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HomeMy WebLinkAbout19055-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY NO Z-23010 Date MAY 23, 1994 THIS CERTIFIES that the building FOUNDATION & ADDITION Location of Propert~ 2900 GP~/~D AVENUE MATTITUCK, N.Y. House No. Street Hamlet County Tax Map No. 1000 Section 107 Block 2 Lot 5 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated MAY 24, 1990 ~ursuant to which Building Permit No. 19055-Z dated MAY 29, 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 NEW FOUNDATION & ADDITION TO EXISTING ONE FAMILY DWELLING AS APPLIED FOR. The certificate is issued to of the aforesaid building. JOHN A. & EDNA POLYN (owners) SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL UNDERWRITERS CERTIFICATE NO. PLUMBERS CERTIFICATION DATED Rev. 1/81 N/A N-273295 - APRIL 21, 1993 N/A · 0~ NO. ~ TO~N OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Yo BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) NO- '~ 9055 Z Permission is hereby granted to: ./0~~ .~.?..~.....~.~.! ................................................. ~... ~ ~.u.~ ,~ ."1, to ..~.~....~,..~).~....~.~....~.....~.....s~/.~...T.~....-..~=.. .... at premises located at ...~.~.._...L~,,~....~M;~J~.,....~~ ...................... County Tax Map No. 1000 Section ..... ,J,,,~..,.~ ......... Block ..... O...~.,.. ........ Lot No ..... .~..~. .......... pursuant to application dated .............. :.~. ...................... 19..~L°..., and approved by the Building Inspector. Rev. 6/30/80 Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN ~ALL 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 architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and '7pre-existing" land uses: I. 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 Buildin~ - $100.00 3. Copy of Certificate of Occupancy - $20.00 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 House No. Street Hamlet County Tax Map No 1000, Section ....... )g.~_Block...Cr. ........... Lo¢.~ ............. Subdivision .................................... Filed Map ............ Lot ............. ~..~u~.~, Permit ..... Date Of Permit.~- ..... ~..l~.~pplicant .......... ; .................. Health Dept. Approval .......................... Underwriters Approval ........... Planning Board Approval ..................... ../.. Requestfor: TemporaryCertificate ...... [JJ.. inalCerticate ...... Fee Submitted: THE NEW YORK BOARD OF FIRE UNDERWRITERS [~. ~.~i~*'~.9 BUREAU OF ELECTRICITY ~- 85 JOHN STREET, NEW YORK. NEW YORK 10038 TMI~ GERYI~IE~ THAT o~y tNe e~ctrtcal ~ulpment ~ ~scrlbed be~w a~ int~uc~ by t~ ap~icant ~mod on the a~ve application numar in the p~mises of ~s examined on and found to be in compl~nce with the NaHonal Elect~cal Code. Lot fiXTURE EIXTURE$ RANGES OVENS DISH WASHERS EXHAUST FANS OUTLETS SWITCHES FLUORESCENT OTHER 10 8 ~0 DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS TIME CLOCKS UNIT HEATERS MULTI-OUTLET SYSTEMS NO. OF FEET DIMMERS SERVICE DISCONNECT S E R V I C 10 }ERCflTR~L · /..~r~AL M&NA~EII This certificate must not be altered in any manner; return to the office of the Board if incorrect. I~spectors moy be identified by their credentials. COPY FOR BUDDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER. Town Hall, 53095 Main Road P. O. Box 1179 Southok:l, New Yolk 11971 Fax (516) 765-1823 Telephone (516) 765-1802 OFFICE OF THE BUILDING INSPECTOR TOWN OF SOUTHOLD May 11, 1994 Mr. & Mrs. John Polyn 2900 Grand Ave. Mattituck, NY 11952 To Whom This May Concern: We are unable to complete your Certificate of Occupancy because of the following reasons: xx An