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FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No Z-18750 Date JANUARY 29, 1990
THIS CERTIFIES that the building ADDITION
Location of Property 425 MONSELL LANE CUTCHOGUE NEW YORK
House No. Street Hamlet
County Tax Map No. 1000 Section 97 Block 8 Lot 27
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated AUGUST-26 1985 pursuant to which
Building Permit No. 17318-Z dated AUGUST 17, 1988
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 ATTACHED INGROUND SWIMMING POOL WITH FENCE ENCLOSURE AND
DECK TO CONDITIONS OF ZBA APPEAL #3396.
The certificate is issued to GARY DOROSKI
(owner)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE N0. N-08471-8/3/89 & N-084714-8/3/89
PLUMBERS CERTIFICATION DATED N/A
Building Inspector
Rev. 1/81
rosat< 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 Q 017 31 ~ Z Date .....~~/..7 19.~.~~
Permission is hereby granted to:
r ~ / ro- a-
ct premises located at ....t~t'..r~.s`d.~...^^..'Tl,~~d.~`t.-L~......tL~
..............................................~~A•
County Tax Map No. 1000 Section Block Lot No ..............T.......
pursuant to application dated S~'+t~/e>~~ ~ 19........, and approved by the
~ ~ js~~e~e
Building Inspector. ~pxx2 EGG, ~/7/~~
Fee `t ~ ~ 50
(ding I ector
Rev. 6/30180
- , ,
TOS1N OP SOUTIIOLD ~ ~ ~ ~ ~
BUILDING DEPART:lEi7T 2
TOLlN QALL
' SOUTBOLD, NEN YORK 11971 DG.'UEP~i.
' TOVV~i OF SOUTNOLD
765 - III02 ~ -
i
APPLICATION FOR CERTIFICATE OF OCCIIPANCY
NEW CONSTRUCTION .......OLD OR PRE-E%ISTItlG BUILDING_ VACAtlT LAND........
LocaCion of Property... L~a~Mon~S-c.~~• Lc` _.-_-.•~-~-c.~ho4.-e,
4
UOUSE NO_ " " "
~~S~TP.EE/T~ UAMLET
Ovner or Ovncrs of Propcrty.....~~~ '~-"'~~S~SI '
County Tas Hap No. 1000 Section ~ ~ ~ o`Z
Block Lot'.........
Subdivision Filed Map ........Lot_._.......
Permit No. 01318 g (SAS ~orU
•••-._..pate of Permit .._.......AppLicant _ ~ Sk'
Health DepC. Approval Undcrvriters Approval ~ ~ g y
PlaaninE Board Approval
Request for Temporary Certificate Final Certificate
~1a s'. .
Pce Submitted: $
APPLICANT..
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' _ . FORM NO. 6
TOWN OF SOUTIIOLD
('q,'~"~; ~ BDILDING DEPARTMENT
TOWN ITAL.
765 - 1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY INSTRUCTIONS
A. This application must bje filed in typewriter Oft ink and submitted~to the Building
Inspector with the following; for new buildings 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 of De~alth Dept. of eater supply and sewerage-disposal(S-9 form).
' 3. Approval of electrical installation from Board of Pire Undervritcrs.
4. Sworn statement from plumber certifying that solder used in system contains less'
than 2/10 of 1Z lcad~. ,
5. Commercial buildings'y industrial buildings, multiple residences and similar.
buildings and installations, a certificate of code compliance from the 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" landluses:
I. Accurate survey of property showing all property lines, streets, buildings and
unusual natural of topographic features.
2. A properly completed' application, a consent to inspect signed by Che applicant
and a certified abstract of title issued by a title company which shall
show single and separate ownership of the entire lot prior to April 9, 1957.
,If a Certificate of ,Occupancy is denied, the Building Inspector shall state the
reasons therefor in r+riting to the applicant.
3. Date of any housing node or safety inspection of buildings or premises, or other
pertinent information required to prepare a certificate.
