HomeMy WebLinkAbout17427-z
' FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Ha11
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No Z-19988 Date JUNE 14, 1991
THIS CERTIFIES that the building ADDITION
Location of Property PRIVATE ROAD EAST END FISHERS ISLAND N.Y.
House No. Street Hamlet
County Tax Map No. 1000 Section_ 4 Block 6 Lot 9
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated SEPTEMBER 14, 1988 pursuant to which
Building Permit No. 17427-Z dated SEPTEMBER 15 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 ADDITION TO EXISTING COUNTRY CLUB AS APPLIED FOR.
The certificate is issued to FISHERS ISLAND DEVELOPMENT CORP.
(owner)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE NO. N-106037 - DECEMBER 6 1989
PLUMBERS CERTIFICATION DATED N/A
Building Inspector
Rev. 1/81
go8ai xo. s
TOWN OP SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON 7HE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
Nfl 0~7~2? Z Dote ...~Y...~":?~-....I 19.f.8.
Permission is hereby granted to:
'~oK aoz-
. ~ ,
..c~~:.....a~..... .
at premises located ot ....~'.Y.~.......SO:.IIM..'Y.td.41Kr...,.Q.f.IR.:......~.a-:AN.Q.de°....4Se~4~G.P~1.dL
Caunty Tox Mop No. 1000 Section ......0.~........ Block,f.:..~..~.....o..aLot No...~.~•............
pursuant to application dated ~~•4.nar~.l.4~1.1•..... ~.7..........., 19.Q..b.., and approved by the
Building Inspector.
Fee 3..>'~.~.T...D........
Building inspector
Rev. 6/30/80
i .
Form No. 6
.
TOWN OP SOUTIIOLD ,
BUILDING DEPARTMENT
TOWN HALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
1. 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 17 lead.
5. Commercial building, industrial building, multiple residences and similar buildings
and installations, a certificate of Code Compliance from archi=ect 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
"pre-existing" land uses:
1. Accurate survey of property showing alI 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. 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 CerCificate of Occupancy - $5.00 over 5 years - $10.00
4. Updated CerCificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00
Date ~..l. , .
'w Construction........ O,1/d~Or Pre- xistin Bui i~d~n
cation of Property....~//..1....~Q~.c-.
House No. ~ Str~/J~.. Het
ewer or Owners of Property.~i~„(;,~~~4~~~Y~/1,~//~y~~[~~j~~~~
aunty Tax Map No 1000, Section...........Block.....C.rl.........Lot.....~~
bdivision.l .............................~.~j~.~./~...Firled Map............Lot{.'.......
rmit No.,~.~,y~,~„ZDaCe Of Permitc¢/ ,~y ^~P~~j~.APPlicant ~~/.~1.~. r~ . ~iy+.C
alth Dept. Approval... '~,/,,,,,,,,,,,,,,,,,Underwriters Approval/,y, l ® ~ Q .
inning Board Approval.,.l/,~
;uest for: Temporary Celrtificate........... Fi ~ Cert' e
. Submitted: $...l~~C~.~f
CRC. yl`73 tai _ ~ / .
c, n z. l 9 9 g~ .............'APPLICANT......
~ _ ~ TT_ -
THE NEW YORK B , IMN~ UNDERWRITERS r~nc>:, 1
1000656
IrY -
8¢ ,NEW YORK 10038
n.te DECSMBSR 06,19B~~, J:le 600266$9189 N 106037
TNIS CERTIFIES THAT ~ ~ d 0
only the a/eetricd egtslpeterst eR1~~ v iced hY the eppl7cent roomed on the drove eppliation number in the premieex of
~ ~ ~
-
FISHSRS iSLAMD S' i,ND, FIBBERS iSGANO, N.Y.
in thefdbtrinX bt ~ ' ~ Ixt Fl. ? Pnd FI. OUT Section Block Lot e-
,{t
race examined un g9 and found to 6e in romplionre with the requirementx of thu Buerd.
s.
