'SHOf,6, NYr 7.1`331 6ENERAI,MANAGER 1 A ,~9'G~ 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. ~LOPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIPICATE MUST NOT BE ALTERED IN ANY MANNER. ~1. =1c:LD I;:SP~CTiUN ~~Un:E ( CONMGNT~ ~ y n ~ ..r 1 . ~ ~ 6 C rA _a ,il • H V_ - - - H FOUt7DATI0N (1st) _ _ FOUNDATIOW (2nd) ~ 2. ~ ? p z o ~ P,OUGH FRAME & J Q PLUMBING y, H 3. ~ m ~ ra IIJSULATIOP] PER N. Y. . • STATE ENERGY g.S, CODE x p a ,_~r 0 y ~ ~ 4 . ~ r . y /j FINAL ez~ ~ ADDITIOP7AL COMMENTS: ~ x ' ro • ~ x ~n ro Jeo H y..... 9 H H O .t,,,~ y 1_ „ ~ A ' r ~ x 0 m ^o H 1 _ 6 ~ , 765-1802 BUILDING DEPT. INSPECTION [v] F UNDATION 1ST [ j ,ROUGH PLBG. ] FOUNDATION 2ND (]INSULATION [ ]FRAMING [ ]FINAL ''1tEMA~tKS: 6 F DATE ~I ~ INSPECTOR ~ i~ ~ l '765-1802 1~~~~ ~ BUILDING DEPT. iNSPECTICJN [ ]FOUNDATION 1ST ( ] ROUGH PLBG. ~ I [ ] OUNDATION 2ND [ ]INSULATION r FINAL [ ]FRAMING ] i REMARKS: ~ ~ i, i i i i ~i 4 DATE ~ ~ ~ INSPECTOR 765-1802 BUILDING DEPT. 1 NSPECTION [ ]FOUNDATION i5T [ ] ROUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [ ]FRAMING [ - FINAL REMARKS: ~C~ ~ _ DATE INSPECTOR v~~?+ _ _ ~.F. COMMERCIAL 1-800-439-0372 Fax:516-477-2534 RESIDENTIAL NEW SUFFOLK CONST. 11600 Main Road East Marion, New York 11939 516-477-0072 1=eb. 10, 1992 Reb; A. Ham~k~an Gaxage G70 Nanxh ~~e.t'd Lane Sou~hokd, N.Y. 11971 Mx. V. Lea~saxd, we axe neclueet~ng an ex~ene~an ab ~2me on bldg. penm2t # 19311 2 dated Augubz 7, 1990, ha we may eampke~te .the Wahl2 . Then have been 2 ~.napee~~ona done wh2ch wexe Uaunda~~ana and bnam~hg. yaux heap 2n ~h2a ma~~en is gneat2y app-aee~.axed. i,y, , ' - T-~ you ~~r Jahn E. M2.l2ex ~ SO(/ ~ c o. ~ ~,g b. P.UG - 61990 ~ mow 4z n o j BLDf,. DEPT. tl ~1.,,Z.~'~--"'~~ TOWN OF SOUTHOLD ~ ~ c ~ - ~ ~ ~ 4 o M ~ ~ i ~ ~ ~ ~ ~ ~ ~ . ~ 3 ~ ~ a ~ ~ ~ 1 s ~ ~ O 1 ! a O f'rnn/«'a ~ ~ ~ ~ ~ ~ j !'r; i ,~i.~ ~ 4~ ~ ~ ~ ~ ut ~ o ~ ~o fem. .a a ~ a ~ ~ pl v, ~ a w ~ ~ u , C ~ ~ (1 ~ 0 ~ ~ ~ ~ ~ (i i ~ A Q I ~ X1I1 tip r,, ~ ~ ~ ~^vy 0 " r~ I ,wn r ~.l V 'SV` 1 fN)Y ni3Sp ~Y.T ~O~ i~~ ~{l? a Standard N Y.B.TA. Form 0002-ROM -Bargain and Sale need, with Covenanb again[ Grantor's Anr-Individml or Cospmatiun. (single sheet) AA CONSULT YOUR LAWYER BEFORE SIGNING THIS INSTRUMENT • THIS INSTRUMENT SHOULD BE USED BY LAWYERS ONLT v~ THIS INDENTURE, made the ~ 1 ~j day of May ,nineteen hundred and eighty-six ~ BETWEEN )rL0 DAVID PAIGE, LTD., doing business at ~~~5v ~j_l 14 Hawks Nest Road, Stony 3~eo]~,~ New York 11790 a party of the first part, and ARTHUR J. HAMILTON and RITA J. HAMILTON, hiS wife 9~9 Harlane Circle, North Bellmore, New York 11710 fir- ~ ~ ~ i, ~ AUG - 6 ~g~ ~I party of the second part, e,.~.~_^,,,n.>~,,, ~ ; - WITNESSETH that the art f theYfij`stitp~„ ,j~ p y a,hP~it'J l``''~sideration of ten dollars and other valuable consideration paid by the party of the second partf;`doe8'°lrereby~a~riL'~~(ty~l release unto the party of the second part, the heirs or successors and assigns of the party of the second part forever, c,,~~q_t,ii, ALL that certain plot, piece or parcel of land, with the buildings and improve nt~ thereon erected, situate, "A lying and being irX3dt~ at Bayview, in the Town o£ Southold, County of Suffolk and State of New York, bounded and described as follows: _x:- BEGINNING at a point on the