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HomeMy WebLinkAbout30305-Z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-30564 Date: 11/17/04 THIS CERTIFIES that the building ADDITIONS/ALTERATIONS Location of Property: 370 TEEPEE TRAIL SOUTHOLD (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 87 Block 2 Lot 22 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated MAY 11, 2004 pursuant to which Building Permit No. 30305-Z dated MAY 11, 2004 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 COVERED PORCH ADDITION, SCREENED PORCH ADDITION, DECK ADDITION, ADDITION AND ALTERATIONS TO AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR. The certificate is issued to SPIRO S & ELIZABETH SPIRAKIS (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. 1060280 04/25/03 PLUMBERS CERTIFICATION DATED 10/12/04 MATTITUCK PLUMBING & HEAT c � ho zed S'gnature 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. 30305 Z Date MAY 11, 2004 Permission is hereby granted to: SPIRO S SPIRAKIS 210 BRIXTON ROAD GARDEN CITY,NY 11530 for ALTERATION AND ADDITION TO AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR. THIS PERMIT REPLACES BP#27416 . at premises located at 370 TEEPEE TRAIL SOUTHOLD County Tax Map No. 473889 Section 087 Block 0002 Lot No. 022 pursuant to application dated MAY 11, 2004 and approved by the Building Inspector to expire on NOVEMBER 11, 2005 . Fee $ 843 . 80 Authorized Signature ORIGINAL 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. 27416 Z Date JUNE 19, 2001 Permission is hereby granted to: RICHARD C HILARY 370 TEPEE TRAIL SOUTHOLD,NY 11971 for ALTERATION AND ADDITION TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR. at premises located at 370 TEPEE TRAIL SOUTHOLD County Tax Map No. 473889 Section 087 Block 0002 Lot No. 022 pursuant to application dated MAY 4 , 2001 and approved by the Building Inspector. Fee $ 843 . 80 Authori Signature ORIGINAL Rev. 2/19/98 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY A. This application must be filled in by typewriter OR ink and submitted to 41WQbuilding 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 1% lead. 5. Commercial building, industrial building, multiple residences and similar buildir, 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 existingobuildings (prior to April 9, 1957) non-conforming uses, or buildings an '-'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 a consent to inspect signed by the applicant I.f 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, 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 Certificate of Occupancy - .25r,. 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential /$15.00,, Commercial $15.00 XDate . . . ��1. ��(�. 1. . . . . . . . . . . . . . . . . . . . . . . . . New Construction. .. . . !:. Old Or Pre-existing Building. . .`./.�. . . . . . . Q Location of Property. . . . . . . . . ..!. e : . . !��.`. `. . . . . . . . .� . ... . . . . . . . - - House No. Street Hamlet Onwer or Owners of Property.. . 5. . . . .S. 3�'.`.1�� . . . . .. . . . .. . . . . . . .. . . . . . . . . . . County Tax Map No 1000, Section .. . .Block. . .Q . . . . .Lot. . . .aa:. . . . . . . . . . Subdivision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Filed Map. . . . . . . . . . . .Lot. . . . . . . . . . . . . . . . . . . Permit No. 391) O -S. . . .Date Of Permit../�1".. . . . . .App1icant.F�1.