HomeMy WebLinkAbout29873-Z FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
NO: Z-29906 Date: 12/10/03
THIS CERTIFIES that the building ACCESSORY
Location of Property: 33595 MAIN RD CUTCHOGUE
(HOUSE NO. ) (STREET) (HAMLET)
County Tax Map No. 473889 Section 97 Block 1 Lot 23 .3
Subdivision Filed Map No. Lot NO_
conforms substantially to the Application for Building Permit heretofore
filed in this office dated NOVEMBER 14, 2003 pursuant to which
Building Permit No. 29873-Z dated NOVEMBER 14, 2003
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 ACCESSORY INGROUND SWIMMING POOL WITH FENCE TO CODE AS APPLIED FOR.
The certificate is issued to JOSEPH J ORLANDO
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
ELECTRICAL CERTIFICATE NO. N-463680 08/31/98
PLUMBERS CERTIFICATION DATED N/A
xt c
Au ori d Signature
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. 29873 Z Date NOVEMBER 14 , 2003
Permission is hereby granted to :
JOSEPH J ORLANDO
33595 MAIN RD
CUTCHOGUE,NY 11935
for
CONSTRUCT AN INGROUND SWIMMING POOL WITH FENCE TO CODE AS APPLIED
FOR. THIS PERMIT REPLACES BP424876 .
at premises located at 33595 MAIN RD CUTCHOGUE
County Tax Map No. 473889 Section 097 Block 0001 Lot No. 023 . 003
pursuant to application dated NOVEMBER 14 , 2003 and approved by the
Building Inspector to expire on MAY 14 , 2005 .
Fee $ 150 . 00
r
Author ed Sign&T-ure
COPY
Rev. 5/8/02
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. 24876 Z Date MAY 13, 1998
Permission is hereby granted to:
JOSEPH J ORLANDO
MAIN RD
CUTCHOGUE,NY 11935
for .
CONSTRUCTION OF AN INGROUND POOL WITH FENCE TO CODE IN REQUIRED
REAR YARD AS APPLIED FOR.
at premises located at 70 DENKEL LA CUTCHOGUE
County Tax Map No. 473889 Section 097 Block 0001 Lot No. 023 . 003
pursuant to application dated APRIL 12 1998 and approved by the
Building Inspector.
Fee $ 150 . 00
Buildin Inspec or
ORIGINAL
Rev. 2/19/98
- 3c)
Form No.6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY 090.1
This application must be filled in by typewriter or ink and submitted to the Building Department with the following:
A. For new building or new use: 44--
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). nGC I BAS
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 I% lead.
5. Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate
of Code Compliance from 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" land uses:
1. Accurate survey of property showing all property lines, streets, building and unusual natural or topographic
features.
2. A properly completed application and 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.
C. Fees
1. Certificate of Occupancy-New dwelling$25.00, AdIditions 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- $100.00
3. Copy of Certificate of Occupancy-$.25
4. Updated Certificate of Occupancy- $50.00
5. Temporary Certificate of Occupancy-Residential $15.00, Commercial$15.00
Date.
New Construction: Old or Pre-existing Building: ✓ (check one)
Location of Property: 3S SR S rYl o Pa� CQTc 40C, c,r-
House No. Street Hamlet
Owner or Owners of Property: -s 0?
Suffolk County Tax Map No 1000, Section pq-7 _j&W0m#MW Block nC-)C) I LotO a > .00 3
Subdivision Filed Map. Lot:
l/-! �0o.3
Permit No. D9£3-7 3 Date of Permit. 4 - Applicant: jo�e-ry Q Ig L AtJ PZ)
Health Dept. Approval: Underwriters Approval:
Planning Board Approval:
Request for: Temporary Certificate Final Certificate: t/ (check one)
Fee Submitted: $
Applicant Sigt t
C >ze . �51�
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE '
1185077 BUREAU OF ELECTRICITY
F 40 FULTON STREET, NEW YORK, NY 10038
Date AUGUST 31,1998 Application No. on file 16671898/98 N 463680
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicant named on the above application number is in the premises of
JOSEPH ORLANDO, 70 DENKEL LANE, CUTCHOGUE, NY
in the following location; ❑ Basement ❑ 1st FL ❑ 2nd FL OUT Section Block Lot
was examined on AUGUST 24,1998 and found to be in compliance with the National Electrical Code.