IIXTtN! ACTS fIXTUeeS RANGES COOKING ORCKS OVeNS aSN WAfN@S EIIMAU4T fADK
ouTeRrs ucAUOtsctuT HuGNStEUT OTRER AMT. K. W. AMT. K. W. AMT.. K.W. ANT. K. W. NAT. M. P.
117 2 30 eS 29 1 9.6 3 F -
Decals wntAa IAOTals NtTUIS AN11ANq axons snclalnr Tau uocKS au uNrt NE.nes nt
stn~~ ~ _ aklklelts _
AMT. K. W. ql R. P. GAS K. P. AMT. NO. - w. M.O. AMT. AMI. AMT. MMS.. TRANS. ANT. N. P. ~ t~T AMT. WATTS E
1 so 9 900
feRVICe DIfCONNlCT ND.OF _ S ! R V 1 _ C E-- -
AMC AMP. TTPt I / tw 1 / Tv S w 3w ] / AW a1ER~.?~~~ a CG
Ca~ wo. a MI-lFG uG.Oi muTUU GF 'TE(IAAI
4.-
Oi1N ANMR11TUfl
5 RW B003T6R FOR DISHf1ASHBR-1
ICSMARBR-1 _ `
MOTORS:2-2 H.P.,1-1 B.P.,1-1 A.P.
PAASLBOAADS:1-21 CIR. 100,1-31 CiR. 20U
i~~. Z Q S CONTRS. INC, LIC./92d-R
P.O. BOX 20'L
F
FISHERS ISLARD, MY, 06390 oelsNtAS RGrsl?oet
11
Per
TMs certiBrate mlNt not M abend in any manner; roturn to 1M ofliu of the Board if incorrect. Inspectors may be idemifiad by their credenfiab.
_
COPY FOR BWLDING DEPARTMENT. THIS COPY ~ CERTIFIGTE MUST NOf BE ALTERED IN ANY MANNER. °
TEL. 765-1802
~oS~EFOCkC~G 'tO~N OF SOUTIIO~.D
y~ OFFICE OF BUILDING iNSPEC"I'OR
~ ~ P.O. BOX 728 ~ ~
y~
u~'+ ~ ~ TOWN HALL ' ~ y~r>1 ~
"O ~ ~ SOUTHOLD, N.Y. 11971 xp L'
~ ,
C E R T I F I C A T I O N
' + Date ~
Building Permit No. dr7/a/ '
/ /
Owner_ 1. Club
' (please print)
Plumber i"//llgK~O ~~hs{eE~t
(please printer ~ '
I certify that the solder used in the water supply'system
contains less than 2/10 of •1% lead.
I
u
(plumbe 's ,,,ignature)
• I
Swor~o beforr e this
/~~-day of JC(A!~ ,
19~L-' Notary Public
Notary Public,. County
TNOMAB F, pOMERTY dN,
. % Nogry Pu No A906689Naw York .
Oustllllro In Suffolk bounty
Ts'rmExplr~sly9/1sIQr/~
~y~~i pC~C~~ T~"~-~Q
~00~"
1-~ ,F'' n~ ..C
h•.
^-.d' ~f'"~'
Town Hall, 53095 Main Road ,y ~ ~
P.O. Box 1179
Southold, New York 11971 t y+~~
TELEPHONE
(516) 765.1938
PLANNING BOARD OFFICE
TOWN OF SOUTHOLD
September 15, 1988
Keneth Edwards
P.O. Box 332
Fishers Island, NY 06390
' RE: Fishers Island Country Club
SCTM #1000-4-4-9
Dear Mr. Edwards:
The following action was taken by the Southold Town
planning Board on Monday, September 12, 1988.
RESOLVED that the Southold Town Planning Board authorize
the Chairman to endorse the final survey, dated and amended
April 11, 1988.
If you have any questions please do not hesitate to contact
this office..
Ver my yours,
l P~
t
..P~Z/+
l y°
BI;NNETT ORLOWSKI , JR.