�� . . !"i.1, . , , , , , , . Health Dept. Approval. . . . .. . . . . . . . . . . . . . . . .Underwriters Approval. . . . . . . . . . . . . . . . . . . . . . Planning Board Approval. . . . .. . . . . . . . . . . . . . X Request for: Temporary Certificate. . . . . . . . . . . Final Certicate. . l.: . . . . . . Fee Submitted: $. . . . . .�`. b . . . . . . . . . . . '(�� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ����� APPLICANT i Il• .l ' iu , A Town Will, 51095 Main nood i �� i ^ 1 I n (516) 7 52 P. 0. [lox 1179 1 1,1 fi-laphone (5 16) 7r�,•1002 Snulllulll, flew York 11971 OFFIC5- OF THE BUILDING INSPFCTon TOWN Of' SOUTI (OLD _C R T_ x F I C n T 1 0 14 _ Dui 1 d.i ng Pettnl t No. 3o-6 Owner ., ( lease pr. .11Pt) plumber: j�Lc"< (please prim;)' ? certify Lltat the solder used In the vinLer supply sy:f tem contsins loss than 2/10 of 1 % lend , _.._((T, 1111itt5erq GJ.ynnFi11��� _ sworn to before me this QCCi clay of 4-9.a Notmry Publics J1 C� C01111t•y M,wy Pdb>L d Now rbrk r Can° mon> a,uiVw 200 7 5 BY THIS CERTIFICATE OF COMPLIANCE THE���� 5 NEW YORK BOARD OF FIRE UNDERWRITERS 5 BUREAU OF ELECTRICITY 5 40 FULTON STREET — NEW YORK, NY 10038 5 5 CERTIFIES THAT 5 5 Upon the application of upon premises owned by 5 5 JAMES MURRAY SPIRO SPIRAKIS 5 P.O. BOX 305 370 TEPEE TRAIL 5 LAUREL, NY 11948, SOUTHOLD, NY 11971 5 Located at 370 TEPEE TRAIL SOUTHOLD, NY 11971 5 5 Application Number: 1060280 Certificate Number: 1060280 5 5 Section: Block: Lot: Building Permit#58 BDC: NSI 1 S 5 Described as a Residential occupancy,wherein the premises electrical system consisting of 5 electrical devices and wiring,described below, located in/on the premises at: SBasement,First Floor,Second Floor,Attached Garage,Outside,Attic, 5 5 was inspected in accordance with the National Electrical Code and the detail of the installation,as set forth below,was 5 found to be in compliance therewith on the 25th Day of April,2003. 5 5 Name QTY Rate Rating Circuit Type 5 Alarm and Emergency Equipment Sensor 3 0 Carbon Monoxide 5 Appliances and Accessories 5 Dish Washer 1 0 1.2 KW 5 Exhaust Fan 5 0 F.H.P. 5 Oven 2 0 6.5 KW 5 Cooking Deck 1 0 5.5 KW 5 Furnace 1 0 Oil 5 Air Conditioner 1 0 36.000 BTU 5 Air Conditioner 1 0 48.000 BTU 5 Wiring and Devices 5 Receptacle 72 0 General Purpose 5 Switch 51 0 General Purpose 5 Fixture 71 0 Incandescent Fixture 11 0 Fluorescent 5 Dimmers 19 0 5 Receptacle 1 0 20 amp Laundry seal Receptacle 1 0 30 amp Dryer 5 Continued on Next Page 1 of 2 5 This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location Indicated. 5 ® t1� Sr BY THIS CERTIFICATE OF COMPLIANCE THE 5 5 NEW YORK BOARD OF FIRE UNDERWRITERS 5 5 SBUREAU OF ELECTRICITY 5 5 40 FULTON STREET -- NEW YORK, NY 10038 5 CERTIFIES THAT 5 5 SUpon the application of upon premises owned by 5 S 5 JAMES MURRAY SPIRO SPIRAKIS 5 5 TRAILP.O. BOX 305 370 TEPEE LAUREL, NY 11948, SOUTHOLD, N 1 Y 971 5 5 5 5 5 Located at 370 TEPEE TRAIL SOUTHOLD, NY 11971 5 5 Application Number: 1060280 Certificate Number: 1060280 5 5 5 Section: Block: Lot: Building Permit-'#5848 BDC: NS11 5 5 5 55 Described as a Residential occupancy,wherein the premises electrical system consisting of 5 electrical devices and wiring,described below, located in/on the premises at: 55 5 Basement,First Floor,Second Floor,Attached Garage,Outside,Attic, 5 S5 5 5 was inspected in accordance with the National Electrical Code and the detail of the installation,as set forth below,was 5 found to be in compliance therewith on the 25th Day of April,2003. 