HomeMy WebLinkAbout27598-z FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-27922 Date: 09/07/01
THIS CERTIFIES that the building REPAIR
Location of Property: 5075 MAIN RD LAUREL
(HOUSE NO.) (STREET) (HAMLET)
County Tax Map No. 473889 Section 125 Block 1 Lot 13
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated JUNE 22, 2001 pursuant to which
Building Permit No. 27598-Z dated AUGUST 17, 2001
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 STRUCTURAL REPAIR TO EXISTING PARTIAL FLOOR SYSTEM IN EXISTING
SINGLE FAMILY DWELLING AS APPLIED FOR.
The certificate is issued to HAROLD AVENT
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
ELECTRICAL CERTIFICATE NO. N/A
PLUMBERS CERTIFICATION DATED N/A
Autho zed Sign ure
Rev. 1/81
FORM NO. 3
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)
PERMIT NO. 27598 Z Date AUGUST 17, 2001
Permission is hereby granted to:
HAROLD AVENT
PO BOX 966
MATTITUCK,NY 11952
for
STRUCTURAL REPAIR TO EXISTING PARTIAL FLOOR SYSTEM IN EXISTING
SINGLE FAMILY DWELLING AS APPLIED FOR.
at premises located at 5075 MAIN RD - LAUREL-
County Tax Map No. 473889 Section 125 Block 0001 Lot No. 013
pursuant to application dated JUNE 22 , 2001 and approved by the
Building Inspector.
Fee $ 150 . 00
Author ed Si ature
ORIGINAL
Rev. 2/19/98
PROFESSIONAL ENGINEER
1725 HOBART ROAD/PO Box 616, SOUTHOLD, NEW YORK 11971
TEL 631-765-2954 • FAX 631-614-3516 • e-mail: joseph@fischetti.com
Date: June 27, 2001
Reference: Avent Property
Mr. Gary Fish
Southold Building Department
Main Road
Southold,NY 11971
Dear Mr. Fish,
With regard to the above referenced property, the design submitted was for the cellar
portion of the floor structure only. No representation can be made as to the structural integrity of
the crawl space because of the limited visibility available.
I can not make neither positive nor negative representations as to the soundness of the
remaining portion of the floor structure. If a further inspection reveals no negative indications,
such as floors not level, walls with cracks, doors that do not close, it be could assumed that the
remaining structure may not contain any defects. There can be no determinations of the
soundness of the floor structure without the complete removal of the floor surface to completely
inspect the sub-structure.
If you have any questions regarding this matter please call.
e truly yours,
Jos ph Fischetti, PE
GC
AUGUST 8,2001
AFTER INSPECTING THE HOUSE AT 5075 MAIN ROAD, LAUREL, WE MADE
THE ACCOMPANYING DRAWING AND FOUND THE FOLLOWING:
1. THE HOUSE WAS BUILT APPROXIMETALY 1760 AND WAS BUILT
WITH THE LOCAL BUILDING MATERIALS OF THE TIME.
2. THE HOUSE HAS SETTLED OVER THE YEARS OVER THE OLD
CHIMNEY BASE,APPROXIMATELY 8' X 9', WHICH DUE TO ITS SIZE,
HELD ITS ORIGINAL HEIGHT. THE HOUSE SETTLED DOWN AROUND
THE CHIMNEY BASE AND SEEMS TO BE HOLDING ON A STATIONARY
CONDITION NOW.
3. THE VARIED SIZE FLOOR BEAMS AND GIRDERS HAVE SOMEWHAT
OF A SOFT SHELL ON THE OUTSIDE BUT ARE STILL SOLID INSIDE.
SOME HAVE BEEN REPAIRED WITH NEWER 2"BEAMS SISTERED TO
THEM ON THE WEST SIDE
4. A SUBSTANTIAL REPAIR HAS BEEN MADE IN THE ROOT CELLAR
WITH A NEW SUPPORT SYSTEM.