• CHAIRMAN
enc.
cc: Building Department
jt
r1ELD IGSP4CTiU;i ~~Dn::. ~ %OMMENT°
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FOUNDATION (1st) o CF'
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IIJSULATIOII PER N, Y,
STATE ENERGY
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ADDITIOPIAL COMMENTS: x
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NATIONAL
~ ~ ' ~ , BUREAU OF STANDARDS
CE~T~~~1~F~RBE~~,pABORATORIES,~lnGE0RG1A30722-2041
PHONE.(O 12 CARPET LAP
' , f i N00108
REPORT OF TEST :7UMDER 435y1
'.nth
March 30, 1968
CLIENT: Shaw Industries, Inc. Lab. Test No. 6Q?151503?
P.O. Drawer 2128
Dalton, GA 30722-2128
'SUBJECT;`=Carpet samplo submitted and Identified by olient as "73848 SITARA,
(031588-15)".
RADIANT PANEL FLAMMABILITY TEST
Specimens of the sample were tested for critical radiant flux in accordance
with ASTM Test Method E-648, NFPA 253 and FTM Standard 372. The value reported
is the average of three specimens.
Test Assembly: Specimens were mounted on "Sterling" fiber reinforced cement
board using 433 Parabond adhesive.
TEST RESULTS
Detailed pate Are Attached Hereto '
Average Standard Coefficient
Critical_ Radiant Flux Deviation OP._Varia_tion
>1.00 watts/s q. cm.
The sample tested meets or exceeds the requirements for NFPA Class I.
For CERTIFIED TESTING LABORATORIES, I~:C.
"Rli~ at roport s o ,~taf~.,ion sL~c~eLec~co with
t:ro cr:;crla set artb in tiro report, any Variation In tho
lp cr7torla nay p dUDS, d(tferont results:'
OUR LLTi[R! AND RCP ORT! APPLY ONLY TO THR 6AM PLL TffTCD ANO ARL NOT NECfffARILY INDICATIV[ OF TM[ OVA6ITIE! O/ APIARENTLY
IDENTICAL OR lIM )LAR PRDOVCil. TH ES[ LETTERL AMD BFPO ATf AR6 /OR TH[ USL ONLY O/ TNC CLI[NT TO WHOM TH CV ARL ADDRF68C0
AND TM FIR COMMV NI<ATION TO ANY OTN CR! OR TH[ Vf[ OP iHL NAMC OI CERTIFIED TE577NQ LABORA 70RIE8, 1NC, MVlT R[c [rVf
u APw ROVAL. THE RCPO RT[ AND L[TT[R!, AND OVA NAM[, OR OUR •LALl, OR OVR IH LIO NIA AR[ NOT UNDER ANY CIRCUM
{ NA710NAL
BUREAU OF STANDARDS
~T~ f E ~ ~G~ LABORATORIES, Inc. (~~CIQ~
.E: (4041 2201 4 0 0 • 1105 RIVERBEND DRIVE • P.O. BOX 2041 • DALTON, GEORGIA 30722.2041 CARPET LAP
• c ~ ' Nb.0i08
"ihls tcct report retntcs fo ln~tattotton In eccord^nce wl:h
t,i~ ~,f1a yu~r~i In$
f~~~PO ^Y Vsrioticn In tho
cn oily ER 43591
Critical
,~__Time_,~_ ~__,Dist.ance•__ __,_Radiant. filux
Specimen 1 30.1 minutes 11.8 centimeters 1.01 watts/sq.cm.
Specimen 2 27.5 minutes 8.9 centimeters >1.04 wattstsq.cm.
Specimen 3 24.8 minutes 9.6 centimeters >1.04 watts/sq,cm,
AVERAGE: >1.00 watts/sq.cm.