C. For Vacant Land Certificate of Occupancy:
1. An application for vacant Land Certificate of Occupancy shall be submitted,
and a certified abstract of title issued by a title company showing single and
separate ownership o,f~the entire lot prior to April 9, 1957 shall also accompany
the application. I£ a Certificate of Occupancy is denied, the Building Inspector
shall state Che reasons therefor in writing to the applicant.
D. FEES:
1. CERTIFICATE OF OCCUPANCY - New Duelling $25.00, Additions to Dwelling $25.00,
Alteration to Dwelling $25.00, Swimming Pool, $25.00. Accessory building $25.00
Addition to Accessory buildings, $25.00 -'Businesses $50.00.
2. Certificate of Qccupancy on pre-existing dwelling - $100.00.
3. Copy of Certificate of Occupancy - $5.00 - over 5 years - $10.00
4. Vacant Land Certificate of Occupancy - $20.00 i
S. Updated Certificate of Occupancy - $50.00
6. Temporary Certificate of Occupancy -$15.00 Residential `
Commercial
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P~41 YOfii: STATL DFPA.'"T:~ET'T OP ETTVIS:OI?I:Er1TAL COMSERVATIOil
Pegulatory Affairs Unit
Eldg. k0, SUNY--P.oom 219
Stony ~roolc, T'Y 1179k
(516) 751-7900
February 13, 1986
Mr. Gary Doroski
42g Monsell Lane
Cutchogue, N.Y. 11935
F.E: 1'0-85-1109
Dear Mr Doroski:
A xevlev° has been made of your proposal to:
Construct a 20'x40'Swimming pool with surrounding deck all
parts of which are to be landward of the existing 10'contour
elevation in accordance with plan on survey by A.VanTuyl 1/14/86
Loc do (1?evised date)
Wes of•Mud Creek,east of Monsell Lane, Cutchogue, N.Y.
Suff. Co. Tx. Map No. 1000-9~-8-2~
Necv Yoxlc State Department of Environmental Conservation has found the
_ parcel xxx pro3ect to be:
Cxeater than 300' from inventoried tidal wetlands.
_ Landward of a substantial man-made structure•
greater than 100' in length constructed prior to September 20, 1977:
xxx Landward of 10' contour elevation above mean sea level oa a gradual,
natural slope.
_ Landward of topographical crest of bluff, cliff or dune in excess
of 10° in elevation above mean sea level.
Therefore, no permit under Article 25 (Tidal ?4etlande of the Environmental
Conservation La*,•~) is required at this time since the current proposal is
beyond State mandated ~urisdictian pursuant to this act. `locrever, any
additional caork or modifications to the project may require a permit. It
is your responsibility to notify this office, in writing, if such
additional work or modifications are contemplated. There is to be no placing
of excavated material, fill or other disturbance seaward of the 10'
contour shown on said plan. Very ~~t~xuly youra,<
C..,..~bCia~ 1 ,
Alternate Permit Administrator
CTI?: DDR : co's
768-1802
~ BUILDING DEPT.
1 PE TI N
NS C O
~I~' ]FOUNDATION 1ST ~ ] ROUGH PLBG.
]FOUNDATION 2ND [ ]INSULATION
]FRAMING [ AL
i~EMARKB: ~o ~
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T""'_"
BATE IN8PECT0 ~ ~
765-iS02
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION 1ST [ ] (ROUGH PLBG.
[ ] FOU DATION 2ND [ ]INSULATION
[ ~~FINAL
^.~L- ~
REIIAARKS: C~ f~
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DATE ~ INSPECTO
765-1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ]INSULATION
[ ]FRAMING [ ]FINAL
REIVIAR 5: ~~/,~~t~-
`9'Z._~ ~
DATE INSPECTOR ~
~®~UFF~U~eoG
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~ TELEPHONE
(516) 765-1892
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Town Fall, 53095 Main Road
P.O. Box 728
Southold, New York 11971
September 3, 1985
Mr. Gary Doroski
425 Monsell Lane
Cutchouge, New York 11935
Re: Pool Construction
Dear Mr. Doroski:
As per your request for a determination on the need of
a wetland permit, regarding the above referenced matter,
please be advised that the Trustees have reviewed your plan
on August 28, 1985 at a regular meeting of the Board and
determined by resolution that no permit is needed subject
to the following provisions:
1. During excavation the fill must be contained so
that it does not wash into the creek.