southerly line of Northfield Lane at the northeasterly corner of land of the Town of Southold, said point being 596.55 feet easterly along said southerly side o£ Northfield Lane from the corner formed by the intersection of the southerly DIST. side of Northfield Lane with the easterly side o£ Dayton Road; from 1000 said point of beginning running thence along said southerly line of Northfield Lane, north 82 degrees 18 minutes 10 seconds east Sec. 150.00 feet to land now or formerly of Frankola; thence along said 079.00 land south 7 degrees 41 minutes 50 seconds east 174.44 feet to land now or formerly of William Demm; thence along said land two courses: Blk. 03.00 (1) south 64 degrees 15 minutes 20 seconds west 39.14 feet; thence (2) north 82 degrees 45 minutes 20 seconds west 116.97 feet to said Lot. land of the Town of Southold, thence along said land, north 7 degrees 005.000 36 minutes 40 seconds west 156.42 feet to the point or place o£ S~ PFo~- BEGINNING. ~'s-: ~ ~ RECE ED ~ ~ = ) REAL ESTATE ~e MAY 23 1988 3~7 y~U . ~7RSU~OLK~ COUNTY TOGETHER with all right, title and interest, if any, of the party of the first part in and to any streets and roads abutting the above described premises to the center lines thereof; TOGETHEk with the appurtenances and all the estate and rights of the party of the first part in and to said premises; TO HAVE AND TO HOLD the premises herein granted unto the party of the second part, the heirs or successors and assigns of the party of the second part forever. AND the party of the first part covenants that the party of the first part has not done or suffered anything whereby the paid premises have been encumbered in any way whatever, except as aforesaid. AND the party of the first part, in comp]iance with Section 13 of the Lien Law, covenants that the party of the first part will receive the consideration for this conveyance and will hold the right to receive such consid- eration as a trust fund to be applied first for the purpose of paying the cost of the improvement and will apply the same first to the payment of the cost of the improvement before using any part of the total of the same for any other purpose. The word "party" shall be construed as if it read "parties" whenever the sense of this indenture 5o requires. IN WITNESS WHEREOF, the party of the first part Itas duly executed this deed the day and year first above written. IN PRESENCE OF: ~r,.,~ LTD. , ~ ,N..i tt v~ 4.4' } 1:: J N G1 .a ~ _ ~ A O.' J i m J ti . 9 W N it 2 Q V7 Z R br'Y fj 1 o •a- tz ac S :L M ~~IL C z`i ~ m ~ ~L N yr ~ I O ~ ! p ' O A 0 ~ O T T ' m ,,.r,........u,. _ 'ox d~z 'VSSiT ~[.~0~ MB(y 'MOp22I.1 ~81?S ~CAiVdFiOJ ~01~[vu[1s1~iI p2oH abpi.~gMaN ii9 ~I.LI.L OflirJliHJ • CSSS ~ HOSSOZf SKY,(OHZ NHOr 6q paTnquTr;Q O{ i~ep[ ,(q Wn{aJ; ~i SS311EMtl30N0 31111 d0 OEtlOS NEOA MSN i0 WEOi OtltlONV1S i dNYdNJ00 HDNV11f1SNI fl7.L1.