FIXTURE RECEPTACLES SWITCHES FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS
OUTLETS INCANDESCENTI FLUORESCENT I OTHER AMT. I K.W. AMT. K.W. AMT. K.W. AMT. I K.W. AMT. H.P.
1 1 1
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL RECPT. TIME CLOCKS BELL UNIT HEATERS MULTI-OUTLET DIMMERS
AMT. K.W. OIL H.P. GAS H.P. AMT. NO. A.W.G. AMT. AMP. AMT. AMPS.I TRANS. AMT. H.P. SYSTEMS AMT. WATTS
NO.OF FEET
1 F 1 20 1 40
SERVICE DISCONNECT NO.OF S E R V I C E
METERNO.OF CC COND. A.W.G. A.W.G. A.W.G.
AMT. AMP. TYPE EQUIP. 1/2W 1 O 9W 3 O 3W 9 0 4W PER 0 OF CC.COND. NO.OF HIAEG OF HIAEG NO.OF NEUTRALS OF NEUTRAL
OTHER APPARATUS:
SWI141ING POOL-1
GFCI-1
*(SWIMMING POOL) This certificate
covers compliance at the date of
inspection only. Because of unusual
environments it is advisable to
fiave frequent test/and or repairs
made by a qualified person.
<<< Continued on Page 2 >>>
GENERAL MANAGER
-per
This certificate must not be altered In any manner;return to the office of the Board If Incorrect.Inspectors may be I"nt Ned by their credentials.
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 2
1185077 BUREAU OF ELECTRICITY
F_ 40 FULTON STREET, NEW YORK, NY 10038
Date AUGUST 31,1998 Application No. on file 16671898/98 N 463680
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicant named on the above application number is in the premises of
JOSEPH ORLANDO, 70 DENKEL LANE, CUTCHOGUE, NY
in the following location; ❑ Basement ❑ 1st Fl. ❑ 2nd Fl. OUT Section Block Lot
was examined on AUGUST 24,1998 and found to be in compliance with the National Electrical Code.
FIXTURE RECEPTACLES SWITCHES FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS
OUTLETS INCANDESCENJ FLUORESCENT OTHER AMT. K.W. I AMT. K.W. AMT. K.W. AMT. K.W. AMT. M.P.
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT. TIME CLOCKS BELL UNIT HEATERS M LTI.OUS ET DIMMERS
SYSTEM
AMT. K.W. OIL N.P. GAS H.P. AMT. NO. A.W.G. AMT. AMP. AMT. AMPS. TRANS. AMT. H.P. NO.OF FEET AMT. WATTS
SERVICE DISCONNECT NO.OF S E R V I C E
METER NO.OF CC COND. A.W.G. A.W.G. A.W.O.
AMT. AMP. TYPE EQUIP, 1 0 2W 1 0 SW 3 0 SW 3 f 4W PER• OF CC.COND. NO.OF HI-LEG OF NI-LEO NO.OF NEUTRALS OF NEUTRAL
OTHER APPARATUS:
ROSLAK ELECTRIC LIC.#3677- L
P.O.SOX 164
CUTCHOGUE, NY, 11935-2453 GENERAL MANAGER
11
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. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
B �A �
D
a
T SET (611R)
ET
E F—+-�+ G . H J I+ K J
SIZE A B C D E F G H J K L
16' x 32' 16' 32' 8' 3'4" 8' 14' 5'6" 4'6" 4'6" 7' 4'8"
16' x 34' 16' 34' 8' 3'4" 10' 14• 5'6" 4'6" 4'6" 7' 4'8"
18' x 36' 18' 36' 8' 3'4" 12' 14 5'6' 11 4'6" 9' 4'8"
IE a, 20'x 40' 20' 40' 8'6" 3'4' 13'-6 15=6 7' 4' 6' 8' 5'2"