2. All discharge from the pool is to be kept out
of the creek.
3. Immediately following construction, all areas of
exposed soil shall be properly protected with a
suitable erosion control device and/or vegetated to
prevent entry of eroded soil into the nearby waters.
If you have any questions, or need additional information,
please do not hesitate calling this office at the number listed
above.
Very truly yours,
1~~ ~ ,~riu-~ ~
Henry P. Smith, President
Board of Town Trustees
HPS:ip
cc: Building Dept.
Trustees
file
THE NEW YORK BOARD OF FIRE UNDERWRITERS p~'`'
fQ03~593 BUREAU OF ELECTRICITY
65 JOHN STREET, NEW YORK, NEW YORK 10038,
Date ~CI{,i{f(i'f' fii „l~$y APPlication No. on file £;L sf)36R<3Jfl.~.~ °f`f ~~{k ~.I~
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced 6y the applicant named on the above application number in the premises of
~iARa llI:JRC1tk7., x,75 ~~C1t~{SFi,tl[I 3,11R$', fiilr~,#e}, t'tTPCfdt~Gtf1+:, (~_Y.
()if'i'
in the ollowin location; B ent ? lat FT. ? 2nd F'l. 3ertion Bork Lot
f a ,itlJrY 9 7~°k>'*1
uws examined on andfound to be in conep[iarreo with the requirernen6r o/this Board.
FI%TURE ECEPTAClES SWITCHES FIXTURES RANGES COOKING DECKS OPENS DISHWASHERS EXHAUST FANS
OUTLETS INCANDESCENT FWORESCENi OTHEH AMT. K W AMi K W. AMi. KW. - qMT. K.W. AMi. H P
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIME CLOCKS gELL UNIT HEATERS MULTI-OUTLET DIMMERS
AMi. K W. OIL H.P GAS H.P. AMi. NO. A.W G AMT AMP. AMT. AMPS. TRANS, pMi H P, SYSTEMS pMi. WATiS
NO.OF FEET
SERVICE DISCONNECT NO.OF S E R V I C E
METER NO, OF CC COND. A W. G. A, W G. A W G.
AMi AMP, TYPE EONF I,e' 4W I $ JW 3 %TW 3 B 4W pER % OF CC COND. NO Of HbLEG OF HbLEG NO. OF NEUTRAIS OF NEUTRAL
OTHER APPARATUS:
<i~rJ Mf3NSEiLi, CrPF.
C.(ii'e7f{c)t9(fA?, fVY> ~,;1934i GENERAL MANAGER
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.
COPY FOR BUILDING DEPARTMENT. 7NI5 COPY OF CERTIFIGATE;MUST NOT BE ALTERED IN ANY MANNER.
r
THE NEW YORK BOARD OF FIRE UNDERWRITERS
f.t?O rQs).) BUREAU OF ELECTRICITY
63 JOHN STREET, NEW YORK, NEW YORK 10038
Date AffGYf,">'~' 47 •1_~)~~? APPlication No. on file 1"i3'~5~;dn$f~f Ff'~ X~ ~~4'i';(. v'~
THIS CERTIFIES THAT
only the a/ectricol equipment as deacrihed below and introduced 6y the applicant Homed on the above opplicotion numher in the premises of
GACtY I)JRL7iK~T, 4,7,5 f~(7P3,LP;?~Sa ILAYQk;, N!?IL(f:{$4, C"t7"(`t"f1f)~rfJT~, T+LY,
in tke ollowin Iocati a ent C)fX'~~
f B ? {st Fl. ? 2nd F'l. Section Block Lot
JP~LY ~,~~'i~73
was examined on aredfound w 6e in contplianre with the rw{uirements o/this Board.