5. WITH GOOD MAINTENANCE THE HOUSE SHOULD BE FINE.
�ti�
I it4l
POL SEQ: 63
THE STATE INSURANCE FUND
199 Church Street New York, N.Y. 10007
(516) 233-3846
Document Type: Group No: Period Covered: . R.B. File No:
NYCCPAP 468 4/01/2002 - 4/01/2003 586 481R
ASSURED: G 496 538-0 GROUP MANAGER: 469
Policy Number:
DAVIS BROS ENGINEERING CORP LOVELL SAFETY MGMT CO L L C C 486 538-0
P 0 BOX 6 125 MAIDEN LANE Data:
BLUE POINT NY 11715 NEW YORK NY 10038
Bill Number:
N/A
NEW YORK CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM
WORKERS COMPENSATION PREMIUM CREDIT APPLICATION
The New York Construction Classification Premium Adjustment Program is available to qualified employers engaged in
construction operations and is applicable for new and renewal policies effective on or after April 1, 1993. In order
to qualify for the program the following conditions must be met:
1. Your policy must have one or more eligible construction classifications.
2. Your policy must be experience rated.
3. You must have an hourly wage of $13.00 or higher effective April 1, 1997.
The eligible classifications for the renewal effective 4/01/2002 are shown on the reverse side.
A special premium calculation, which may result in a premium credit for you, will be based on average hourly pay
rates for each classification of construction operations. If you qualify for this program, please send the completed
Premium Credit Application to the New York Compensation Insurance Rating Board so that your premium credit may
be correctly established.
New York Compensation Insurance Rating Board
200 East 42nd Street
New York, NY 10017
Attention: Auditing Division
PLEASE DO NOT RETURN THIS FORM TO THE STATE INSURANCE FUND
The Board will advise us of applicable premium credits. We shall apply the initial credit, and any subsequent
revisions, based on advice we receive from the Board.
WITHOUT AN APPLICATION, YOUR PREMIUM WILL NOT REFLECT ANY PREMIUM CREDIT. A NEW
APPLICATION MUST BE FILED EACH YEAR IN ORDER TO BE CONSIDERED FOR A PREMIUM
CREDIT UNDER THIS PROGRAM.
For each classification (both construction and non—construction) covering your company's operations in the State of
New York, report the total New York payroll (excluding overtime premium pay) and the corresponding total number
of hours worked, for the third calendar quarter (JULY, AUGUST, SEPTEMBER) as reported to taxing authorities for
the year preceeding your policy effective date.
Note #3: If you did not engage in construction operations during the third quarter as'indicated on the
Application, the requested information to be provided should, then, be for the last complete
calendar quarter prior to the effective date of your workers compensation policy for which
there was payroll for eligible construction classification codes.
Note #3: If you are a new business (no prior operations), submit the requested information, for the
first complete calendar quarter following the effective date of your workers compensation
policy, when available.
Note #3: In the absence of specific records for salaried employees, you should assume that each
individual worked forty (40) hours per week.
Please retain your payroll records on which this application is based. For you to receive any premium credit to which
you are eligible, we are required to verify, by audit, the reported information.
Thank you for your cooperation.
THE STATE INSURANCE FUND
U72SA1 (9/2000) Turn Page Over For Premium Credit Application
NEW YORK
WORKERS COMPENSATION-PREMIUM CREDIT APPLICATION
INSURED DAVIS BROS ENGINEERING CORP BOARD FILE NO. 586 481R
POLICY NO. G 486 538-OEFFECTIVE DATE 4/01/2002 CARRIER The State Insurance Fund
NOTICE: This application will not be processed unless it is signed and completed in its entirety. Contact your agent,
broker or insurance company if assistance is needed.
1. Classification(s), Code(s), Total Wages Paid for residential work only or Limited Payroll for commercial work
applicable to the Payroll Limitation Law, Total Hours Worked and calender quarter reported must be indicated. The
Classification(s) aand Code(s) applicable to your policy currently are shown. You may add additional classification(s)
and code(s).