OUR LITTE RL AND RCPORTL APPLY ONLY TO THC LAM PLC TCLTED AND ARE NOT NCCESSARILY INDICATIVE OI iH[ OUALITIp OT MPARfNTLY
IDENTICAL OR {IMILAR PRODUCT{. TN [L[ L[T TER[ AND R[PORT{ APE IOA TNL ULE ONLY OR TNL CLIENT TO WHOM TNCY ARF ADDPE{{[O ~
ANO TN CIR COMMVNICATION TO ANY OTNCM OR TH[ VLL OI THL NAM[ OP CERTIFIED TES TINE LABORATORIES, INC. MU{T R[C[IVt
OUk PRIOR WRITT[N APP ROVA4. `H/ REPORT) AND LLTYCR AND OUR NAM L, Ow OUw [CAL[, OR OUw IH[IONIA AR[ NOT VNbER ANY CIRCUM
- , mn ~n tu• RPNL RAL PU SLIC.
. s ' ~ ~ I NATIONAL
' BUREAU Of STANOAROS
C E ~t'!'R1~~~ E D LABORATORIES, i~~, ae~~p~
PHONE: (404) 2261400 • 1105 RIVERBEND pRIVE • P. 0. BOX 2041 • DAl70N, GEORGIA 30722.20d1
• , , s CARPET LAP
NO 0106
REPORT OP TEST tiUMBER 43592
March 30, 1988
CLIENT: Shaw Industries, Inc. Lab. Test No. 6421515032
P.0. Drawer 2128
Dalton, GA 30722-2128
SUBJECT: Carpet sample submitted and Sdentified by client as "73848 SITARA,
(031588-15)".
SMOKE DENSITY (NBS}
Smoke density tests were performed as directed in ASTM Test Method E G82-79.
The results of testing are as reported below. Detailed data are attached
hereto.
Operating Conditions
Radiometer Output: 8.1 MV Irradiance: 2.5 watts/sq. cm.
Fu[•nace Voltage: 115 V Burner Fuel: propane
Pressure: Positive Under Three Inches Of Water
TEST RESULTS
Flaming Mode Non ~Flamitlg Node
Average _ w Al~erage
Corrected Maxfmum Specific Optical Density
Di( (Corrected) 163 210
Specific Optical Density (DS) At 4.0 Min. 167 35
For CERTIFIED TESTING LABORATORIES, INC.
'JO Fra resident
lp
OUA LfiiER/ ANO ALPO RT/ ApPLY ONLY TO THL /ANDES TESTED ANO APL NOT N[C[L[ARILY INOfCATI VR O/ TNC OU ALITIRL OY APPARENTLY
tOCNtlCAL OR LIM ILAR RRODUCt1. THE/L LETTER/ ANO Rfp ORT/ ARE POR TH[ U[R ONLY O/ TM; CLI[NT TO WHOM THEY ARL ADOp C•S[O
ANO 7H[IR COMMVHICATWN TO ANY OTNEA/ OR THR VLL OP 7HR NAMR O/ CER T7 p1ED 7E8T7N6 LABORATORIE B, INC. MV/T RLCLfV[
OVA /RIO R_WRITT4N^ARROYAL. tH[ R[PORT[ AND L[TT [R0, AHD OVR NAN OR OLR LCAL{, OR OUR INLIO NIA AR[ NOT YN DER ANY CIRCVf9
- w AnvpRYlLlNO TO THE OCNLRA4 PU/LIC.
i sal.