~. OOY~IH~ B~TM STLj }NOS`IIL~IKH )o {.anuaa {e ww~u • r FZS,I2I 3 NOZ'IIIAIKH • r 2InHS2IK xio33nS !xmo.t ao aixnoo •asz 'SJIKd (IIAEIQ 000'SOOI aoz 0 0 ' £ 0 ~~o~a •ox H7.LJ.I. • I NOT3.08S S.LOt/ S,EOINVE~ ,LSNIVOt/ 1NVNHAO',~ HlIM yy , ~ ~arar~ a~u~ puu uiu~r~u~ 11~JY a~1~L'I ~~'uatl1i7~~ ~ _ . : 8 a7~ ~;~~d )~~tll'OE ualiW Ya11dK"d wwl /':klunyj nectroN'LOIEISYON yioA NoN to ale1S'OllHnd AtlV10N NVW1H03tl VIHINAO / •o;slay; ssauJ~M se aweu y pagi3asgns awp awes ay; JE •1ap1o a>[~~ .Cq o;alayJ aweu s / y pau8{s ~q ;EyJ pllE 'uoiJ 'ssau;iM p~ES 'ay ;EqJ pue :awes a~{; a;naaxa -elodloa p~ES ;0 51o;aalip ;o p1EOq ay; ;0 1ap1o ,Cq paxld{e MES pUE ;uasald SEM 'SSOUJIM ~UIigl3aSgR5 p{ES `ay 3EyJ OS SEM JI JEyJ : ~EJS aJE10d10a yans 91 JUdU1n1JSUl p1E5 OJ liuawnlJSUi Eu~o8alo; ay; p'ainaaxn oyM pue u~ pagrlasap pax1,PE ~Eas ay; JEI~] :UOIJEiOdJOa piES ;o ~Eas ayJ sMOU~ ;enpinipu~ ay; aq o; ay Jeyi ; JuawnlJsu[ $mo8alo; ayJ pa;naaxa gmyM pue ui smouyay 3Eyi paquasap uo~Jelodloa ayJ ' ~~17 ~/~d ~/~~;o • o E sa isal a P P P P ~ 1N?(//~~~ ay; sl aq ;EyJ • N J p y ;ey3 ~es uE asoda i Moms ' ~/+~-~1 ~ ~~J/O~r ,C~np aw .Cq 8uiaq 'oym 'paluienboe ,i~~EUOS1ad wE I woyM y~~/ SN/~~ •oN JE sapisal aY{ Jeyi des yi!m JuawnlJsuj 8uco~alo; ayJ o; ,ssau;im ~uiq~losgns ay; pu xsodap ~p woms ~np aw .(q 5uiaq 'oym 'umou~~ aw of awEa .Cpeuoslad ^/SS~y~pr ~ ff <~/V~/~7 awEa 6peuoslad aw alo;aq ' 6I ;o .Cep ayJ u0 aw a1o;a9 ~ 6I ~Ysryl'e ;o .CEP ayi u0 ltf i0 A1Nf100 ')fYOA M1N i0 311I1t 1fS nkf.Sy~i~U d0 ALNII00 'M>tOA M!N d0 i1V1S I i •auies a ; aJnaaxa •awes a ; ainoaxa ;EyJ paBpa~MOU.yaE puE ';uawnl;su~ 8wo8aio; ay; painaaxa JEyJ paBpa~MOU~aE pue ';uawnaJsu~ ~uio5iao; ay; painaaxa oyM puE ui paquasap ~Enp~nipuu ayi aq of umou~ aw of oym pue ui paquasap ~enp~nipui ayJ aq o; umuu>f am of i i awEa 6~~euoslad awEa ~Cpeuoslad aw alo;aq ' 6I ~I ;o .Cep ayl up aw a1o;a9 ~ 6I 30 .CEP ayi u0 itf i0 A1N11~00 'J1710A MAN i0 Il~lf {ft i0 A1N000 'ilYOA MiN i0 71Y1S ' 8O~~d ~~©QZ. • BOARD OF HEALTH ~ • • - • 3 SETS O~PL.\NS FORMNO.t SURVEY TOWN OFSOUTHOLD CNECfi BUILDING DEPARTMENT SEPTIC PORCf . TOWN HALL j~~.~.a $OUTHOLD, N. Y. 11071 NOTIFY ~ TEL.: 7G5.1II02 CALL ..~SP.~J.'= + 1.7Q.?J . MAIL T0: E•xautincd(. i4!aV`.~.., 19 .J U . . . Approved `~^~}rt'.?b .7.., 19rJv Permit No.l.~.t~. [ ..n.C~.(p . Disapproved a/c P~~•~ • LI \J, ~y~~y • f n `\*/U/ (Boil ing Inspector) ftt`~tl/B~„t/•DG• nEP4• '{OWN OF 50U OLO APPLICATION FOR BUILDING PERl41lT _ Date 15 .rte. INSTRUCTIONS a. Titis application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 of plans, accurate plot plan tlFSCale. Fee according to schedule. b. Plot plan showin; location of lot and of buildings on premises, relationship to adjoining premises or public streets rcas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- o n. c. The work covered by this application may not be commenced before issuance of Building Permit. , ;I. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such permit ;1 be kept on the premises available for inspection throughout the work. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy :.i ::ave been granted by the Building Inspector. i'PLIC,\TION IS HEREBY MADE to the Bui]ding Department for the issuance of a Building Permit pursuant to the "Lone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or ..~::ons, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. I:cant a;rees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to :ut: onzed inspectors on premises and in building for necessary in ns.~~,y-/,`It (Signnature or"np li~~a'rftQ,oyn~ na eL4-w~ ~ a'rr p .ratron).. . Mailing ddress of applicant} ..;ether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ~wN~Q' _ a ~J(Z7.f-~?