FIXTURE ECEPTACLE$ SWITCHES FIXTURES RANGES COOKING DECK$ OVENS DISH WASHERS EXHAUST FANS
OUTLETS INCANDESCENT RUOREECENi OTHER AMT K.W. AMi K.W PMi KW AMi K W AMT. H P.
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS $PECIAL REC'PT TIME CIOCK$ FELL UNIT MEATER$ MULTI-OUTLET DIMMERS
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SERVICE DISCONNECT NO.OF $ E R V I C E
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<<( e'olil,:Rnraa,t2 reu £'ttr~~
GENERAL MANAGER j~'
Per tlF
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'NDT BE ALTERED IN ANY MANNER.
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.1 o MAIN ROAD -STATE ROAD 25 SOUTHOLD, L.I., N.Y. 11971
®1 r~ TELEPHONE (516) 765-18()9
ACTION OF THE ZONING BOARD OF APPEALS ~j
Appeal No. 3396
Application •Dated September 3, 1985 (Complete File 3/4/86)
To: Mr. and Mrs. Gary Doroski [Appellant(s)]
425 Monsell Lane
Cutchogue, NY 11935
At a Meeting of the Zoning Board of. Appeals held on May 28, 1986,
the above appeal was considered, and the action indicated below was taken
on your [ ] Request for Variance Due to Lack of Access to~Property
~ New York Town Law, Section 280-a
[ ] Request for Special Exception under the Zoning Ordinance
Article Section
[X] .Request for Variance to the Zoning Ordinance
Article XI , section 100-119.2(6)
[ ] Request for
,Application of " for a Variance to the Zoning
prdinance, Article XI, Sec ~1on "r60`-~TT9.2{B) for permission to locate
proposed pool with decks and fence enclosure within 75 feet of wetlands
and highwater mark, at 425 Monsell Lane, Cutchogue, NY; Norwald Sub-
division Filed Map No. 1275, Lots 31-35 inclusive; County Tax Map
Parcel No. 1000-97-08-27.
WHEREAS, public hearings were held on April 3rd and May 1st,
1986, in the Matter of the Application of GARY DOROSKI under Appeal
No. 3396; and
WHEREAS, the board members have personally viewed and are
familiar with the premises in question, its present zoning, and the
surrounding areas; and
WHEREAS, at said hearing all those who desired to be heard
were heard and their testimony recorded and transcribed; and
WHEREAS, the board has carefully considered all testimony and
documentation submitted concerning this application; and
WHEREAS, the board made the following findings of fact:
1. The premises in question is located along the east side
of Monsell Lane, in the Hamlet of Cutchogue, is identified on the
Suffolk County Tax Maps as District 1000, Section 97, Block 08, Lot 27,
and is known and referred to as Lots 31-35, inclusive, Map of Norwald
Subdivision No. 1275.
2. The subject premises consists of a total area of 37,703
square feet, with frontage along P1onse1l Lane of 276± feet, and
greatest depth of 150± feet. The premises is improved with a
single-family, one-story frame dwelling as more particularly shown
on survey amended 1/14/86 (received 3/4/86), and set back at its
(CONTINUED ON PAGE TWO)
DATED: June 2, 1986. CHAIRMAN, SOUTHOLD TOWN ZONING BOARD
OF APPEALS
Form ZB4 (rev. 12/81)
~Pagel2 - Appeal No. 3396
Matter of GARY DOROSKI '
Decision Rendered May 28, 1986
closest point from Monsell Lane 31 feet) at its southwest corner).
3. By this application, appellant requests permission to
locate an 16' by 32' pool with varied deck areas and fence enclosure
on an angle (northeast to southwest direction at long axis) with a
setback of not closer than 24' to the high marsh grass borderline
or 50 feet from the rear property line as shown by survey map amended
January 14, 1986, prepared by Roderick VanTuyl, P.C.