o
JET ANGLE CLIP
NIGHT SET (6"R) ® NpT I
R SET }T
KIT t PAMEL O
\ MADMAN
PLATE
FILLET y�J
CORNERS
•A
II 2•VERMICULITE O
PANELS OR SANG
CONCRETE STAKE
TYPICAL COINER ASSEMBLY FOOTER
6 DEPTH MIN.
SET GENERAL NOTES:
VT.TlCA%IGHT SET(611R) I %TRUSIDN's O1IN TALL SPWLS�� FROM LINER ADJUSTABLE BRACE
I SET 2. Nr Eps °TY"EPEFl1EEU D"TYOdE'11LEW"OIPYEMTE
IS 4TO BE USED. TYPE It MVINY EQUIPMENT
KIT Is To of MOIIrITEO NO MOTE THAN E0• JlitM
BO
WATER AND TIP OF ARD SHALL BF B'SS'
FROM DEEP END WALL.
EXCAVATION NOTES
1. split. TO HAVE MINIMUM % m CAPACITY
OF 2000 P.S.P.
2. LOCATE TOP OF POOL AT LEAST S• ABOVE
BURRWNDING LAND ELEVATION. 510 SUMPTER DRIVE FORT WAYNE, INDIANA,
S. EXCAVATION SMLL BE 2' LARGER THAN roof 46804,U.S.A. 219-432-8731
NNGLE ALL PANELS a 0 ALP WELL.VOIDS UNDER BABE OF
4.BACKFILL WITH NOH-EXPANSIVE MATERIAL. DRAWING NUMBER SCALEkAPPROVED
yMp_ia
TYPE = STL00- I 3/32' = I�� BY
DATE TITLE
EMBLY SET RECTANGLE
ING STRAIGHT SET (61'R) THIS BROCHURE IS FOR ILLUSTRATIVE PURPOSES ONLY
CORNER SET The manufacturer makes only those representations which are stated in
its written Warranty.Any other representations,statements,or contracts
)WARE KIT made by the dealer and or the contractor to the customer regarding any
R materials produced by the manufacturer are attributable to the dealer and/
Or the Contractor only.The dealer or Contractor who sells or mSAIIS your
pool is an independent Contractor and not an agent or employee of the
manufacturer.The construction methods illustrated are suggestions and
apply only to normal ground conditions.There may be additional precai
tions and/or methodS of construction.The responsibility is the contractors.
ed minimum standards for residential pools. If diving boards or slides are to be used
I Spa 8 Pool Institute's minimum standards prior to installing diving boards or slides
lal Spa&Pool Institute,2111 Eisenhower Avenue,Alexandria,VA 22314.703/838.0083
TOWN OF SOUTHOLD PROPERTY RECORD CARD
97
OWNER STREET 7 VILLAGE DIST SUB. LOT LJ
CvtG & �
FORME ,OWNER N E lQa i1450tl ACR.
r
S Wr v 10 ( W TYPE OF BUILDING J
Z , I�ysXQ - Melds �L /1 oa�L a �/� f�a�
z i SEAS. VL FARM COMM. CB. MICS. Mkt. Value e~ l717
t
LAND IMP. TOTAL DATE REMARKS , . . J �0 �� r /f
!,f'c
67t '7'
00 700 40
3 7
0 T S- n!r ,3/ Q44t'4_(xI5:)
�v 5 Es z �fi LI 499 m- �IoC♦riKvAes Pla c I5 QD
loo0 000 000
AGE BUILDING CONDITION
NEW NORMAL BELOW ABOVE
FARM Acre Value Per Value
Acre
Tillable — 3 FRONTAGE ON WATER _
Woodland FRONTAGE ON ROAD 1-14-f f 6 s—
Meadowland DEPTH
House Plot I BULKHEAD
F7 12
Totals A .,wG .— I DOCK
COLOR UI A( �e TRIM UV Nlf
� I I
111 +1
f i
�1
r I I
/
I r 1 I l
Extension �— — Y j
Extension f
Extension
I Foundation I �� Bath v�d Dinette
Porch Basement t ({ Floors �a K K.