5 5 Name OTY Rate Rating Circuit Tie 5 Paddle Fan 1 0 5 Receptacle 12 0 GFCI 5 SService 5 5 1 Phase 3W Service Rating 200 Amperes 5 5 Service Disconnect: 1 200 cb 5 Meters: 1 5 c5, S 5 5 5 5 5 5 5 seal 5 5 2 of 2 This certificate may not be altered in any way and is validated only by the presence of a raised seal at the,location indicated. MEMO mum5 i 16 j.� -OT tAy tb►T�►TaK�sTCOM WKVW ctT �►.1,-E�•tb.NnowS►wt Me_��Le v 2s� Awo. T M i1" to= -- b•1 D.2 • 22 + z 1171 IL 98 . • 400<01 • REOADONAID G. FEILER ! • t 6 DGF l�� 406mah road,* Ma"awk,NY, t IM�X161.2 , �fylE, D15856 �� { • 7 r A woo t qj fIL 4t A 3 rt THORIZED ALTERATION OR ADDITION IS SURVEY IS A VIOLATION OF E i 3"7209 OF THE NEW YORK STATE `=l �)) r /�+'q•� .TION LAW.- C. - i OF THIS SURVEY MAP NOT BEARING j t (� A1,0 ND SU-V'Y.,R'S ft—D SLAL OR j[['�'�+�! ! ..'t f ? L�— V C. L T I. f SLD SEAL SHALL NOT BE CONSIDERED A VALID TRUE COPY. :NTEES INDICATED HEREON SHALL RUN 10 THi PE',.SON FOR WHOM THE SURVEY ARM,AND.ON HIS BEHALF TO THE bMVANY,GOVERNMENTAL AGENCY AND G INSTITUTION LISTED HEREON,AND - - - ASSIGNEES OF THE LENDING INSTI-L GUARANTEES ARE NOT TRANSFERABLE NTIONAL INSTITUTIONS OR SUBSLQUEN7 - Cl'7 GY L—.c.-,/' f''J!�t%1'��✓'•°•''! h.,./J �1`t►�`��� d i� 1�"° '� I""s`ti�rE'�_F'.�Y.'i r^t* ,,,,�,�•t+1.t'��:,T 1'+1,h � '�F:� rz - TOWN OF SOUTHOLD PROPERTY RECORD CARD OWNER STREET 70 VILLAGE DIST. SUB. LOT IYO 71, FORMOR OWNER N E ACU Ilk S W TYPE CfF BUILDING RES. �q/� SEAS. VL. FARM COMM. CB. MICS. Mkt. Value LAND IMP. TOTAL _ DATE REMARKS O o o © 112 0 a gov �aoo / o00 SiG17-3 Em, 1- ti 15, 914 - ar/ ate a s ®. AGE BUILDING CONDITION NEW NORMAL BELOW ABOVE FARM Acre Value Per Value Acre Tillable FRONTAGE ON WATER Noodland FRONTAGE ON ROAD Aeadowland DEPTH Aousolgt, ✓ BULKHEAD dotal DOCK 0 LVA -- y: MUM N■■■■■■■■■■■■■■■■■■■■■■■■ PRS :,;¢A�,,'zr, ■■■■■■■■■■■■■■■■■■■■■■■aa■■■ Nw ■■���r■■■ ■■■■■■■■■■■■■■■■N■■ .ww■■U■O■■E■■■■■■■■■■■■■■■■■■■ ■►�11��■►`��■�'�:'��'��■NN■■■■■NDN■■ 1�i�,s■i�/JaN■i■■a��]i■■■■■■i■■■ __ _ . . . _ __ _ _ !�►���■■■i�►�a8[E�ia■■epi■N■■■i■■■ ON, ■■a■an■a■■■■■a■a■aMEM a■■ : .. ■r►aaro■l�I�■��■�s��■r■rl�N■■■■■■■i ■ISLIP2i■i■■Moosup%■■N■■■■ONE Foundation Basement Interior Finish IFire Place Type Floor . . ■�■� . . ... . .. car BUILDING PERMIT REVIEW CHECK LIST DATE REVIEWED: 6' //9 /O1 , DATE SUBMITTED: S / ¢ /O1 APPLICANT NAME: ,r,s lar. SCTM# -- DISTRICT: 1,000 SECTIO :_7 BLOCK:_ LOT: 22 STREET: 3 76 ��eK %r-Q,/ CITY: S SUBDIV. NAME: PROJECT DESCRIPTION• ADD ALT ACC OR N/D: ARCHITECT/ENGINEER: ei �c FAST TRACK(:Y]ES)RNO SINGLE & SEPARATE CERTIFICATION-REQUIRED: YESCRN�aOOTES: 1srs7-%,rr- LOTS 40,000SF-100-24.Lot recognition.(CREATED before June 30,1983),UNDERSIZEDJAN.1997 100-25.Merger.(A nonconforming at any time after 7/1/83) ZONING: PERMIT ESTIMATE AMOUNT: $ X00 K .00 PERMIT USE: EXISTING: SFS INTENDED: ZONING DISTRIC : R4 R80 AC CONFORMING: YES o N REQUIRED LOT SIZE: �O/< SQFT. WHERE ACTUAL LOT SIZE FRO . Ax CARD ACTUAL LOT SIZE:,20�,,¢ SQFT. REQUIRED `-REQUIRED REQUIRED 1ST FOUND:FRONT:16 'PROPOSED:Q&r' SIDE M-1-15 / PROPOSED:/'/ ' REAR: Sy 'PROPOSED* 2ND FOUND:FRONT: ' ACTUAL: SIDE YD: '/ ' ACTUAL: '/ ' REAR: ' ACTUAL: ' LOT COVERAGE: AJkLOWED % EXISTINCK sf % NEW: sf % TOTA sf1 CORNER? YES o O WAT ER FRONT? NO DESCRIPTION: S3' ' FLOOD COMPLIA E ZONE: PRE-FIRM 3/18/80 ANEL #: 164 FLOOD ZONE:_, AGENCY PERMITS REQUIRED FOR REVIEW INCLUDED IN APPIAATION TOWN SPETIC PERMIT: YES o O SUFFOLK COUNTY HEALTH DEPT: YES or , (BED #): DTE: / / PERMIT#:RIO _ APPROVALS RE UIRED: J NEW YORK STATE DEC: PRE-DEC 9/1/75 YESor SOUTHOLD TOWN TRUSTEES: YES or TOWN ZONING BOARD APPROVA YES r �►.