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Home My WebLink About17522-z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No Z-18149 Date JUNE 28, 1989 THIS CERTIFIES that the building ACCESSORY TNGROUND POOL Location of Property 6300 MAIN RD. EAST MARION N.Y. House No. Street Hamlet County Tax Map No. 1000 Section 038 Block O1 Lot 1.1 Subdivision Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated OCTOBER 7 1988 pursuant to which Building Permit No. 17522-Z dated OCTOBER 11, 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 INGROUND SWIMMING POOL & FENCE AS APPLIED. FOR _____ The certificate is issued to JOSEPH & SUSAN CHEREPOWICH (owners) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A UNDERWRITERS CERTIFICATE NO. N042909 - OCTOBER 31, 1988 PLUMBERS CERTIFICATION DATED N/A ilding Inspector Rev. 1/81 rosaa xo. s TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MU5T BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N o ~i 17 5 2 2 Z Dote .....~.C'~sd:Qt-$.e...........~.L.........., 19.~.$. Permission is hereby granted to• ...A ..............'........ ~ ......~..~~.......... .-.~Q:?4.`..~:3` .......................................... .. ~.. I C# f ct premises located at ...W..w~ ....................°~:~..............:...................................... 0.1?:tr.!~!:?.............. .............. .. .. .... .. .... .. .. .. ........ (.~...~. .~. .. ~ .. . ~ ..... .. .... .... .................. .... .. ...... .. . . .. ...... .. . . ..... ... . . .... . ... .... ........ ... ..... ... . .... ........ County To Map No. 1000 Section ......Q.w~g....... Block ........Q.~........ Lot No....~.:.\ .............. pursuant to applicotion doted ....Q.G!~Grx?o-?1A......~ .................... 19~~..., and approved by the Building Inspector. Fee $.1 ~"D.:...:~... ...... / ~lM. .................. ..... . ........ ui ding Inspector Rev. 6/30/80 q III ~~~ TOWN OF SOUTIIOLD ~~~ 2 6 ~~~~ ~i ~ BUILDING DEPART2fENT ,. - ~`~~~ TOWN HALL \h~ROf-fI!i.f~~~'~°,' SOUTIIOLD, NEW YORK 11971 765 - 1802 APPLICATION FOR CERTIFICATE OF OCCIIPANCY DATE..~~~~__.. NEW CONSTRUCTION ._ ~_,OLD OR PRE-E%ISTING BUILDING......9ACANT LAND........ Location of Property....-~~,~,_ ~~/a.~~~-_.._-.~! /5/~~`_,-.-•- NOUSE NO. STREET ~~ ,/ LZ/Y ''~^/~„-, ,,/~/ - - - . HAMLET Owner or Owners of Property.:'J.(~>~/, _'r_~~~~~ ~ls~~y,y)An /ti '1 p' ' / . C7Ls.14 ~. ...... . County Tax Map No. 1000 Section ~ 3~, Block/~^~I Z/- 1/~l-.. Lot-.. .... Subdivision ....................... Filed Map ........Lot.......... Permit No. ./7S.o~:~..Date of Permit ,,Q~(/p~(~„Applicant .rC7f•./:`,f°f,(/fQ~S-,~VJc. Health Dept. Approval ....../I/~~1;..,,.. Underwriters Approval,l~~~~/p8.__. Planning Board Approval ... !?/~/.~,_,,,,,, 111 Request for Temporary Certificate ....... ~/ Final Certificate ................ Fee Submitted: $,,,,,,,,,,,,,,,,,,,, APPLICAN ~~~~'`'........... reVpp- 10/14/8/8 U l~P.t.. ~ ~) (a ~ Yi eo ~ lgigy lELD IliS:`cC;1U;i ~~DAiE ~ i;OhfMENT° ~.+ ~ t. " ~o m , ( : - ~ ~ y r FOUtJDATION (1st) - - o [' r c~ OUNDATIOtJ ( 2nd ) _ _ ~?