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HomeMy WebLinkAbout17344-z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No Z 18460 Date OCTOBER 13, 1989 THIS CERTIFIES that the building ADDITION . Location of Property 405 BIRCH LANE CUTCHOGUE House No. Street Hamlet County Tax Map No. 1000 Section 83 Block 1 Lot 28 Subdivision BIRCH HILLS Filed Map No. 4908 Lot No. 13 conforms substantially to the Application for Building Permit heretofore filed in this office dated AUGUST 12, 1989 Rursuant to which Building Permit No. 173442 dated AUGUST 24, 1989 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 A DECK ADDITION TO A ONE FAMILY DWELLING The certificate is issued to WALTER & PATRICIA FINGER (owner xxxxxxxxxxxxxxxxx) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL. N/A UNDERWRITERS CERTIFICATE N0. N/A PLUMBERS CERTIFICATION DATED N/A i B ildi g Inspector Rev. 1/81 gosas xo. s TOWN OP 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) NQ 017344 Z oate ....&,~~5..° t9..~~ Permission is hereby granted to: moo.. ~ ' . , ~ . . . ~ .....c.ti. . . cY premises located at .......TQ..,,.J'~..........~`,+~~G.~...,!1~iFZ..~ .............................................................................................................9.................................................. Cvunty Tax Map No. 1000 Section Block Lot No.........°lc~ pursuant to application dated 19........, and approved by the Building Inrrspector,~ Fee V .Oj~/,x4 uild nspectori""/" Rev. 6/30/80 I . _ _ _ FORM NO. 6 C~~~JC,~` TOWN OF SOUTHOLD Building Department _ ~ Town Hall ~.,p~} Southold, N.Y. 11971 APPLICATION FOR CERTIF LATE OF OCCUP Bl.rc,' u~rr: oW~~rV CAF ~qurtsOtt7 Instructions A. This application must be filled in typewriter OR ink, and submitted ~ eu~~ to the Building Inspec- torwith the following; for new buildings or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unuwal natural or topographic features. 2. Final approval of Health Dept. of water supply and sewerage disposal-(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installa- tions, acertificate of Code compliance trom the Architect or Engineer responsible for the building, ~ 5. Submit Planning Board approval of completed site plan requirements where applicable. 6. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate wrvey of property showing all property lines, streets, buildings and unuwal natural or topographic features. 2. Sworn statement of owner or previous owner as to use, occupancy and condition of buildings. 3. Date of any housing code or safety inspection of buildings or premises, or other pertinent informa- tion required to prepare a certificate. C. Fees: Additions $25.00 POOLS $25.00 ALTERATION $25.00 1. Certificate of occupancy New Dwelling $25.00, Accessory 10.00 Business $50.00 2. Certificate of occupancy on pre-existing dwelling $100.00 3. Copy of certificate of occupancy $ 5.00, over 5 years $ f0.00 4.Vacant Land C.O. $ 20.00 S.Uodated C.O. $ 50.00 Date NewConstruction,,,,,,OldorPre-existin/gBuilding /Vacant Land Location of Property , , . , ~r/,~', , n ~F , C/'f-~-~© CJ.