NATIONAL
BUREAU OF STANOARD$
E R~'I~! E D lABORAtORiES, (nc, a~~p~
'HONE:~404)226~1400 • tt05RlVERBENDDRIVE ~ P. O. BOX 2047 • DALTGN,GEORGIA30722.2041
r r - CARPET LAp
NO 0708
ATTACHMENT TO REPORT NDMBER 43592
Flaming Mode
Chamber Temperature (Start) 100° F 100° F 100° F
Specimen Number: 1 2 3 pvg•
Minimum ~ Transmission (TM) 6.5 3.3 3.0 4.3
Timo To Attain TM (Minutes) 6 7 4 5.7
Maximum Specific Optical pensity (DM) 157 196 201 185
Clear Beam (DC) 21 21 24
DMC (Corrected DM) 136 175 177 183
SpeclPle Optical Density (DS) At 1.5 Ninutes 20 26 24 23 -
Specific Optical Density (DS) At 4.0 Ninutes 153 178 199 167
A'on-Flaming Mode
Chamber Temperature (Start) 100° F 100° F 100° F
Specimen Number: 1 2 3,~„ Av_g:__
Minimum 8 Transmission (TM) 1.1 3.6 4.0 2.9
Time Te Attain TM (Minutes) 17 19 20 18,7
Maximum Specific Optical Density (DM) 259 191 185 212
Clear Beam (DC) 2 1 1
pMC (Corrected DM) 257 19Q 184 210
Specific Opticai Density (DS) At 1.5 Minutes 2 2 1 2
Specific Optical Density (DS) At 4.0 Minutes 36 39 31 35
OUR L[TTCflJ AND RVOATJ APPLY ONLY TO THE BAM PLL Tdf T[O AHO ARC NOT N[CL98ARILV INDICATIV[ 01 TM[ OVALITItl O/ AP/ARLNTLY
ID[NTICAL OR [IM ILAR ARODUOT[, TNEBd LETTER[ AND REPORT[ AR[ /OR TN[ USt ONLY O/ TH[ CCI[NT TO WHOM iHdY ARC AODA[JDLD
AND TN [IA COMMV NICAiION TO ANY OTHLRa OR TNR UH[ O/ TN[ NAM[ O/ CERTI LIED TE571N6 LABORATORI[B, INC. MV[T R[C[IY[
OUR /RJOA WAITT[N A/PRO VA L. TH[ R[roM) AND LETYEAa, AND OUR NAM[, OR OUR tEAi[, OR OUR IN910 NIA AR[ NOT UNOCR ANY CfRCUM
m ea/e IM ADY CRT151N0 TO TN[ QEN[ftAL IU9LIG.
LINDSAY LIE BIG ROCHE ARCHITECTS FRANCIS M Rocxe A L A.
ASSO CLA TE
D A V I D G. H O L L O W A Y A I A
816 HARTFORD ROAD - WATERFORD
CON N 06385 - 442.169 442.4120
May 17, 1989
Mr. K~ Horton
Office of Building Official
P. O. Box 1179
Southold, NY 11971
Dear Mr. Horton:
Re: Alterations and Additions to
Fishers Island Country Club
Fishers Island, NY
Enclosed are two copies of the test reports for the carpet
installed in the above referenced project. Please forward one copy
to the Fire Marshal for his records. Thank you.
Sincerely,
LINDSAY LIEBIG ROCHE ARCHITECTS AIA
David G. Hol--oway, IA \
enclosures - 2
[ FORPd NO. 1
/ TOWN OF SOUTHOLD
BUILDING D[PARTI~+iENT
SOUTY,OLD, f1.Y. 11971
~~p.. TEL.:7G5-1202
Examincde S~~A~m1d?~r . ~ ~ , 19 ~ APplication No .
0 r
Approved 1 b, 19 Permit No..~.7~°~7.
Disal>provcd a/c
~
~~.....1?~~-a~,c~.~ .
(Building Inspector)
APPLICATION FOR BUILDING PERMIT `~?y,,~
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Build
Inspector, will: 3 sats of plans, accurate plot plan to scale. Fee according to schedule.
b. Plet plan showing location of ]ot and of buildings on premises, relationship to adjoining premises or public sire
or areas, and giving a detailed description of layout of property must be drawn on-the diagram which is part of this ap;
cation.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d. Upon apprcral of this application, the Building Inspector will issue a Building Permit to the applicant. Such. pen
shall be kept on [he 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 Occupar
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
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances
Regulations, for [he construction of buildings, additions or alterations, or for removal or demolition, as herein describ,
Tl:c applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and
admit authorized inspectors on premises and in buildings for necessary inspections.{
r(Signature of applicant, tlr name, if a corporation)
f....~..... o .