2. Construction and non-construction wages must be included. DO NOT include the payrolls for subcontractors and
independent contractors.
3. Each executive officer's wage and title is to be separately shown under the appropriate classification code. Hours
worked for each executive officer are to be stated as 520 per quarter. TOTAL
NEW YORK TOTAL
CLASSIFICATION WAGES HOURS
CODE PAID* WORKED
--------------------------------------------- ---------- --------------- ----------
BUILDING MOVING-SHORING ETC&DRVRS-U 5703
--------------------------------------------- ---------- --------------- ----------
TERRITORY 2 DIFFERENTIAL 10.0°OA 9127 N/A N/A
--------------------------------------------- ---------- --------------- ----------
CLERICAL OFFICE EMPLOYEES NOC-U 8810
--------------------------------------------- ---------- --------------- ----------
CONTRACTORS PERMANENT YARDS ETC-U 8227
--------------------------------------------- ---------- --------------- ----------
TERRITORY 2 DIFFERENTIAL 10.0% 9127 N/A N/A
--------------------------------------------- ---------- --------------- ----------
SALESMEN-COLLECTORS OR MESSENGERS-U 8742
--------------------------------------------- ---------- --------------- ----------
PAINTING OR DECOR&DRVRS NOC--U 5474
--------------------------------------------- ---------- --------------- ----------
TERRITORY 2 DIFFERENTIAL 10.0% 9127 N/A N/A
--------------------------------------------- ---------- --------------- ----------
--------------------------------------------- ---------- --------------- ----------
--------------------------------------------- ---------- --------------- ----------
*EXCLUDING OVERTIME PREMIUM PAY. Overtime premium pay is the wage paid above the straight time hourly pay.
Ex: If an employee earns $20/hr, but earns overtime pay at an hourly rate of $30 or more, exclude any wage paid
over $20/hr rate.
THE FOREGOING IS BASED ON ACTUAL WAGES AND HOURS WORKED,
AS REFLECTED IN OUR PAYROLL RECORDS, FOR THE COMPLETE
CALENDAR QUARTER ENDING SEPTEMBER, 2001
SIGNATURE TITLE DATE
TELEPHONE NUMBER
U729C (9/2000) U729CI
Diane Herold,Architect
P.O. Box 884
Westhampton Beach,New York 11978
August 27,2001
Building Department
Town of Southold
P.O. Box 1179
Southold,New York 11971
RE: 5075 Main Road,Laurel
Gentlemen:
On August 3,2001,Ernie Davis,Davis Bros. Engineering Corp.,and I inspected the
foundation of Harold and Loretta Avent's house at 5075 Main Road, Laurel. This
inspection was made to ascertain the condition of the foundation and floor framing only
and provide the information to the Town of Southold Building Department for purposes
of review for the issuing of a Certificate of Occupancy for the building.
Ralph Williams of Orient and a respected historian in the area had looked at the house
and estimated the original structure dated to the 17602. This house is typical of houses of
this age that have sloping floors and doors that have been cut to that slope. In particular,
the floors of this house slope away from the large central fireplace foundation consisting
of solid rubble,brick and stone. The foundation below the original section of the house
is stacked stone. The foundation below the rear addition is concrete block creating a
cellar for the mechanical equipment and a crawl space. The original floor joists are hand-
hewn logs that are mortised into log girders. The floor joists in the rear addition are
standard lumber. In the original root cellar, standard lumber has been recently used for
floor framing to support the deteriorated floor joists.
The existing foundation shows no evidence of continuing deterioration at this time and
has stabilized. Also,at this time,the floor joists are in stable condition. For the age of
the house and foundation, it is reasonable to expect the conditions that exist. With good
maintenance,the house should continue to have a stable foundation and floor framing.