~,.. • • - • • • • House No. rot ~i i ~ / ~ ~ / Hamlet Owner or Owners of Property ~ .t. 1L; ~ C , , , , ; ~ r , . County Tax Map No. 1_0/00 Sec~ti~n `.g~........ Block ....~.q! Lot.. Subdivision . ~!!L', !I, r!, ~!S , , , , , , , , ,~~.r iced Map No. :9f' ,Lot No. , , , , , , , Permit No~./.o~ Date of Permit ~.'z.w-~,/3Applicant . Health Dept. Approval ........................Labor Dept. Approval Underwriters Approval ........................Plannin Board A 9 PProval Request for Temporary Certificate .....................Final Certificate Fee Submitted $ . Construction on above described building and per it eels all applicable t:odes and regulations. Applicant . cC.~ ~ C/ CC) ~ ~ ~c~ C~ =1ELD Ir.srsc:,u:1 ~~uATE ~ ;;odKr~~rrrs y .1 . 7 H~ _ - H FOUIJDATION (1st) a FOUNDATTOIJ (2nd) - b~ 2. z~ O P,OUGH FRAME & Q~~ PLUMBING 3 . x' m ea H I1ISULATIOAI PER N. Y. ' STATE ENERGY CODE x A ~ ~ c^~ 4. FI;JAL ~'1 o~ z ADDITIONAL COMMENTS: x 1~ _ co x b~~ \ H z ,~1 • r`, y T' x o m H v U - w - ~ ' J~.~ - - - - a~ - ~ ~ - - ~ - ~ - i ~ - w C ~ ~h- ~ ti - ti , - r~-w-- - - N - - ~ t - - - _ _ - ti ~ - - - - - - - _ . _ - - i ti v _________._,I, _ _ C~_______ )l _ . ~ i- - ..___W . _ - i . _ ,__r ~ . , _ fir. ~ - _ - - I - ~ ~a~ I - - _ - - b - - i i ! i ~ i ~ ~I i ~ _ ~ ~ ~ I ~ ~ ~ ~ j _ . _ . __r . i _ _ _ ~ _ ~ ~ i ~ r~ J, - L - - - o - - ~ - ' - ~ - - ~ - ~ - - - _ - - _ - ; ~ . ~o - _ ~ ~ - - - ~ - , S~1zr«,py. TEL. 7G5-180 c~~FFOC~C ~ ~ `~O G~~ T0~ rl OI' SOUTIIOI,I3 ' ~ OFFICE OF BUILDING iNSi'F.CTOR "~~p ~ P.O. I30)C 1 17 9 ~ ~ 1' ~ TOWN HALL ~ l SOI)TIIOLD, N.Y. i 1971 ~Ql ~ . `~~r" September 21, 1989 Walter S Patricia Finger 405 Birch Lane ~ ~ Cutchogue, N.Y. 11935 ~E~ ~ i,~ SLOG. bEPT. To L4hom This May Concern, 'TOWNUFSOU7MOlD We are unable t.o complete your Certificate of Occupancy because of the follo~~~ing reasons. An application for Certificate of Occupancy S slot nn fi].c. (ENCLOSED) D]o Underwriters Certificate on file. Phe check .i::( t on file.) $25.00 No 1L:a].th Dept. Approval on file. No final inspection has been made. P]e~u>e contact our office on L-his matter. - Thank you for your cooperation. Ih~.ildir,g Pcrm.i.t. U 1 7 3 4 4 Z Building Dupl. tlo Plumber ;;older. Certificate on file. ( a].1 permits involving plumbing briny i~sucd after April 1,1984 ) TOWN OF SOUTHOLU BUILDING DEPART?LENT TOWN HALL • SOUTIIOLD, NEW YORK 11971 ~ 765 - 1802 APPLICATION FOR CERTIFICATE OF OCCIIPANCY DATE.. NEW CONSTRUCTION ._.._..OLD OR PRE-E%ISTING/ BU/ILDING..X _,pACANT LAND........ Location of Property.. ~lr~'~1 F~~r~r.~ C° ~i~G~~ ~ HOUSE NO. ` STREET/ HAMLET Owner or Owners of Property.. ~ / ~ ~ ~ Q e ~ ~ c~ ................................~i/, P~...... County Taa Map No. 1000 SecCion Block Lot......... Subdivision.........._./ Filed Map ......,.Lot........