application for Certificate of Occupancy is not on file. (Enclosed) No Underwriters Certificate on file. xx The check is not on file. S25.00 No Health Department Approval on file. No final inspection has been made. No Plumber Solder Certificate on file. (All permits involving plumbing being issued after April 1, 1984). BUILDING PERMIT # 19055z Please contact our office on this matter. cooperation. Thank you for $OUTHOLD TOWN BUILDING DEPT. THE NEW YORK BOARD OF FIRE UNDERWRITERS eAs : .t 185077 BUREAU OF ELECTRICITY ~-- 8~ JOHN STREET, NEW YORK, NEW YORK 10038 Oete ~'E}'tRtJ'AR'~ 03; 19[)5 /Jpplication ~o. o. file ~5'1. B3794/94 N 341 ~594 THIS CI=RTII=IE$ THAT only the electrical equipment as described below and introduced by the applicant named on the above application number in the premises of ,JOHI~I P )LX/N 2900 GRgND AVI/IN[~ ~ i'~'I!TITUCI< ~ N'. Y~ in the fotiowing location; [] Base~nent [] Ist Fl. [] 2nd FL O[~'J~' Section Block ~s examined on O'I~.[IP~F~Y 30,1995 FIXTURE OUTLETS RECEPTACLES 17 SWITCHES FIXTURES INCANDESCENT FLUORESCENT 10 5 2 DRYERS and found to be in compliance with the National Electrical Code. RANGES OVENS OTHER OTHER APPARATUS: SHOK~ DETECTOR, .- 1 SYSTEMS NO. OF FEET E R V I C E 4 ROSIa%K BLFJ..TRIC LIC. #3677-E P.O.BOX 164 CUTCHOG[I~I, NY, 119.35 ~t~A[ MANAgeR :11 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. ~.I£LD~-i~S Y ECT i0N FOUNDATION (1st) FOUNDATION 2. (2nd) ROUGH FRAME & .FLUMBING INSULATION PER N. STATE ENERGY CODE FINAL ADDITIONAL COMMENTS: z ~ I ~1~UILDING DEPT. INSPECTION 765-1802 BUILDING DEPT. INSPECTION FOUNDATION 1ST [ ] ROUGH PLBG. FOUNDATION 2ND ~'NSULATION FRAMING FINAL 765-1802 BUILDING DEPT. .INSPECTION FOUNDATION 1ST FOUNDATION [~FRAMING REMARKS: DATE ROUGH PLBG. INSULATION FINAL 'INSPECTOR 765-1802 BUILDING DEPT. ,INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [~SNSULATION [ ] FRAMING FINAL REMARKS: / DATE. ~ 7 / ~n. ',.s,'"CTO. ESTAB. 1872 WILLIAM t- JAEGER II P.E., I-S. RONALD E. HARTMANN L.S. RICHARD A. SMITH R.A, January 21, 1994 HAWKINS WEBB JAEGER ASSOC. P.C. ENGINEERS - ARCHITECTS - SURVEYORS - PLANNERS 200 EAST BROADWAY, PORT JEFFERSON, NEW YORK 11777 PHONE (516) 473-1900 FAX (516) 473~}486 FRANCIS A. HAWKINS 1913 HERMAN P. HAWKINS 1962 CHARLES S. WEBB JR. Mr. & Mrs. John Polyn 2900 Grand Ave. Mattituck, NY 11952 Re: Project No. 93-0891 Structural Inspection Dear Mr. & Mrs. Polyn: On November 30, 1993 my firm performed a re-inspection of your residence under construction at the above address. An initial inspection was performed by this firm ~-, 1990. This inspection revealed defects in construction related to structural stability and poor workmanship. The current inspection confirmed that all defects observed during the first inspection were corrected by the contractor. These corrections included the leveling of the floors and reinforcing the structural support system for the residence's configuration. If you have any~ further questions regarding the inspection, please feel free to contact this office. Sincerely, Richard A. Smith R.A., RAS: j am A.I.A. INSPECTORS (516) 765-1802 VICTOR LESSARD, Principal CURTIS HORTON, Senior VINCENT R. WIECZOREK, Ordinance ROBERT FISHER, Assistant Fire Building Inspectors THOMAS FISHER GARY FISH OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD May 23, 1991 SCOTT L. HARRIS, Supervisor Southold Town Hall P.O. Box 1179, 53095 Main Road Southold, New York 11971 Fax (516) 765-1823 Telephone (516) 765-1800 Mr. John F. Magas Department of Consumer Affairs Veterans Memorial Highway Hauppauge, N.Y. 11788 Re: Mr. & Mrs. John Polyn - Building Permit 919055 