„a z o ~ ROUGH FRAME & PLUMBING Y 3 ~ 3 ~ p o '~ . x 70. m m IIJSULATIOPJ PER N. Y. ., y STATE ENERGY k f~ CODE 9 x 4 d.~' r ~ . H ~• FZ;dM. ~2~ ADDITIONAL C ENTS: z m x x ro•~ H ,~ >! y \ H z '~O ~ . ~ M a _ r ~ ~ d m • H v ~ool3x? THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY QC"YORA:N 31 ~ Q~i JOHN STREET, NEW YORK, l~HIg7rFt8FiR/1SW738 N OQ?4O9 Dote Applicotion No. on file THIS CERTIFIES THAT Doty the alactrieat equipment w dsacrihed 6eloro and introduced by the ondicont nomsd on the shove epplicetlen numher in the promlaea q/ OSk:PH l1HFREPOAiCH, MATH ROItD, /P07~r: ~i?,7, w,AS'1,`-MfiRI'UN, N.Y,. ~r (rit'P in the JolloLCinp hrca~e~nR~ ~aae~ ^ tat F/. ^ Ynd Fl. ,Section Bloek LDt urea examined on and found to 6e in compliance aif.h the reyuiremenU of this Board. NItTURE ACIRS ~ SWITCHES NI(TURRS RA NOB CAOKIN6 DECKS O VlNS dSN W ASNNS El(NAU ST FANS S 1 ANDESCENT FIUDREKCENi v AMf. K. W. AMT. K. W. AMT. K.W. ,VAT. K. W. AMT. N. P. DRYMS f41M1ACE MOTORS NTURE MFLIANCE FHDE~ S/ECIAL REC'~i TReE ClOCR4 tllll UNR IN/1TERt MUli40UTIRT DIMMlRS AMi. K. W. dl N. P. GAS N. P. AMT. ND. A. W. G. T. P. AMT. P5. TRANS. AMT. N. P. ~ ~ ~T AMT. wAfTs SERVICE gltONNRCT NO.tM S E R V 1 C E AMT. AMP. TYPE ~ t / eW 1 B JW I B ]W 3 / AW ~. DPFR%C~D. OP CC. C D. NO.Oi NIAEG Of ~ W 1 0 ND. Or NEUTRALS OF ~P16UIGPAL OT~R AMIIRATU5: 1 Y *( Sii"fM}f7NG PpQI.} 'Phis cert'itcvlf!? r<rvers ~Otnpl,9.anec at the ctahe of lnBpE'Ct]On On~]r. NecaueP Ot' llil l)`+ilflf ~~.Et84~:rOREIEntR )t la adYi.aablea tL) have frequent test./and or ren:Tirs Di>Rde by a qua,l i f i ed per. r;~n. Jc>DY b~UFit:Y,f~Q .~'~ T'A9' t,ANY: MA'l"T1~TUt"R, NY. 17.95:? ti Al MAt1AOSR I~1CkiN;~x; NO_ 2"tllU b: ~ ~ ~ ~ Per i ~ This certificate must not bs altered in Orly manner; return to tM office of the Roord if incorrect. Inspadors may be iderrKTisd by tMir cradenNGls. OOrY ~ EINt.ORi6 DEPARTMENT. THIS COPY OF CERTIFIGTE MUST NOT ~E ALTERED IN ANY MANNER. A W ' ,.. 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'a % ,3 .~ £ Z, <y a DATE ~ 6' I ~ I a. „r, ~4&3:.~~.,`i' ,. ,.." ~~k~~, s ,...,~,. a~,) ~.,r . r,: ax,,~rn . t .. , r~~ nta ~. FEE ~s G . -.- ~tiV._~.L • OCGLG~.~NGY OR NOTIFY RUIL~NVG D~('rX~r;~'.nl h,~T AT gtl~~ e, 7&5-180? 9 AM TO + P~}" 'r(JN THE u~~''S,'Sd~~Aw~V`, FOLLOWING INSPECTI} ~~};; ' VUI~~NpU]' CERTIFICAT~~`; 1. FOUNDATION Tai,',7 r~EOt}iREG ~ ,Xas~ FOR PouREDCONCHe7e '`~~1F OCCUPANGY „.:,~; 2. ROUGH -FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST r.~t: ~ ~~ BE COMPLETE FOR C.O: If CoppCr tubing iS used ALL CONSTRUCTION SHALL MEET for WateP di8tributing „ ~~ ~;~;~ THE REQUIREMENTS OF THE N.v, system: piping shall b9 STATE CONSTRUCBON & ENERGY ''^ CODES. NOT RESPONSIBLE FOR of types K or L only '+~ ' DESIGN OR CONSTRUCTION ERRORS UNDERWRITERS CERTIFICATE REQUIRED ems' SUFFOLK CO. HEALTH DEPT. APPROVAL H. S. , NO, <;;F " r. ~'~ V !' STATEMENT OF INTENT : THE WATER SUPPLY AND SEWAGE DISPOSAL SYSTEMS FOR""`THIS RESIDENCE WI ~ LL ~ ~ ~ CONFOR ~~O TWE~ST ARbS'OF~.THE /; ~ ~ ~ SUFFO " DE EALTH SEitVI S. Ear" ( ;' ~sl /~ ~ °~ A P CANT- ; ~4: 'SUFFOLK 'COUNTY DEPT`„=' OF > HEALTH ^ ''S ~'~1/~I'?