_. ~~J7 _ / Permit No. 0~/-.3~~Date of Permit ~~~,~~=Applicant .~'U.:,~ q ~ . . . . . . p f . . Health Dept. Approval Underwriters Approval.. Planning Board Approval .oV Request for Temporary Certificate Final CcrtificaCC 1 Fee Submitted: $ ~J2.c~C!2J.. • ~ 10/14/88 4 ~ FORM NO. 6 ' ' ' TOWN OF SOUTUOLD i BIIILDING DEPARTMENT TOWN BALI 765 - 1802 APPLICATION FOR C~ATIFICATE OF OCCUPANCY INSTRUCTIONS A. 'This application must be'filed in typewriter OR ink and submitted to the Building Inspector with the follojring; for new buildings or new use: Final survey of prope{~Cy with accurate location of all buildings, property lines, streets, and unusual natural or Copographic features. 2. Final approval of Beath 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 solder used in system contains less than 2/10 of IZ lead.' 5. Commercial buildings,lindustrial buildings, multiple residences and similar. buildings and installations, a certificate of code compliance from the Architect or Engineer responsible for the building. 6_ SubmiC Planning BoardApproval of completed site plan requirements. _ B. For existing buildings (prior to April 9, 1957] non-conforming uses, or buildings and "pre-existing land µses: I. Accurate survey of property showing all property lines, streeCS, buildings and unusual natural or topographic features. 2. A properly completed application, a consent to inspect signed by the applicant and a certified abstract of Citle 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 waiting Co the applicant, 3. Date of any housing code or safety inspection of buildings or premises, or other pertinent informationrequired 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 of ',the entire lot prior to April 9, 1957 shall also accompany Che application. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasoc~s therefor in writing to the applicant. D. FEES: I. CERTIFICATE OF OCCUPANCY - New Dwelling $25.00, Additions to Dwelling $25.00, Alteration to Dweliling $25.00, Swimming Pool, $25.00. Accessory building $25.00 ' Addition to Accessory buildings, $25.00 - Businesses $50.00. 2, Certificate of Occupancy 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 5. IIpdated Certificat~'le of Occupancy - $50.00 6. Temporary Certificate of Occupancy - $25.00 Residential $50.00 Commercial . ~~I -ev, 10/14/S8 /'1"f ~r~'' TEL.7C,5-180 O; C% T0~1'! OIL SOUTIIOI,d~ ' Oi~f'iCEC)CESUILDING INSPECTOR ~ q, ~ TOWN IIALL ~yy SOi1TI10LD, N.Y. 1 1971 O~J~zu" ~ September 21, 1989 Walter 6 Patricia Finger 405 Birch Lane Cutchogue, N.Y. 11935 To LVhom This, May Concern, We arc unable co complete your Certificate of occupancy because of the folloi•ting reasons. An application for Certificate of Occupancy ].S tlOt on fil.c. (ENCLOSED) D!o Undcrc•~ritcrs Certificate on file. Che cliccF: .i::( t on file.) $25.00 No flcal.th Dept. Approval on file. No final inspection has been made. Please r_ontact our office on this matter. Thank you for your cooperation. Ih+.ildir,g Pcrm.i_t Q 1 7 3 4 4 Z Duildinq Dopt. " t!o Plumber ;;older. Cert.ificat-e on file. ( a7.1 permits involving plumbing briny issued after April 1,1984 ) k, r t ~r%y . , IL L1 t ` O ~ ~ , T.. d'.. 