4. Article XI, Section 100-119.2, sub-paragraph B requires
all buildings located on lots adjacent to tidal water bodies other
than the Long Island Sound to be set back not less than seventy-five
(75) feet from the ordinary highwater mark of such tidal water body
or not less than seventy-five (75) feet from the landward edge of
the tidal wetland, whichever is greater.
5. It is the opinion of the board members that: (a) the
pool and deck areas should be located as far back from the marsh and
wetland areas as possible; (b) any draining or discharge from the
pool, or irrigation, shall not run into the tidal areas; (c) that
the requested setback of 24' is substantial in relation to the
requirement of 75 feet, being a variance of more than 50%; (d) that
an alternative would be to reduce the deck areas proposed between
the existing house and the pool construction in order to minimize
the wetlands setback.
6. For the record, it is noted that previous applications
have been made concerning this property as follows: (a) Appeal No.
3310 rendered February 14, 1985 conditionally permitting an accessory
shed/garage structure in an area other than the required rearyard;
(b) Appeal No. 2040 rendered June 12, 1975 for the construction of
the residence with a setback of not closer than 30 feet to Monsell
Lane.
In considering this appeal, the board finds and determines
that in locating the proposed pool, deck and fence enclosure at a
distance not closer than 60 feet from the rear property line and
not closer than 28 feet from the wetlands areas: (a) the variance
will be the minimum necessary; (b) the circumstances are unique;
(c) the practical difficulty under the circumstances are sufficient
to warrant the granting of same; (d) there will be no substantial
change in the character of the district; (e) the interests of
justice will best be served by allowing relief, as conditionally
noted below.
Accordingly, on motion by Mr. Grigonis, seconded by
Mr. Douglass, it was
RESOLVED, that a Variance for permission to construct
pool, deck and fence enclosure BE AND HEREBY IS in the
Matter of the Application of GARY DOROSKI, Appeal No. 3396, SUBJECT
TO THE FOLLOWING CONDITIONS:
1. That there be no construction within 60 feet of the
rear property line and no closer than 24 feet from the wetlands area
at its nearest points;
2. The pool wall must be reinforced every six feet with
12" by 12" block piers and properly backfilled, particularly on the
water side (to maintain strength from water flow);
3. Proper ground cover shall be placed so that no topside
erosion will result (for example, sod, low bushes, etc.).
Vote of the Board: Ayes: Messrs. Goehringer, Grigonis,
Doyen, Douglass and Sawicki. This resolution was duly adopted.
lk GERARD P. GOEH INGER, AIRMAN
June 2, 1986
FORM NO. t
TOWN OFSOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765.1802
Examined ~./~.7......., 19.~.~ / Q Received.. , 19
Approved • ......,/19~~Permit No? 7v~.~~J.~.!
Disapproved a/c .....~j.~'~~?1.~~
l~°~ / / , .
~ildi Inspector)
V
ss~pp~AC®OA~I-ELI •~PPLICATION FOR BUILDING PERMIT
~V~lY1G 5(' r 1
ENCtOSE POOL TO CODE Date 19 . .
UPON COMPLETBON
BEFORE "WATER" INSTRUCTIONS
a. Tlris application must be completely filled in by typewriter or in in ' ~ ~ ~I { ctor, wit}r
sets of plans, accurate plot plan to scale. Fee according to schedule.
b. Plot plan showing location of lot and of buildings on premises, rel ~ ~ blic strce
or areas, and giving a detailed description of layout of property must be 1~n f this app
cation.
c. The work covered by this application may not be commenced before~'s
d. Upon approval of this application, the Building Inspector will issued r acT"nY'"'Such pern:
shall be kept on the premises available for inspection throughout the work. gg.
e. No building shall be occupied or used in whole'or in part for any prTr r rca e o Occupant
shall have been granted by the Building Inspector. I• ~
APPLICATION IS HERlBY MADE to the Building Department for tl~rss ~ er it scant to t~
Building Zone Ordinance of the Town of Southold, Suffolk County, New ~~r)~~d c e dinances
Regulations, for the construction of buildings, additions or alterations, or~fogf•~' describe
The applicant agrees to comply with all applicable laws, ordinances, building code, housing co e, and regulations, and
admit authorized inspectors on premises and in building for necessary inspedti`otI"s. ~
(Signature of applicant, or name, if a corporation)
r f, II'I '
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builde
Name oC owner of premises ~ 14J'5~.7~oS~1 .