~/$D'- h""k3~, ' ; :,,SERVICES- '~` FOR ~ APPROVAL ~OF, :' ~a~. ~.~+~~~ r•~~~~,~.~y,.,,~~~' , ( J ~^Z ; , ~~bNSTRUGt,-ON ONLY TE - ,r~ -. D ._ . _ _ ' .. (._._. -,...,.~-~v.,.,. ~ , A A7, ~ ,H. S:~REF. NOi' ` "' ' ;APPROVED; ~v1Ar,~iaM E~sr ~.,/~'yt/ ypy~~, SUFFOL,IE~',CO. TAX MAP DESIGNATION: " >- ~ gIST ,~'~SECT: ~= ~' ~ . BLOCK %~' ~ PCL. OWNERS.AgbRE35: c~ G' A L Gt' : ~4.r". J ~i A~~Ax ~3Q C30~J` S~ ~7 ~ ~~+.~7`' n9.4~~r~+V, hl.~Y. 1199 ~. _..- _.... ..~.___....~..~..._..~_. _m_ C~~~taurs f'io.r! .lrr ll' Cv rrra ~'"a ba b T'~,*t.~ '477-O9f.~d , ~ . ~ .r ~ , ! ' ~ DEED L. ~ P. •TEST HOL '-- 5 AMP :~ 3 I .i. .:'.. ? a ' f. ~ Una~h 1 lt " a! a watwn w adikbn 7.30/,f ~ to thi9 UNey Ic b WelMlbn bi ' Saedon 7204 of tho Naw Yark >ZtAtO _ .. - .. ~ ~" ~' Copia4 6f thin Purvey mep riai baOMnj ' ~ .~ ~O (T i7- ~' : ~ ~ tn(r (and eunrayo(Y inkad ten{ a . _ r ,_ . ' emtbesad anal slMll nei.6e cbneiltred to W e valid We copy. -~ ~- . ~ ' x ~ ., b' ~ _ Oua(arreaae IrMkatad ftareort phptl nin ' 6PIY IO ih6 pe(tbP fal Wiiael the tUNay ' ' IB prepared, end on tdt Lahaif t0 ttro ' i ;: title compBnV. ebvammenial agaPCy afe/' - ~ ~ ;. ~~ ~~ ~:: 'r lending Inetitutlpn Ilatbd hereon and to the aBi , r ~ - ~F.c ~ fdd~ ~ "- e gnaea of the iendtny Mtti , lotion. Ciaa(amaea pe TM ttantbr.bia c tP audr i l Y , ., s r , t pna nttitudont er tuWeetnM . r .',SEA '~% ~a : F NP :° ~ - p Ly 6 ~~ MAi'aCtltri~~Vl~f.1 Y4 ~~#(~ b ~+ '' LICENSED LIAfVq'BURVE C9REENMkJR7 't N6W ~ rv '~' ` ~''- f~ ~GK V~, dip "~v 4~ ~~;; ( h s~ p lANO~ i t t V ~ f s~' ~ r~~ ,~: ~~~ h.++ r K , D ~'(".1. (---~C\/'J~~----"-' FORMN0.1 `` LL \~J TOWN OF SOUTHOLD OL'T ' BUILDING DEPARTMENT 7 I9$$ TOWN HALL POUTHOLD, N.Y. 11971 gLp~, pE~,:i TEL.: 765-1802 TOWN OF S UTHOLO Q Examined to ......... .... 19 .. . Approved a~~..`}''~'~'`...~.i...,19~~.PermitNo. ~.?.~.?-?-.~ Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Received...........,19... Date ... J.Q~G........., 19 2i~ a. This application must be completely filled in by typewriter or in ink and submitted'to the Building Inspector, with 3 sets 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 b"y the Building Inspector. APPLICATION IS HEREBY MA~E to the Building Depaztment 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 p p g essary inspections. admit authorized ins ectors on remtses and in buil in or net (Signature of applicant, or name, if a corporation) (mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises SP' •V `!~~~~•~! • • • • •~t•i•~~~• !`~~ ~•1•~•H• • • • • • • • • • • • • ........... .... (as on the tax roll or latest deed) If pl t is a torpor do ignature o duly authorized officer. (Name and title of co o to officer) ^^~~ q r - Builder's License No......4 !.Z :.1~•-L ........ . Plumber's License No . ....................... . Electrician's License No . ..................... . Other Trade's License No . .................... . ~.~ a a ~+ aS ~ ~~4nro.~ 1. Location of land on which proposed work will be done . ..............~, ................ .............. . House Number Street ~ Hamlet // County Tax Map No. 1000 Section ...... Q~.