�,cERED ARCO, Sincerely,
S
Fi EROS �� •
O as O
Diane Herold
S+� 14061
O
ATF OF `��y
AUGUST 8, 2001
AFTER INSPECTING THE HOUSE AT 5075 MAIN ROAD,LAUREL, WE MADE
THE ACCOMPANYING DRAWING AND FOUND THE FOLLOWING:
1. THE HOUSE WAS BUILT APPROXIMETALY 1760 AND WAS BUILT
WITH THE LOCAL BUILDING MATERIALS OF THE TIME.
2. THE HOUSE HAS SETTLED OVER THE YEARS OVER THE OLD
CHIMNEY BASE,APPROXIMATELY 8' X 9', WHICH DUE TO ITS SIZE,
HELD ITS ORIGINAL HEIGHT. THE HOUSE SETTLED DOWN AROUND
THE CHIMNEY BASE AND SEEMS TO BE HOLDING ON A STATIONARY
CONDITION NOW.
3. THE VARIED SIZE FLOOR BEAMS AND GIRDERS HAVE SOMEWHAT
OF A SOFT SHELL ON THE OUTSIDE BUT ARE STILL SOLID INSIDE.
SOME HAVE BEEN REPAIRED WITH NEWER 2"BEAMS SISTERED TO
'ITEM ON THE WEST SIDE
4. A SUBSTANTIAL REPAIR HAS BEEN MADE IN THE ROOT CELLAR
WITH A NEW SUPPORT SYSTEM.
5. WITH GOOD MAINTENANCE THE HOUSE SHOULD BE FINE.
�All GAt"
NEW YORK CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM
APPLICATION INSTRUCTIONS
1) Determine the classification code applicable to a// employees of the business. This
includes clerical workers, salespersons and executive officers (unless they are excluded
from coverage) but does not include subcontractors and/or independent contractors.
2) List each classification code on the application (unless the insurance carrier has already
done so). This includes both e/i ib/e and non—a/ioib/e classification codes.
3) For policies effective prior to 4/1/01, determine the total gross wages (excluding premium
overtime pay, bonuses, commissions) and hours worked for each employee. For policies
effective on or after 4/01/01, determine the limited payroll (excluding premium overtime
pay, bonuses, commissions) and hours worked for each employee performing commercial
work in accordance with the Payroll Limitation Law. For employees performing work on
one or two-family residential housing, report the total gross wages and hours worked.
The program uses the third quarter (July, August and September) payrolls as shown
below:
Policy Inception Date Third Quarter Payroll
April 1, 2001 thru March 31, 2002 2000
April 1, 2002 thru March 31, 2003 2001
April 1, 2003 thru March 31, 2004 2002
April 1, 2004 thru March 31, 2005 2003
(Premium overtime pay is the amount paid over and above straight time. As an example,
if someone worked 40 hours @ $6 an hour and 2 hours @ $9 an hour, the employee
should be included on the application for 42 hours @ $6 per hour ($252). The additional
$3 paid for the 2 hours of overtime is excluded as long as the payroll records are
properly maintained.)
Total the payrolls and hours worked by classification code as well as by the type of
worked performed (rsidential or commercial). List each applicable classification code on
the application showing the residential total payroll and the limited commercial payroll
on separate lines. This means that the same classification code could appear twice on the
same application. Hours worked for non-eligible classification codes are not required. The
payrolls of all employees are to be included, even those earning an hourly wage that is
less than the minimum hourly wage for eligibility under the program (currently $13.00
per hour).
The program grants credits bases on the average hourly wage for those classifications
codes eligible for the program. If an employer has more than one policy which can be
combined for experience rating purposes, include the total wages and hours worked for all
policies on the application. An example of this would be wrap-up policies. —
4) List each executive officer on a separate line showing the applicable classification code
for each executive officer. Also indicate each executive officer's title.
5) List the actual quarterly wages for each executive officer. The Rating Board will make
any adjustment for minimum and maximum wages when the application is processed.
Include each executive officer for 520 hours if they are classified under an eligible
classification code. Hours worked are not necessary if the executive officer is classified
under an ineligible classification code.