Dear John: Enclosed is a copy of a letter I sent to Mr. & Mrs. John Polyn regarding the final inspection I did on there house May 10, 1991. As you can readily see by the content of the letter I have requested that a letter be submitted to the Building Department by a licensed architect or engineer. The letter must address the recommendations requested by William L. Jaeger II P.E. , L.S. I have also contacted Richard Larsen and informed him that there is quite a large discrepancy between the contract price and the amount he put on his Building Permit application. He has been informed that a stamped set of plans are required for the job, being that it exceeded $20,000. His contract, which Mrs. Polyn provided me with a copy, reads over $30,000.00 ~orth of renovation. I would appreciate any type of assistance you could provide me with regarding this matter. If there is any way I can help you further, please feel free to call me at 765-1802. It is best to call between 3:30 and 4:30 in the afternoon as I am on the road doing inspections most of the day. Sincerely, SOUTHOLD TOWN BUILDING DEPT. Building Inspector GJF:gar encl. INSPECTORS (516) 765-1802 VICTOR LESSARD, Principal CURTIS HORTON, Senior VINCENT R. WlECZOREK, Ordinance ROBERT FISHER, Assistant Fire Building Inspectors THOMAS FISHER GARY FISH OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD SCOTT L. HARRIS, Supervisor Southold Town Hall P.O. Box 1179, 53095 Main Road Southold, New York 11971 Fax (516) 765-1823 Telephone (516) 765-1800 May 20, 1991 Mr. & Mrs. John Polyn Re: Building Permit 919055Z final inspection of and conditions to be met prior to issuance of a Certificate of Occupancy Dear Mr. & Mrs. Polyn: After conducting a final inspection on May 10, 1991 and careful consideration a Certificate of Occupancy can not be issued for Building Permit #19055 until a number of conditions are resolved. Firstly, there is the outstanding matter of an engineers report, signed by a William L. Jaeger II P.E., L.S. dated November 8, 1990. In this report he makes a number of recomendations. These recomendations are made to correct problems that he sees as both structural and cosmetic in nature. Before a CO can be issued these recomendations must be taken care of and a letter from either the same licensed engineer or a similar qualified engineer or architect must be forwarded to the Building Department. There are also a few conditions that exist that are not mentioned in the engineers report. One of them being the fact that the 3" waste line that was temporarily installed has a Y coming down from the toilet fixture and flowing in the direction of the cleanout. It is apparent that it was installed improperly with the waste water flowing in the wrong direction. It was stated by the contractor, a Mr. Richard Larsen that the waste line was a temporary hook up and that a new waste pipe system was going to be installed when his part of the job was complete. As you know, I have been in contact with a Mr. John F. Magas from Consumer Affairs. I will be forwarding a copy of this letter to him along with an inspection report. Mr. Larsen will also be receiving a copy of this letter. I would also like to remind you at this time that it is unlawful to occupy that part of the building under construction covered by the Building Permit. A CO must be obtained before that part of the building can be occupied. In closing I hope for a speedy resolve to this matter. If you have any questions or if I can help within my capacity as a Building Inspector for the Town of Southold, please call be at 765-1802 anytime between the hours of 