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
(Name and title of corporate officer)
~
Builder's License No . % 'MA/IEDiAT~LY'.
ENCLPOONE POOL TO COpI(;
Plumber's License No . gEFOgE MPLE1ryON
"WATER
Electrician's License No. r . ~ ~ ~ ~ '
Other Trade's License No . .
1. Loartion of land on which proposed work will be done . .
hfouse Number SSytreet Hamlet
County Tax Map No. 1000 Section ~7........ Block ~ Lot ...~%7......... .
Subdivrsion filed Map No. Lot..............
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ~ r~~A\
b. Intended use and occupancy i~""!'?~• d'~"'fi`!~:'Y~~~S~`~•"•'~"•~-•1• •o~~•~T~
r~{
3. Nature of work (check which applicable): New Building Addition Alteration
r'
Repair Removal , Demolition ' ....Other Work .
au'r: <-1u~ ~•,,c ~r~~Sl sc~.'Y.,.^,• ~eol~?~=cK (Description)
~q Soy , - ` ~ u' j`~,.~~ a~~-~ p„o~
4. Estimated Cost............ • Fee ........i......................... .
(to lie paid on filing this application) '
5. If dwelling, number of dwelling units ~ Number of dwelling units on each floor r .
If garage, number of cars , .
6. If business, commercial or mixed occupancy, specify nature and extent of each hype of use .
7. Dimensions of existing structures, if any: Front . , `.{.:.......Rear . U~' Depth ~
Height 2r Number of Stories . . .
Dimensions of same stmcture with alterations or additions: Front : Rear .
Depth ......................Height • ..............Number bf Stories .
8. Dimensions of entire new construction: Front Rear ........Depth .
He+p}tt Number of Stnr;es ........:^'t.o~l- 20 4 ~ : . .
~ 9. Size of lot: Front , Rear . ~ Depth , . .
/10. Date of Purchase ..`9'.-.Sp.:8.3 Name ofFo~~ntterOwneri.~^:~~~:°:k~.~,~-°"•"1"`1.^:
11. Zone or use district in which premises are situated , . , ~•za;c~-e,,~~K1„ , , , :
12. Does proposed construction violate any zoning law, ordinance or regulations',.. esl . ~:e~: ':fl. , , . ,
,.13. Will lot be regraded `.j:?-$ .....Will excess fill be•i'emoyed From pramisesc Yes 1^
14. Name of Owner of premises n r? s,Fc; , ,Address . 4 Z.S;',r?W S e i ~ ,Phone No. 7 : ? ~ i.. .
Name of Architect . ...................Address , { .....Phone No............ .
Name of Contractor . .Address i .....Phone No............. .
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and,~ndicate all set-back dimensions fro
property lines. Give street and block number or description according to deed, and show street names and indicate wheth
interior or corner lot. o
A D A3 NOtEO
f1ATE: I~t.RN /73/~
FEE: 2 ey;
' NOTIFY~~ BQI~;~ A
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FOLLOWII~Ki ,
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STATE OF NEW YORK, S S
COUNTY OF
being duly sworn, deposes and says that he is theapplicai
(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 thelsaid work and to make and file th
application; that all statements contained in this application ar`e true to the best of His knowledge and belief; and that tl
work will be performed in the manner set forth in the application filed therewith.
Swom to before me this
i
..day~o/f 19 ~.S
Notary Public, , • County
K DE YOE ~
lo, (Signature of applicant
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