~...... Block .......I .......... Lot .....Ca ~......... . Subdivision ... _......' ............................ 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 ......... ~ `:~1 ~~~ ! ~!~ ~ ........ . b. Intended use and occupancy ........ /"'~31 ~~T~~.Ly~+¢?.~~i,-~.~;*~pgQ ~z,,,~G" 3. Retuair of work (check which applicable): New Building .......... Addition .... , ..... Alteration .. . . p ...... .Removal .............. Demolition ..............Other Work ..... ........ . (Description) 4. Estimated Cost ....... ,~~z~0; ~~ .................. Fee ......................~............. , . ', (to be paid on filing this application) 5. If dwelling, number of dwelling units ............... Number of dwelling units ion each floor ............... . If garage, number of cars ....................................................................... 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use .................... . 7. Dimensions of existing structu#es, if any: Front .........:.....Rear .............. Depth .............. . Height ...............Number of Stories ....................................................... . Dimensions of same structure with alterations or additions: Front ............. . ... Rear ................. . p .' ...Height ......................Number of Stories ..................... . De th ................... 8. Dimensions of entire new construction: Front ............... Rear ...............Depth .............. . Height ...............Nu3nberofStories,............................................,.......... 9. Size of lot: Front ......... ............ Rear ...................... Depth ...................... 10. Date of Purchase .........:................... Name`.of Former Owner .................. , ......... . 1 I . Zone or use district in which premises are situated ......... ~~! ~~!7T.f1 ~ ............................ . 13. Will lot be re raded I late any zoning law, ordinance or regulation: ..... !?~ ....................... . 12. Does proposed construction vi~~~o ~«l~ Address ...................Phone No............... . 14. Name of Owner of premises . •y~s........ , ' ' ' ' ' • Will excess fill be removed from premises: Yes No Name of Architect ........... ... Address .. . ................Phone No...,,^^~~ . .. .... y Name of Contractor ..t}.:~Z~:~I~G y¢.. ~.~... Address h?fg7~"Y.~~.. Q.l~, ,Phone No..a4~~:. y~ ~>( . 15. Is this property located within 1.00 feet of a tidal wetland? * Xes ..... No ..... * If yes, Southold Town Tzustees Permit may be required. PLOT DIAGRAM ' Locate clearly and distinctly all buildings, whether existing or proposed, and, indicate all set-back dimensions from property lines. Give street and bloc~C number or description according to deed, and show street names and indicate whether interior or corner lot. ' aE 5~~~ ~ TG~~~ S~.rrc ~~~ _-- STATE OF NEW Y RK 4 COUNT OO~m~ ~ S.S ..... . /v... y~. ~G:~~ .4/. d. :..... being duly sworn, deposes and says that he is the applicant (Name of indivi al signing c ntract) above named. 