~~• ~!~,~+~trLi~^!...~..~~"t~i...~~. ~~~s~i~; t ff~°s w~FF . otvner of premises . (as on the tax roll or latest deed) ~r.t is a corporation, signature of duly authorized officer. ' ...................~~.j......... (Name and title of corporate officer) ;,Icr's License No . ::nbcr's License No . _:;rician's License No . ' :':cr Trade's License No . . ' ,.:aeon of land on which proposed work bvill be done: ' Nuntbcr Street Hamlet ..::nty Tax i\lap No. 1000 Section 9 • • • • • • • • • Block ~ , , • Lot .....J~........ ' ,,t:,fivision Filed ~fap No. Lot . ..INantej . 'aac existing use and occupancy of premises and intended use and occupancy of proposed construction: I ~71MrL'.1,.~w~Lt-rtiG- A. Existing use and occupancy.... ••••••••,r••• B. Intended use and occupancy........ 1 ~1 - _ Nature'of work (check which applicable): New Building Addition Alteration . Repair Removal Demolition ..............Swimming pool............ Tennis Cour[ Accessory Building..........I'ehce .......Other [fork............ . Estimated Cost Fee (to be paid on filing this application) if dwelling, number of dwelling units Number of dwelling units on each door . ICgaragc.numbcrofcars lC business, commercial or mixed occupancy, specify nahuc and extent of each type of use . Dimensions of existing structures, iC any; Front . Roar Depth . . Hciaht Numbc'Ir of Stories . . Dimensions oC same structure with., alterations or additions: Front Roar , . Depth . . Height ......................Number of Stories , . Dimensions oC entire new constntc~tion: Front Rear Depth , , , , , , , , , , , , , , Height t:'ttt u. umber of Stories . Size of lot: Front .......=~'1~~ ~..I......... Roar Depth Date of Purchase •s ~i;;n r-, r ~ ................Name of Former Owner . Zone or use't{isrt~ . i<~ 1~t ~tt~)p~'+ It pr~mises are situated . . Does proposed construction"vtolatG any zoning law, ordinance or regulation : . . ~~ill Sot be regraded Nill excess fill be removed from premises: ,Yes , No . . Name of Owner of premises . ..........Address ...................Phone No............... . . ,`:amt of Architect ..............Address ...................Phone No................ . Name of Contractor , ' ......Address . .Phone No.. . ..Is this property loo~Ced within 300 feet of a tidal wetland? *YES....NO.... °If yes, Southold Town .Trustees Permit may be required. PLOT DIAGRAM ecate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions from :;ty lines. Give street and block number or description according to deed, and show street names and indicate whether •::or or comer lot. I, II . ~I ~)I' \EN YORK, S.S i Y OF being duly sworn, deposes and says that lie is the applicant (Name of individual signing contract) ;:~mcd. .:Ito,,,,,,,,,,,,,,,,,,,,,,,,; ,,(Contractor,agcnt,corporatcoCficcr,etc.)~•~~~~~~~~~~~~~~~~•~~~~~~~~~ owner or owners, and is duly ajtthorized to perform or have performed the said work and to make and file this r_uon; that all statements contained in this application arc trot to tltc best of his knowledge and belief; and that the ~•4v11 be perl'omtcd in the manner sett forth in the application filed thcretvittt. t 'm to before me this ~ ~ ......................day of ..{..................,19... tiry Public . , County I, ~ • • , . • • . • ' • • • • . (Si;nature.of apPlicant7 . • I,