Porch ) (Ext. Walls WeUdJ�a a Interior Finish S� �/n ek- LR.
Breezeway (� = 0 2 azo 'Fire Place 4 e Heat 12, J, f f 4� DR.-
Garage `�2 )( JY = 6 �I 1 I ` Type Root Gib JQ Rooms lst Floor BR.
Patio Recreotion Room Rooms 2nd Floor FIN. B
0. 6. (Dormer Driveway
Total
aTe( ' S oo I
McRker V.cl�e�SM GhM. ✓AAS+s/e _ !z'Ji = —dv�l
= yoz4
la \
N
t 33 , iF
M� 001, 61
L ok4R
0
R
/2e 00, oe/NSON
M Q M \
K Cr
O aoil ��
� s
h
M \ "!ho o
o%e' IVO
s 930 "per S 93 4
0
.\
x S),j-+pd r
V
F' e
,t
R eO� v ,
..,7 .ia ,
300 '�', ^C ,,� .•�., D/ �' ^Q/
it 1
2 e /0 7 IrP CID'
ielo
+h O �•
33
Q
0 930
v s n�
O� o
C 4 ' cz 23 c0, n 1
4sS E' •. o
aC/QrFs
SURVEY OF PROPERTY �Q
AT
CUTCHOGUE 004- y�e as
TOWN OF SOUTHOLD 4N h' "IMMEDIATELY
SUFFOLK COUNTY,N.Y. F ENCLOSE COMPLETION UPON COOMPLETION
1000 - 097 - OI - 23.3 BEFORE "WATER"
SCALE la = 50'
NOV . 12 , 1987 CERTIFIED TO
NOV. 17 , 1987
SOUTHOLD SAVINGS BANK
JOSEPH S. ORLANDO
ELIZABETH ORLANDO
p ANDS PECONIC ABSTRACT, INC ,
b
,A•%'YG 9G
FG�oci`O
N. Y. S . LIC . NO . 49668 Prepared In accordance with the minimum
standards for title surveys as established by
A the L.1.A.L.S. and approved and adople
P I E ��1 S d ENGINEERS , P .C, for such use by The New York State
( 5 �� 6fsiee0 O Title Association.
P. 0. LOT NUMBERS REFER TO !MINOR
MAIN SUBDIVISION " MADE FOR WILLIAM L. a
SOUTHOLD , N. Y . 11971 MURIEL A. MURRAY
87 - 854
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION IST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] I ULATI
[ ] FRAMING
[ FIN
[ ] FIREPLACE & CHIMNEY
a6wLsREMARKS:
DATE � � � �3 INSPECTOR �
FIELD COMMENTS ,
T
- H
FOUNDATION ( 1st ) a
0
FOUNDATION ( 2nd ) m o
r
z .
z
o �
ROUGH FRAME & �
PLUMBING FF
V
3 . z
M
m
INSULATION PER N . Y. 'a
STATE ENERGY
CODE
x
/ m
/ _�r
4 , 11 m
3 V
lL . e� HLZ
FIi4AL (e j- itO
o
z
ADD ONAL COMMENTS : s p
`pOI�
mm��
'ou 1
Hl
H (�
r
2
m Z
- r
H
T
p .
m
^o
H
BOARD OF UEALTN . . . . . . . . . . . . . . .
FORM NO. 1 3 SETS OF PLANS . .•_ . . . . ... . . . . . .
TOWN OF SOUTHOLD SURVEY . . . . . . . . . . . . . . . . . . . . . . . .
BUILDING DEPAR174ENT CHECK . . . . . . . . . . . . . . . . . . . . . . . . .
TOWN HALL SEPTIC FORM . . . . . . . . . . . . . . . . . . .