3~ ~t F~yN~ i S x K of ~ ~ ;.l` - - '(f k~ r i o5. ~ ~ }"fi Y~1 R r . ~ R Y . e f ~ - K. it Xft' x ?Ix~ A I J,, ~j! ~ ilk ~ ~ : V T' ! - /5y?~ t .ter! y j ~Y' fi ~ lJ Y / , L ~-0 a T k a ~ f ~ - ~~yy~ v~V'VJJVv `s ~ T <N~~`,^..' - ~ - , C 5 YY ) t" lam. N ' }T5 ~ ~ C~ ,moo ' t)2 b t. T.,ak. +iit~~ .a "w . i i r { r ~ ~ G~ ` x :Q , I t,{({ , . K: v qs~ i x ~ 5N r, f .y~•~ _ _ t YI f ~ L~ :~2II t BT t~I~T K r~l ~ x.. ~ i~ ~ ~~J, - w R 5 t i } ~ _ ~?~~R x. ' , r F f K 't n s { - , ~ - W~ i }hi , it I' N S 1 _ V 4 ~ \j A ` 1 ~ • ~ may. t ~ r . M 1 r ` y,f 7'Y + l a ~ ~ P ~ w R ~4 y r. 3 ins}.b "irv -"~v l't~-~wR ~9' T. ) sa iE ' ' . 'Y'nt~ ~ y a i x ~ d - ~ ~ n , t x5~j}f ~A Al t ><45 ,y ~l 9i .£'.k a~rr t s- ye ! - Y { Rj` i y, - E~;~ t L ~ .o. y ~ ` ' ~~jJGrh ~t f t. 111 II _ ~ ~ ~ IVDrE'Z."y~ ?lr?15;~~.fi~s`~TQ°N]FiP~C?F`~I2~E~~ R , h. w ~~~z.u cr~u~aa-Y cLCSZL~'ra~~ce.. UN UTHOItIY RFD TRIT~AY7[f~~,A DI N t: - ~~y - ~ ' , tr- i0 HIS SURVEY IS A VIOLATION OF: ' " ~ ~Y ~ ~ .~7~~.~EV ),.~~Q ':f'~'a ~.{~`y- ~ ~~>jwT~~d!w~.~ SE ION 7409 OF THE~NEW YORK STATE"` y"~' ~~7 ~,~~.~t ~y ~~.~.~'~'~P+A~-{~~. EDU ATION UW : ~ ~ /'"U T GH V R,1 L./ ~ ~ y ~y y"~ -..----~.•--~~,.+a.q~ CO IES Of THIS-SURVEY MAP N07 $$I~jj}}C LFam~! [[-F+~ (/y ~ _ A~ :T1EiJ~RJCI ~:?__t .,-{T. ~ ~aF-t~,~,.s-}u. ~ 1y w~UF'~(C~,f-FY; THE lAN05URVETOR'S INKED SEAL°~°(.f~ryiy, ~F,'r71/t..i L.C1il~~~iN 1e -C)~_-~~~~C~"~ \~AS~I I~..i.E~M ~.5... ~'1' FM SSfD SEAL SMALL NO7 & CONSR7ER70 ~ F,. TO E A VALID TRUE COPYr ~ ~ ~ j ' GV RANTE[5 INDICATED HEREON SHALL RVN. - ~ ~ w~~. I~i,~~ ON TO'TY.E JERSON fOR WHOM THESURVEY - ~ ~ ~ ' • _ z c xV~. IS P'EEPAR[D,~AND ON HIS CEHALF TO'THE ' - - - s C e+. y y, f. w~ 1-sr~ t ~f 'C. ~ 717 COMPANY, GOVERNMENTAL AGENCY AND - _ t+1G~K-~1E~F~"~.f:Fd'll/ C?Cf K'/~S aJrw~? LEN~ING INSTITUTION LISTED HEREON, AND ~ ~ ~ , , - ~L~-..~~'}~ " tO fHE ASSIGNEES Of THE LENDING INSTI- - ~ T ' - ttt ,_-F~ ~ ~ - ~ - - - - f - - - - - - - ~ r ~ - - - - - - _r ~ A ~ ~ i 1 ' ~ IV ~ - _ _ -h j---f- ' - - ; - - I ~ ~ ~ - - i i I I ~ r---•-~ 0 ~ ~ 1 C- - - - - - - - - ~ I i ~ I " I - - t I _ I_ _ i ~ _JI_ _ l - ~ ~ i j ~ L r j ~o. 7- fi ~_-~-cam -a-- - - _ ~ i__i__.-~. ~ ~ _ i ~ i ~ ~ ~ - - . i i ~ ~ ! ~ - ~ ~ - ~a t - - - ~ - n i ~ M_. _ ~ ~ -~1---- ~ ~a--- - - ~ ~ ~ ~ ~ a- - ' G ~ - ~----------c _ _ or c . . (1 _ T ' l~~,~•f/I;_~~^~'~i BOARD OF AEALTH ~ .~i ~ ~~{Ifl i ; ~ ~ 3 SETS OF PLANS ~J~ I;` FORM NO. 1 . SURVEY T ~ TOWN OF SOUTHOLD CHECK ~ BUILDING DEPARTMENT SEPTIC FORM . gLpp, TOWN HALL TOWN OFSOl1TH0lA SOUTHOLD,N.Y. 11971 NOTIFY 7~J d TEL.: 765-1802 CALL Examined . •~/~G.,l~//. • • . • 19 MAIL T0: ~X ~ ~ Z~ , Approved /~7......., 19~Permit No. ~7J'. ~7 ~ • Disapproved a/c p~gl,°°~ (wilding pector) '~t~~~'°°A~P`PLICATION FOR BUILDING PERMIT Y S i~ ~~~~ii Date ..