8:30-4:30 Monday to Friday. Sincerely, SOU~OLD TO~WN BUILDING DEPT. GariSh. Fish Building Inspector GJF:gar cc to: Mr. John F. Magas Mr. Richard Larsen INSPECTORS (516) 765-1802 VICTOR LESSARD, Principal CURTIS HORTON, Senior VINCENT R. WIECZOREK, Ordinance ROBERT FISHER, Assistant Fire BuiJding Inspectors THOMAS FISHER GARY FISH OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD May 31, 1991 SCOTI' L. HARRIS, Supervisor Southold Town Hall P.O. Box 1179, 53095 Main Road Southold, New York 11971 Fax (516) 765-1823 Telephone (516) 765-1800 Mr. Richard Larsen Box 251 Wading River, N.Y. 11792 Re: Building Permit %19055-Z Premises: 3000 Grand Ave., Mattituck, surf. Co. Tax Map %1000-107-02-05 NoYo Dear Mr. Larsen: Enclosed please find a copy of the letter that I sent to Mr. & Mrs. Polyn dated May 20, 1991. As you can readily see, the project is going to have to have an okay by Mr. Jaeger or a similar qualified engineer or architect. Very truly yours, SOUTHOLD TOWN BUILDING DEPT. GJF:gar encl. Gary J. Fish, Building Inspector INSPECTORS (516) 765-1802 VICTOR LESSARD, Principal CURTIS HORTON, Senior VINCENT R. WIECZOREK, Ordinance ROBERT FISHER, Assistant Fire Building Inspectors THOMAS FISHER GARY FISH OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD SCOTT L. HARRIS, Supervisor Southold Town Hall P.O. Box 1179, 53095 Main Road Southold, New York 11971 Fax (516) 765-1823 Telephone (516) 765-1800 May 20, 1991 Mr. & Mrs. John Polyn Re: Building Permit 919055Z final inspection of and conditions to be met prior to issuance of a Certificate of Occupancy Dear Mr. & Mrs. Polyn: After conducting a final inspection on May 10, 1991 and careful consideration a Certificate of Occupancy can not be issued for Building Permit ~19055 until a number of conditions are resolved. Firstly, there is the outstanding matter of an engineers report, signed by a William L. Jaeger II P.E., L.S. dated November 8, 1990. In this report he makes a number of recomendations. These recomendations are made to correct problems that he sees as both structural and cosmetic in nature. Before a CO can be issued these recomendations must be taken care of and a letter from either the same licensed engineer or a similar qualified engineer or architect must be forwarded to the Building Department. There are also a few conditions that exist that are not mentioned in the engineers report. One of them being the fact that the 3" waste line that was temporarily installed has a Y coming down from the toilet fixture and flowing in the direction of the cleanout. It is apparent that it was installed improperly with the waste water flowing in the wrong direction. It was stated by the contractor, a Mr. Richard Larsen that the waste line was a temporary hook up and that a new waste pipe system was going to be installed when his part of the job was complete. As you know, I have been in contact with a Mr. John F. Magas from Consumer Affairs. I will be iorwarding a copy of this letter to him along with an inspection report. Mr. Larsen will also be receiving a copy of this letter. I would also like to remind you at this time that it is unlawful to occupy that part of the building under construction covered by the Building Permit. A CO must be obtained before that part of the building can be occupied. In closing I hope for a speedy resolve to this matter. If you have any questions or if I can help within my capacity as a Building Inspector for the Town of Southold, please call be at 765-1802 anytime between the hours of 8:30-4:30 Monday to Friday. Sincerely, SOb"D~OLD TOWN BUILDING DEPT. Gary ~F. Fish Building Inspector GJF:gar