SOUTHOLD, N.Y. 11971
TEL�:�765-1802 1 NOTIFY:
9d. KO-fwanr'�vf� CALL . . . . . . . . . . . . . . . . . .
Examined. 19 /p-rp/ 1rrnn MAI -TO: . . . . . . . . . . . . . . . . . . . .
Approved. ..... ./[...., 19J..1,p-. Permit No. .............� ....................................
Disapproved a/c ........... _ .............................. .....
(Hill ldiug Inspector)
APPLICATION FOR BUILDING PERMIT Date. . .i!�h . . . . . . . . 191y
INSTRUCTIONS
a. 'Bias application must be completely filled in by Lypedariter or in ink and submitted to the Building Inspector wi
3 sets of plans, accurate plot plan to scale. Fee according to sdlechlle.
b. Plot plan shoving location of lot and of buildings an premises, relationship to adjoining premises or public
streets or areas, and giving a detailed description of layout of property mist be drawn on the diagram which In part of
this application.
c. 'Ilse work covered by this application My not be commenced before issuance of Building Permit.
d. Upon approval of this application, the Building Inspector wilf issue a Building Permit to the applicant. Such
permit doll bekept on the premises available for Inspection througJnout the work.
e. No building shall be occupied or used in dole or in part for any purpose whatever until a Certificate of
Occupancy shall have been granted by the Building inspector.
APPLICNnOII IS ILMBY 1VSC to the Building Department for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the lbwn of Southold, Suffolk County, New York, and other applicable Lava, 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 lava, ordinehhces, building code, housing code, and
regulations,land to admit authorized inspectors on premises and In building for necessary inspections,
y..:t:.S..d.�!T....7!!c:.......
(Signature of applicant, or name, if a corporation)
:...IUA....?.�a.....n.11;7.T/!?( C��.
1 4 . l . : 4
(Mailing address of applicant)
State wl`ietjp _
ng�r,,,,+ ppI1GBDCi: owner, lessee, agent, architect, engineer,- cedb
general contractor, electrician, pluer or Ixuilde
Cc��v„Ilz .............. ............................................. ....
Name Naof caner of premises .............!he_.f:....!{/'`�_.... .(.m.�/:.�7.....Q
(as on the tax roll or latest deed”
) . JlqZ
If app cal 'a a corpor - on, i tar of duly authorized officer. 1150 _C0
....... .... NOW N ILIM AT
(Nam and title of c rporate of .r 7115'1M f AM TO 4 FM FOR THE
FOLtaANN NN 11110 0ME:
1 PO N DAMON • 7M RMMED
Builders License No. ...,a4��'6??. tNMPOUMGONCNM
a MBmG
Pluhbers License No. ........`............... & INSULAIM
4. FINAL - CONSTRUCTION MUST
Electricians License No. G ✓�/,4...�? f L BE COMPLETE FOR C.O.
Other Trade's License No. .................... ALL
((CC�OQQNSTRUCTION HE
MEET
s•STA1E C�N��Ol� HE N.Y.
I. Iceation of land on dhirJbnnproposed work will be drone................. .. .ENbRf,Y••-
..............................(`�u ...P,1...........................
� ��III 0W.BRROKS...
[louse Nnber Street ��++ 1.^'� liandet i
County Tax Map No. 1000 Section .....d.l. ... Block ....... Iot ...p:3:.J....
Subdivision ...................................... Filed Map No. ............... Lot ...............
(Name)
2. State existing use and occupancy of premises and intended use anal occupancy of proposed construction:
a. Existing use and occupancy .................�..p n�/4?470101y;...................................
b. Intended use and occupancy ............ )T: 2. to40 L
.. � ,, � 1
Tr r6Off...................
01r,Y WeV to e7hac' .:,;,n:,v Y:rauil
Yinuo7111' Rud n,W�:.Ipuo
880}il'A1zn0.on
,If YaM Yumjy j mia
3. P4hiure of work (crock w.lddh applicable): New Wilding ........... Addition .......... Alteration ..........
Itelwir ............ Rmoval ............. Demolition ............ Other Wrk .fW1'0kt%f!✓k....r4'A.G-.