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 mak8 and file this application; that all statements cogtained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manger set forth in the application filed therewith. Sworn to before me this '~ n ~-- .............. . ~~ ..day of .....~.C!rf ... ...., 19 ..~ ~/~ ~ ~c~ Notary Public, .. ~~~a~/aY. ~ . County ',,_ ` ~ ~~ _ QuelHied In 9uNn r.,....... ,~..~. (Sig of applicant) FORM NO. t TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. 11~J71 TEL.: 765-1802 C•xamincd ... ..... Approved ... ....., .. not o. .. ...... BOARD OF HEALTH ............ 3 SETS OF PL.\NS ............ SURVEY ..................... CHECK ...................... SEPTIC I'ORM ................ NOTIFY CALL ............... .... MAIL T0: y,,_ ~~~~ f~yF, ~{~?-a~~~ )~/~,~ Disapproved a/c ..................................... ? • (Building Inspector) Y APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Date .......'~~/.7....., 159 a. Tltis application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 sets 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 Re;ulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. The applicant agrees to comply with all applicatite laws, ordinances, buildingodg,'ho ing code, and regulations, and to admit authorized inspectors on premises and in building for necess,,rry`ir~tspectio s, [ure of appl~ic°an , or name, if a corporation) (Marling address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. .............~rJ.~.e't/........../............../.... ....................................... Name of owner of premises ...~~CG ..!~. ~~L~.~N ..~11~i/~L°~L7GG1l.~~ .......................... . (as on the tax oll or latest deed) If applicant is a corporation, signature of duly authorized officer. •--._, (Name and title of corporate2officer) // Builder's Licensc No. ....~-, l ~f~~~7.~..... . Plumber's License No. ..:- .................. . Electrician's License No . ... ................ . .--- Other Trade's License No . .................... . 1. Location of land on which proposed work will be done. . ~`. /.v~. , ,,~fogjit( /C4yf~ • • • • • • . , I{ouse Numbcr Street. Hamlet pp'~ ~ County Tax htap No. 1000 Section .. D.D.. • • • • ... • . BI'ock ....../ , • , , , • , , , • Lot .... /".~ ......... . Subdivision ..................................... Filed t•Iap No. .............. Lot .............. . (Name) -. State existing use and occupancy of premises an/d int//ended use and occupancy of proposed construction: a. Existing use and occupancy ... ~.! i'.M!!y.. /s-••G Si r•~4'!/('t'!......... .......................... . JJ ... • b. Intended use and occupancy .. • • • • • ~~~~• •~I~'•~• •~~~ A~L~,../Q ~~~ 3. Nature of work (check which a~'pplicable): New Quilling .....•..... Addition .......... Alteration Repair .............. Removal .............. Demolition ... .... • • • • • • .Other Work .~,Gl~• t,Fen1Gr~' ,~92°~c.U+J l~o~ (Description) 4. Estimated Cost ............'I~A°~~. ~ ................... Fee ............... .. . .. .................. 