(Mailing address of applicant)
State whethzr applicant is owner, lessee, agent, arc!ritect, engineer, general contractor, electrician, plumber or build
~~e~
~ /
Name of owner of promises . (;!!~d .
(as cn the tax ;oil or latest deed)
If applicant is a corporation, signature of duly authorized officer.
....4 ~ ~ . .
(Nan and titlo of co ~ rate officer)
Builder's License No. L3,. P.~7~. `/~.L -
Plumber's License N:,. , . ~,Zj~,//`f~, , , , , , , , ,
Eh:ctrician's Liccnsc No. ..`?o2Y.: ; , , , . , .
Other Trade's License No. ..v73~--;.~~,~':. , , , , , , ,
I. Location of land on which proposed work will be done. .C~1~Y...~. , ..~~k~/~ ,~Sk~r~'
....~...7........
• House Number Street Hamlet
County Tax Map No. 1000 Section ......:y Block Lot .
Subdivision Filed \tap No. Lot .
(Name)
2. State existing use and occupancy of premises//and ,~inJntended use and occupancy of proposed construction:
a- Existing use and occupancy 7~~~ . ,(,dz4nG-/r/„ ~rlu~ .
@~ ~ lQ~t~
/[rt'~'~(. ~'Lt22. e2n~ ~a~CCC.ka ~~.r ~ c~ , ,~~rr1R~~
• Repair Re{vocal , ~liernolidon Other'rVork .
(Description)
(to be paid on filing this application)
i. It dwelling, number of dwelling units Number of dwelling units on each floor .
Ifgaragc,numbcrofcars
i. If business, conunercial or mixed occupancy, specify nahtre and extent of each type of use .
r. Dimensions of existing stntcttires, if any: Front Rear Depth .
Height ................N~unberofStories...,.......
Dimensions of same stntcture~,with alterations or additions: Front Rear .
Depth ..................',....Height • .........Number of Stories .
f. Dimensions of entire ne•,v construction: Front Rear ...............Depth .
Height ...............NuunberofStories.......................................................
Size of lot: Front .........i, Rear Depth .
Date of Purchase .........L ...................Name of Fonuer Owner , .
I. Zone or use district in wtticlt premises are situated .
Does proposed construction violate any zoning law, ordinance or regulation : .
3. ~4'il1 lot be regraded Wili excess fill be removed from premises: ,Yes Ni
1. Name of Owner of premises ...................Address Phone No.
Name of Architect ........j Address ,Phone No.
Name of Contractor .................Address ...................Phone No.............. .
I i
PLOT DIAGRAM I
Locate clearly and distinctly ~1] buiklirgs, whether existing yr proposed, and. indicate all let-back dimensions fror.
roperty lines. Give street and block number or description according to decd, and show street naanes and indicate whethe
acrior or corner lot. ~i
I
i
i
I
II
i
l
STATE OF NEW YORK, ~ S.S
COUNTY OF u (-~u I,k •
• • • • • • • • i ~ ~ , . . being duly sworn, deposes and says that he is the applican
(Name of ' dividual si ning contract)
rove named. 1/~ Q~
(Contractor, agent, corporate officer, etc.)
f said owner or owners, attd is d,i,ly authorized to perform or have performed the said work and to make and file thi
)plication; that all statements contained in this application arc true to the best of his knowledge and belief; and that th
ork will be performed in the manner set forth itt the application filed therewith.
worn to before me this
y l
.............da of ~ti9u:s-F......., 19gg.
rotary~y~P,~u~~bl~ic,~~ 4~b ~ ~ County _
• -"~"(1~ ti 1'~ MAR~`[~?~~!p, PANKIEW~ICG . , .C i/ii" • ur/ ~e,~~2~.~ii~, ,
a.%; ~ - ,VnTpRY ~,PgE~IC, STIt7E OF ~~rW VORN • • .
~ N4.,52~2879E0 ~ SUFFOIIf Q111lN'(V ,
i.MMIS'it1N E%PiRES y/va/9o •
i