~..~:'Z. 19.~.~ ~ INSTRUCTIONS ' a°. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 sei:s 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 or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- cation. ' c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such permit shall 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 shall 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 Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. o (Signatu/r~eC ot" applicant, o/r na/me, if a corporati`o/n) • (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. lY/Cfi P ~C ~ / ~ • i~~ • n as trod ~~DA~E:. .~P.x . . Name of owner of premises / ~ r r ~ / r ~ ~ ~ (as on the tax roll or latest de o FEE: ggY: If applicant is a corporation, signature of duly authorized officer. NtJTTFY UI OE AT 786.4802 8 AM 10 A PM OR THE FOLLOWIPIGIN91RIrCflONS: (Name and title of corporate officer) 1. FOUNOATIOAI-~- TWipREQI ` FOR Builder's License No. ~2~ 2. ROUGH - FRAIYNNp ; M,ilAASM16 8. INSULATION Plumber's License No . 4. ftNAL - CONSTRUCTION MUST 8E COMPLETE FOR C.O. Electrician's License No . ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF tHE N.Y. Other Trade's License No . STATE CONSTRUCTION 8 ENERGY CODES. NOT RESPONSIBLE FOR 1. Location of land on which ro osed work will be done. 'DESIGN OR CONS,TRUCTIQ~L~RRORS, • , , , nP P House Number Street Hamlet County Tax Map No. 1000 Scc~tio~, ~3....... Block Lot ~.o . Subdivision e ~ ' ` / • • • • • • • Filed Map No. : r~d .r~. , , • Lot . ..S (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy J-E'S i~(•Pr/c~ F, • b. Intended use and occupancy , . ~.~s," ~I 'j • ' 3. Nature of work (check which a{yplicable): New Building Addition Alteration Repair Rempval Demolition Otherli.~.1G~:S:'.... (Description) - 4. Estimated Cost ~~~.~0©C?: . Fee . / /f ( P n , . Number of dwellin ou its onlea~~floor rs'appl`idxtl'o`ti~""' If dwelling, number of dwellin• I pets /~'/l7. , ; , , , , • , , , , , , , , d? g If garage, number of cars ~ . . y~ 6. If business, commercial or mixed occupancy, specif~~YY nat~u~;e and extent of each ty,~e of use l1~~17, . , . , , . 7: Dimensions of existing structures, if any: Front ..0.~ , :T:....... Rear . ~ 7..:~`...... Depth .:2,~......... . Hei ht / Nu ber of Stories , , , , . P ithalterationsoradditions: front ~7 ~ Rear.. 7..7:.r........ De th ....r~~.......... 8. Dimensions of entiresnew con t • • Height . ........Number of S o 'es . ' ruction: Front , . lP!~ , Rear . Depth . Height . . Nu ber of Stories ' r 9. Size of lot: Front /``~Ot.~....... , , Rear 2~"OS , Depth .-nth'. 2. 5 E . ,„~'~4, 69^, Date of Purchase a~ . . Nine of Former Owner , , ; ; c'. ; . 10. ~ Ili Zone or use district in which remises are situated . . . . . . , , , . , . P . 12.' Does proposed construction violate any zoning law, ordinance or regulation: JY. S`~ ; . . . . 