/{/�
(Description)
4. listillated Cost ........(�401�:.cP.... fee ............................
(to be paid on filing this application)
S. If dkelling, :taller of dwelling units ............ Mnber of. (welling :nits on each floor ................
ifgarage, dtaber of este ......................................
6. if Ixdshhess, mnnercial or mixed)occupency, specify nature and extent of each type of use........ ............
7. Mnensiahs of existing strictures, If any: Front....... ... ...... Rear ............... Depth .................
Ikhight ......................... Pwtrber of Stories ......................
Dinenaions of sane structure with alterations or adklitions: Front ............... Rear ... ............
Dlepilh ................:... llelglht .................... N■hber of Stories .. .. .. ........ .
D. Diaensiahs of entire new construction: Front ................ Rear ............... Depth ... ...........
Ileigit ......................... Nmber of Stories .....................
9. Size of lot. Front .................... Rear .................... Depth ....................
10. Date of Purchase Nam of Fortner Owner ................... .................... .
H. tae or use district in %Aiidi premises are situated ........................................................... ...
12. Does proposed cahatruction violate any zoning law, ordinance or regulation. ........................
13. Will lot be regraded .....YG�5.......... Will excess fill be removed from premises: YES
M. Napes of Owner of premises �° ..L1� vo1!!r'y0lxklreae ....CG4% EfL Gfi4 •• i :. None Pb.
Nape of Architect .................................... Address .............................. Phone No.
Na■re of Contractor . ! ..R4 .. StlA/ . : a�V.. ....................... Address fl.:r �... te �
No.
15. is this property within 30D feet•of a tidal wetland? * YFS .......... W ... ....
*IF YES, SM1111D 'IUldl 91d1.SIIr1S ELIAlif My W MAITRO. -
PLOT DTAGRAN -
locate clearly and distinctly all buildings, whetiher existing or proposed, and indicate all set-back dimensions
from property lines. Give street and block saber or description according to (Led, and slww street rwdes and indicate
(dhetber interior or corner lot.
"IMMEDIATELY"
UNDERWRITERS CERTIFICATE ENCLOSE POOLTO CODE
UPON COMPLETION
REQUIRED BEFORE"WATER"
iii3p S`ld b4J I n< .
SIM rAmron"AUSE IS
N 1f as.rrwh..' 1 v a '
TA TN3A4"M90 01110JN)� V%VK v'v d ° $ U -r
3L?T 403 M4 ► Or MA 0 S(Mf4W � � � F � A �"i, A
:eMtNT9i'1M8irYYr►tJ04 6,��r� 'w� � z. � ? x.
03AIU034 OWT • 001PAPP104 t
V311411111110 41111114111M M4
st1Y#I#W'94 Ei18A1AA4 - 111p110A
tzl lrllY,�x•� a, .1 A 1�>f `1Rt113 .•
[X 6*1 wt, �.
...:,:..�.. , �. t°•N ..ly�•....................Iheiug duly sworn, delxhsea ahxl soya that be is the applicant.
(Minwof irxlividharl,,sigrli{tg-&#Ttraet#
idhwpe awned,,. =l'CS65^7 3 TR?3
Ile--Is the .............. .......J: fi....0X..C/
..... ...........................................
(Cahtractor, agent,-corporate officer, etc.)
of said owhher or wners, and is duly autlnrized to perform or have Imrforied the said work nix] to nuke six] file this
applicatinh; tint till staterents contained in thin application Ore true to the beat of bis kixxiledge and belief, mxl
that the work will be performed In the manner set forth in the application filed therewith.
9wurn to before me Oita p
..... . :/....-......(lily o• .. ...I9..
`btary Public .. 10UM • .......
ery Public.S Newyork .....
Qualified In County (Sigrnture of Applicant)
No.01 S 250
Term Expires 31,