6) Sign and date the application and mail the application to:
New Vork Compensation Insurance Rating Board
200 st 42nd Street
Nev irk, NY 10017
At n: Audit Department
(SEE REVERSE SIDE)
ELIGIBLE CLASSIFICATION CODES
0042 5102 5402 5506 5703 6235 7538
3365 5160 5403 5507 5709 6251 7601
3724 5183 5428 5508 6003 6252 7855
3726 5184 5429 5536 6005 6254 8227
3737 5188 5443 5538 6017 6259 9526
5000 5190 5445 5545 6018 6260 9527
5022 5193 5462 5547 6045 6306 9534
5037 5213 5473 5606 6204 6319 9539
5040 5221 5474 5610 6216 6325 9545
5057 5222 5479 5645 6217 6400 9549
5059 5223 5480 5648 6229 6701 9553
5069 5348 5491 5651 6233 7536
PROGRAM CREDITS
Average Credit From Average Credit From
Hourly Wade Manual Premi m Hourly Ware Manual Premium
Under $13.00 0% $24.01 - $24.50 19%
$13.00 - $14.00 3% $24.51 - $25.00 20%
$14.01 - $15.00 4% $25.01 - $26.00 21%
$15.01 - $16.00 5% $26.01 - $27.00 22%
$16.01 - $17.00 6% $27.01 - $28.00 23%
$17.01 - $18.00 7% $28.01 - $29.00 24%
$18.01 - $19.00 8% $29.01 - $30.00 25%
$19.01 - $19.50 9% $30.01 - $31.00 26%
$19.51 - $20.00 10% $31.01 - $32.00 27%
$20.01 - $20.50 11% $32.01 - $33.00 28%
$20.51 - $21.00 12% $33.01 - $34.00 29%
$21.01 - $21.50 13% $34.01 - $35.00 30%
$21.51 - $22.00 14% $35.01 - $36.00 31%
$22.01 - $22.50 15% $36.01 - $37.00 32%
$22.51 - $23.00 16% $37.01 - $38.00 33%
$23.01 - $23.50 17% $38.01 - $39.00 34%
$23.51 - $24.00 18% $39.01 and over 35%
THE NEW YORK COMPENSATION INSURANCE RATING BOARD REQUIRES
THAT THE ENCLOSED APPLICATION BE SUBMITTED TO THE RATING BOARD
SIX (6) MONTHS IN ADVANCE OF THE POLICY RENEWAL DATE. ANY
APPLICATION SUBMITTED SUBSEQUENT TO THE DUE DATE MUST BE
ACCOMPANIED BY A LETTER EXPLAINING THE REASON FOR THE DELAY.
THE RATING BOARD WILL NOT ACCEPT ANY LETTERS AND APPLICATIONS
WHICH ARE RECEIVED MORE THAN TWELVE (12) MONTHS AFTER THE
POLICY EFFECTIVE DATE.
U-729J
U72911 - 9/2000
ASSURED: G 496 538-0 GROUP MANAGER: 469
DAVIS BROS ENGINEERING CORP LOVELL SAFETY MGMT CO L L C G 496 538-0
P 0 BOX 6 125 MAIDEN LANE
BLUE POINT NY 11715 NEW YORK NY 10038
N/A
n BOARD OF HEALTH
. . . . . . . . . . . . . . .
FORM NO. 1 3 SETS OF PLANS
q TOWN OF SOUTHOLD SURVEY • . . • . . .
BUILDING DEPARTMENT CHECK . .. . . . . . . . . . . . . . . . . . . . . . .
�= TOWN HALL SEPTIC FORM . . . . . . . . . . . . . . . . . . .
SOUTHOLD, N.Y. 11971
7!' _ r' D TEL: 765-1802 NOTIFY: f-! - �(o0�
CALL . . . ./7 //. . . . . . . . . .
Examined.................. 20.... "� e 39p MAIL TO: . . . . . . . . . . . . . . . . . . . .