13. Will lot be regraded , N ~ .........Will excess fill,he re~ov¢d'fr'om premises: " 'Yes No P ...,9....... Address ~ Phone No./~~ , , , , , . 14. Na ne of Architect remises~~., /i~cr..~n ec .S- ~5 .CQ,~ gs'$' ' sE .Address ...................Phone No. . Name of Contractor ..:5~./...'i Address ...................Phone No............: ' IS'.Is this property located within 300 feet of a tidal wetland? *YES....NO.k~~~ *If yes, Southold Tows Trustees Permit may be required. PLOT DIAGRAM ' I 'Locate cleazly and distinctly all i buildings, whether existing or proposed, and, indicate all set-back dimensions from property lines. Give street and block pumber or description according to deed, and show street names and indicate whether interior or comer lot. I , '{,r , ~e rr n 2.n , 4' ~ r ~A ran ,c r i • r~ A ~1 .~1 ~\M' ~ ~ 1 1 irt~ 1 , ; t ,y t j y ~ 'r y ~ r'r ~ yM e, ~~}f. x , r se t~Al~~~~~ v t, i 1'~~a+n~ i ~.n d~fi~~.n .s~ai„ t _ r ' ~ , " ;°~a: ~r'4~`i^'~,.Nt?1'~ LIST i~IS)-~S~I2.E~~T/~.~(3°P9f1~!~{~b~'yEa~{~(ryf'~Iq'" :.i ~ n t{r~i~''h' ~~c ~ a r .~1~+ ~.A~J-~V ~~it']~+f'IL tY' y YY ~ 3.t r x S A'j~h y~~~P+ 4 Pr r. ~ StiF.F~L1Z '.+/MC1=1-i.i-.4~.I~ 'JJ 1"~I e x ~ P: 1 rty~~~~ f ~ rXl -ik. K - ~"S,~w>W 'f:,}~gn• ~....~-Z~.._~ v E~, t ~ 1' K~~ ~i i,- ^^^;RG4A} i \ I ~ t ~h 1 it ~~~y. YY tTX yr, y p q l 1i ~ r qi I tY ~ ~ a ~ 4T•+Y` V+ t i 1 ~ I l , , ~ [ ~ I F r ~l / r f r ~ -r 'K9 r d r r44A n .l.y rd r r ~r+ e r r,d<^r r y F j~ ! 1z ~ ~ W~y~(s r J r ~l i y o-b le 1 ~ r 1 W d ~ y~yp r r< 5 K r r,.Y ~ a,, r~ ' ~r ~ d a' ~ rf' ~F ~i w.~".'~ f 1' >,t S ~ n ~ P tYi~r 4 r w r~'r 1 ~ r r z y k y r r ,i i D~ ~ t', ~ s ,~y~i ixd ~ , r 6 q 1n '4 r I t ! ~ r x y _r rv y r a i~ 7 appppr'i ! r ( t / a v r r i C ~ rl tr ~ t 1 ~ r ~~A~~~% IypH ~lr r q,/t+~ l ~ : f A o ~a ~,Sk~ ' r RAC r i r .y 's. .dtt~'~ > { ~ y ' Y e t Js k w r. i d jf ~ r `M1 ~ ~ ep ~1, 1~4x i `3S1" S 4 i t t"r': ~ i ~ ~Et n ,s ~ h' y ,6 rd: , ~ t r n? i Y S S r. r i i r~ t I ~ y f!~ r~ 0 fi r r ¢^e Y //gy~pp A~ S x~ v r'+ 4 y~, i , dWIiF a kRO~ ~1~~1"r~( .r ~r ~i ? ~ ti m ~r' $ ' ! ~r}-y ; Ti~Y F.~'~ tM ?.v 1 " Y 9x'f 5~. ',tY• A 1. r ,k. in.- t 91 r~ !u hi(1RR t1 ~1+1i r _ _ ' _ , ' ~ , STATEI~•I#'Rh1HktA'Ti'mrRl{;a: i~5 .t, ~t t ' COUNTY OF AI 3.NS?i ;1f'3 i?~{]:i,>SI~?vt.' T'~3~A 9.IAHu U'rl?11.3t,4at :~tr.'~ :'f. ' ' ' ' ' ~t• ' T ' }t5' i~N,~, ]N Iiri lr9', • ~ • • • • • • • . • • • . • , . being duly sworn, deposes and says that he is the applicant above nygt]~Pg~~ $~,yyJ~~~t~ygltrt)g,contract) i;6lrsRil3 #t~tYC3tts']ff'NC1::• fa s' He is the............ (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly',authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner het forth in the application filed therewith. Sworn to before me this 'i " Notary Public, ~ . 77 ; , , ;h/.•~.Y~-:...... County j HELEN K~ . ~m47 7878 Shte New'falt ' (Signa a of applicant) - Term Expires Itrerch 3Q,1~9,.:~1 - ~ ~