5 If aara'le number of carsvelhn ~I (to be paid on filing this application) g u its ..... ,r', , , , , , , , . Number of dwelling units on each floor ... , ~- b n ~.•....... ~ .~ y.•. •.•••••.. 6, If business, commercial or mixc,d occupancy, specify nature aqd extent of cachaype of,use .. • • 7. Dimensions of existing structures, if any: Front . :Rear ~ 'I. ~ ~ • ~ • • • • • • • ' Height .......... Number of Stories • .......... ........... . .. Depth.............. . Dimensions of same structure with alterations or additions; Pront • • • • • • • • ' • • • ' ' ' Depth ....... . 'r .. lIcight . ......... • .'- ............. Rear ................. . 8: Dimensions of entire new constntction: Front , ' ' ' ' ' • • • • • Number of Stories ..................... . Height .............. Rear...,.............. Depth .............. . Number of Stories . ,a, , ; • ., • • . ~ 9. Size of lot: Front ..'~.S.d, ..... Rear .....`~i,~,u ...............................: i . .. ... .. ............. Depth 10. Date of Purchase , ......./, 9$7• • • • ame of F enOt er • • • • • • ........... . . 1 1. Zone or use district in which premises are situated . , , , ~O, , • 12. Does proposed construction violate any zoning law, ordinance or regulati~,,~/'~ • • ~ ~ • • • • ~ • • • • • ~ • ~ • • • • • • • • ' 13. Will lot be regraded ...., t~„ "•'•"•••••••••••••••••~•••••. ~-r/~ 1Vill excess fill be removed fro remises: Yes No 14. Name of Owner of premises ~J,1~~{;~,t~i~~~~~ddress I~SCk~,(Yfo,~,/ j2~,p,~ ~asTne No. Name of Architect ~ ~7~'d• •~~• • . . •i.>ly__,~y_~•••••..•.•.,Address . .PhoneNo.. Name of Contractor (.6/f~ Tt?~'C~J ~~q,, .Address ~9Ke~Feyp fr/,/,n~• •~r• • • ~ • • • • • • • ' IS.Is this property located within ,Phone No.°f.7„];-/¢/D{{,~ •. 900 feet of a tidal wetland? *YES,.,.NO 1C. *If yes, Southold Town Trustees Permit may be required. _. I PLOT DIAGRAM Locate cleazly and distinctly all~l buildings, whether existing or proposed, and indicate all set-back dimensions from property lines. Give street and block ;number or description according to dead, and show street names and indicate whether interior or corner lot. ~re,e- ,~ -f~ ~t G ~cQ ~~cru~~ey 3 yo~t ~{~ STATE OF A'EW~1'ORI` COUNTYRF ..~~~~ k , , , • S.S .,b I. • • • • • • • ' , ~~ ~.~.. • • • • • • .... being duty sworn, deposes and says that ho is the applicant (i\a c of individual signit)g contract) above named. He is the ...................... .... (Contractor, agent, corporate officer, etc.) • • • • • • • • • • • " " " of said owner or owners, and is dulyiau[Itorizcd to pgrform or have performed the said work and to mane and file this application; that all statements contained in this application arc true to the best of his knowledge°and belief; and that the work will be performed in the manner Set forth in the application Filed therewith. Sworn to before me this ' • ............~(.~.......dayof.'.. ~~:" ......., 1981 Notary Public,(~'~"'~, !(l; • • • • , • • ~t,~~~, ~ County O RUTH M. MY S ' NOTARY PUBLIC, Stets of New York • ~~~ a(,~..... . No. 52 • Y841400 ' Gtuelif4d in Suffolk Coupty (Signature of applicant) CommUeion Expkee Aprlt 30, j19 Q'P -