.�J 5
Approved.................. .... Permit No ..� ...................................
Disapproveda/c ..................................
...................................
......................................................
_ ................................
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
Date. . . . . . . . . . . . 20.
INSTRUCTIONS
a. 'This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector wi
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 application.
.c. The work covered by this application may not be meed before issuance of Building Permit.
d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such
tCrmit 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 HERESY MATE 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.
.....................................................
(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 / l
...�--.. ....!J.:........ ...........................................................
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
.........................................................
(Name and title of corporate officer)
Builders License No. .........................
Plumbers License No. .........................
Electricians License No. .....................
0
Other Trade's License No. ....................
1. Location of land on which proposed work 'll be done..................... ... ...
............................ ? . �. ✓�� �� ............................
_ ....................................
House Number Street Hamlet ... .. ...
County Tax Map No. 1000 Section .. ..... Block .........I...... Lot ......13.......
Subdivision ...................................... Filed Map No. ...
Lot ...............
(Name) ........
2. State existing use and occupancy of pr j s and * tended use and occupancy of proposed construction:
a. Existing use and occupancy ...........:✓.
LV /11. ...........................................
b. Intended use and occupancy �, fie`/��
3. Nature of Work (check which applicable): `
pP ): New Building .......... Addition
Repair .. .... Removal ........ .......... Alteration ... .....
• ..... Demolition ............ Other Work .......................:..........
3 OD1D / (Description)
4. Estimate(] Cost .... ........... fee
°
(to be paid on•filing.this•application)
S. 1E (LielIing, mxiivr of dwelling units ............ Number of dwelling units on each floor ................
ifgarage, number of cars ......................................
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use.........-
7. Dimensions of existing structures, if any: Front................ Rear ..... Depth ..••.••.•..
height torics Number of S ... _ _ .
Dimensions of same structure with alterations or additions: •Front - .• . Rear
Depth .................... Height .................... Number of Stories...............................
8. Dimensions of entire new construction: Front ................ Rear ............... Depth ..............
Height ......................... Number of Stories .....................
9- Size of lot: Dont .................... Rear ..................... ........ Depth ....................
10. Dace of Nrrc]mase ..................... Name of Former Owner .......................
II. Zone or use district in which premises are situated ...
12. Does proposed construction violate any zoning law, ordinance or regulation: -
13. Will lot be regraded .................... Will excess fill be remved from
premises: YES Ep
14. Nares of Owner of premises Address
Nare of I4�''D!�7 Vi fSG .. l .. / n ........ Phone No. ..............
C ................... Address J` �• 7� 2'1.5
• ......... Phone No.
Name of Contractor
........................ Address ............................---Phone No. ...... ........
15. is this property within 300 feet of a tidal wetland? * YES .......... NO .(�,�
*IF YES, MMUD IUM-TRUSIFI:S PM41T MAY BE RE(�LIMM. ...
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions
From property lines. Give street and block number or description according to deed, and show street names and indicate
kiether interior or corner lot.
VVIE 01` N zW YORK,
SS
....... IM0 .... v �.�..........
..........being duly sworn, deposes and says that he ns Chea licanC
Name of individual signing contract)
bove named,
eis tlme ....................��C� !/�./ . ......................................_........................
Mwitractor, agent, corporate officer, etc.)
f: said owner or owners, and is duly authorized to perform or have performed the said work and Co make and file Chis
pplication; ghat: all sCatements contained in this application are true to the best of his knowledge and belief; and
hat the work will. be performed in the marnier set forth in the application filed therewith.
worn Co before me this
an. ...day of ....44,y.-t;....:20,0 /-
Notary Public .. •"V... .. ---.....
�v
........ �.........
(Signature of Applicant)
LINDA J.COOPER
Notary Public,State of New York
No.4822563.Suffolk CIITP 1(�0
Terra Expires December 31, ��
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Professional Engineer
1725 Hobart Road
Southold, New York,
June 20, 2001 631-765-2954
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