cc to: Mr. John F. Magas Mr. Richard Larsen Richard Larsen Const.Co. Inc. Box 251 Wading River NY 11792 Contract made this day between Richard Larsen Construction Mr & Mrs John Polyn,residing at Grand Ave Mattituck,NY. To of a new basement and two additions to the above residence. Co and consist Ail construction to conform to a set of plans a'nd speciflcation's attached to and made a part of this contract. Construction to begin within one week of a building permit approval,' and to take aproximately one to two months to complete. P~yment schedule is as follows. a. Upon beginning of excavation .$7,950.00 b. Upon completion of half of block walls $6000.00 c. Upon completion of all block walls and floor .$6000'~'00 d. Upon completion of rough carpentry of both extensions e. Upon completion of both extensions $3850.00 f. Upon completion of backfill,cleanup and all construction and electrical work .$3000.OO Total Price $31,800.00 Richard Larsen SPECIFICATIONS CUSTOMER Mr&Mrs John Pglyn-Grand Ave~Mattituck NY Foundation-Full basement,12 courses of 8x16 cement block,Bilco entrance door,steel lolly columns every seven feet on girders,four Andersen utility basement windows,four inch thick floor,as per plans. Extensions-Carpentry,roofing,insulation,sheetrock as per plans. Interior paint two coats of latex flat white.Guttgrs seamless white. E~ectrical_Basement four ceramic light bulb fixtures(on switch) Extensions as per code(light over door,one ceiling light per extension,two exterior plug fixtures~If existing circuit panel is inadequate customer will pay extra to have it upgraded. f Lt, IIy c_ol,,,mt4f ~' ..................... ~ BOARD OF HEALTM ; , FORM NO. 1 SURVEY ............. TOWN OF SOUTHOLD CtlEC[ ~.l~m ................ ~ BLDG. DE~. BUILDING DEPARTMENT SEPTIC FORH ....... TOWN OF SO.OLD TOWN HALL ......... ~'~ ~OUTHOLD. N.Y. ~1071 NOTZ~Y ~ Ex~mi~d ..... MAIl TO: o ...................... proved . . ., . Pe~it No. . ... Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRU~IONS a. Tl~s application must be completely HIIed in by ~pewfiter or in ink and submitted ~o the Buildi~ ~ector, with sets of ~lans, accnrnte plot plan to scale. Fee according to schedulo. b. Plot ~1~ showinE location of lot and of buiI~s on ~remises, relationshi~ to adjoinin~ ~remi~ or pubHc streets or areas, and ~iv~g a det~led description of layout of ~ro~erty must be drawn on the diagram which ~a~ of t~s ~. The work covered by tMs a~licaHon may no; be commenced bofore issuance of. Bufldin~ Peril · ' d. U~on a~roval of thi~ a~lic~tion, the BuHdin~ Inspector will issued a Buildin~ Pe~it to the app~ ~sh~ll b~ ke~t on the ~remises available for inspection throu~out the work. ' ~. No build~g shall be occupied or used in whole or ~n part for ~ny purpose whatever until a CeHifl~ of Occu~cy shall have been grated by ~e BulldOg Inspector. ' APPLICA~ON IS HEREBY MADE to the BuHd~ DeCrement for the issuance of a B~dinE Pe~it ~u~uant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, ~d other applicable ~. Ord~ce~ or Regulations, for the construction of b~d~gs, addition~ or ~lterations, or for ~emoval or demolition, ~ ~re~ d~sc~bed. Tim a~plicant agrees to com~ly with all n~lica~e laws, ordinances, bufld~ coOe, housin; code, an~ r~hdons, anO to admit authodzed ~specto~ on premises and ~ build~g for necessa~ ins~~~ ...... ~C~f;~.~ '..~~ ....... (Signature of ~pplicant, or nam e, if a corpor~mn}' ' ' (Mailin~ ~ddress of applic~t) Stat~~a~ a~ent, ~chitect, cn~ineer, general contractor, electrician, plumber or builder. Name or owner of premises J 0~ (~s on th~ tax roll or l~lest deed) I~ ~ppHca~t i~ ~ co~mdon, signature of duly ~ulhofized of~cer. Builder's License No ..... l ~o.5~1').. l../~- .......... Plumber's Liccnse No Electrician's License No ...................... Oil rTr d ' '~eI.i No Location of land on which proposed work xvill be done: llouse Number ' Street, ' Hamlct ....................... Counw Tax Ma o 1000 S~ction ............... · Block ...... Lot " bdi ........... "' "~ ' ' Su vision .............................. , ...... ~iled Map No. (Name) .............. Lot ......... State existing use and occupancy of premises and intended use and occupancy of proposed conslrucliom , -- a. Existing Usc and occupancy ~w~ ~ ~/~ ~ . . ................... - ................. ~ J~., ~ 3t~&.~3 · ~ ......... '~ --~ , ~t~ ~,~0>? ~z~'l~q ~t~ ........... 3. Nature o£ work (check wh ch applicable): New Building ......... Addition ........ ~l~t'on ........... RepeaT. ............. Rl~moval ............. Dcmohtmn .,. ..; ..... ~z.ra~n,,, poet ............ 4. - .... ........ F-- ' ' .. 5. If dwelling, number o£ d~vclling units . tg/./~/~/],,~?./[.~. (to be paid on filing this application). ............. Number of dxvelling 'units on each floor ................ Irgara~e number of cars ' 6. If business, commercial or mixed Occupancy, specify nature and extent o f each type of use . 7. D mens ons of ex~stmg structures,;ff any: Front ........... Rear ............. H,cight ............... Number of Stories .... ~ ..................................... Dunensions o£sama structure ,v,ta alterations or additions: Front D. pth .. .................... ,. I:Imght ...................... Numbcr,of Stones ................ H L-, ~t ........... o ....iS[,umb~r of Stories .... ~. '.~ .-C(.~.~.~..~.-.-.~. .......................... 9. Sizeo£1ot: Front ...cY...~?:.~./.: ,' ~, ~-J-~9~ " ' no,,h .~_/2,~ ...... 10. Date et urchase ....... ./.7'.0.0. ............... .15/amc of Former~Owner ...................... I I. Zone or use district in whic 12. Does proposed Construction violaie any zoning law. ordinance or regulation: ... ~..d2 .................. x _. ...... 13. Will lot be regraded ·; ..... ,.~..~?.. ~ .............. Will excess fill be removed from r~remises:_ Yes .r'~... Ne. 14. Name of Owner or premises dp.r'(.~../..m./2,,,4<...' ...... Address .~/-.~..g..~. ~..S~'.'.'.'.'.'~'.//..'?.m~. ('~'mne No..2~.'~'..?.~.~.,O. .... Name'of Architect ........... Name of Contractor ~j~//~,~.,~.' 15.Zs this property locat!ed within 100 feet of a .tidal wetland? ~YII$ .... NO,~2.. ~If yes, Southol. d Town [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 tines. Give street and block nhrnber or description according to deed, and show street names and indicate whether interior or corner lot. ScotC~}~.* 7660 ,,post.it" Telephone Message p~d Da WHILE, YOU WERE OUT ~~___WAS iN re $~:£ yoU operator STATE OF NEW~Rk-C7~- I ~- ! COUNTY OF....~..~..'~-~... 1.[~. ~,S ................................................. being doly sworn, deposes and says that he is the applicant (Name of individual signiitg contract) above nar~cd. Hc is the i ' ' ;' i; 'ir' ~:v'n' 51,'and'";i .......................................................... '?'~~ agent, corporate officer,' etc.) , ' :'"' of said o n e dulg authorize~,rform or irate performed the said work and to make and file this application; that all statements contai,md in this applic:~tio,t are true to the best of his knowledge and belief; and that the work will be performed in the manneriset forth in thc application filed therewith. S~vorn to before mc this ~ · ; 'c " NO, 4879505 Qualified in 8uffolklCeun~J Commission Expire~ De~nblr 8, le~-~ (Signature of applicant)