�: ��,�.� �• Kf_�L)TOWN PLAN. BOARD APPROVAL: S o TOWN HISTORICAL PRE (SPLIA/): YES NO NYS ENERGY• ES �R NO : �/ EGRESS: VENT: LIGHT: BUILDING PER1C�fITS OPEN/EXPIRED: BP9 -Z C/0/ Z- �t - s�ows �/ u/i HAVE PRE CO'S : Y OR N BP -Z/ C/0 Z- NOTES: •. �w a c .•e _ �� �Y -s"""`` SK r �' /ter � / %l� _ tAJ,G .;?41 _Socr FEE STRUCTURE: FOUNDATION: SF FIRST FLOOR SF SECOND FLR //76 SF INIT OTHER TOTAL TOTAL: JA9.L SF FEE FEE FEE FOT( -#01( SF)- ( SF)=3914-K SF X $.2G =$ 7 +$ ?S +$ --- = $ W3 &0 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [✓] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ v]'F� 1NG [ ] FINAL [ i/ FIREPLACE & CHIMNEY REMARKS: DATE � �Y INSPECTOR BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] R GN PLBG. [ ] FOUNDATION 2ND [ INSULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE 8 CHIMNEY REMARKS: C DATE �113 [ D Y INSPECTOR �j 76!i-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ ] RO PLBG. [ ] FOUNDATION 2ND [ INSULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE fl CHIMNEY REMARKS: 0706- DATE %C DATE � ay1NSPECTOR .*SLI M-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ ] ROUGH LBG. [ ] FOUNDATION 2ND [ ] 1 CATION [ ] FRAMING [ FINAL [ ] FIREPLA� & CHIMNEY 6 REMARKS: 7s olf DATE1��3 INSPECTOR �^Z� 1 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ J ROUGH PLBG. [ ] FOUNDATION 2ND [ ] 1 ULAT [ ] FRAMING VIFINA [ ] FIREPLACE 8 CHIMNEY [ ] FIRE INSPECTION REMARKS: Pm In A DATE � 401VINSPECTOR ` 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] IN ATION [ ] FRAMING [ FINAL [ ] FIREPLACE 8 CHIMNEY [ ] FIRE SAFETY INSPECTION REMARKS• \ •Ca. A 4,9 11 ZZI DATE �v �� � INSPECTOR 4 FIELD INSPECTION REPORT DATE ,l COMMENTS I1W FOUNDATION ( 1ST) I� H h =q. II OUNDAT___====(2ND ION ) F =__= ------- ___ ROUGH FRAME I J PLUMBING I INSULATION PER N. Y. ; STATE ENERGY I H c CODE j I I , H FINA anon=== --� ADDITIONAL COMMENTS: __--_— OX ZZA In fr a AF H -- tv m ro H i4i►Vi� U r�tilflllHULN t3; 111.111NU?BKMl1 A1J?L1(Afl0N (htEC:KLIS" BUILDING DEPARTMENT Do you have or need the following,before applying TOWN HALL Board of Health SOUTHOLD, NY 11971 3 sets of Building Plans f TEL: 765-1802 ---s r Survey P) RM i�fi�.rL � �` Check Septic Form N.Y.S.D.E.C. Trustees Examined �o _,20_� Contact: Approved if _,204/ Mail to: Q0N P4.0 Disapproved a/c P.o •toX uo9 2 M�j'C►�L)C,� Phone: 2cl 8 5+5 Building Inspector APPLICATION FOR BUILDING PERMIT Date 5�� , 2001 INSTRUCTIONS a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3 sets of plats, 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 waterways. 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 issue a Building Permit to the applicant. Such a 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 what-so-ever until a Certificate of Occupan is issued 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 coinply with all applicable laws,ordinances,building code,housing code, and regulations,and to admit authorized inspectors on premises and in building for necessary inspection (SignaW of applicant or name,if a corporation) �o 92 mPCM-n (Mailing address of applicant) ) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner of premises C )P,0L.�1 S P l (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. Other Trade's License No. 61 1. Location of land on which proposed work will be done: House Number Street Hamlet �; v;!P 01A County Tax Map No. 1000 Section 8 7 Block 62 41��ot ' 2 Subdivision Mor of N0NN,&"ft1p W*4-e(L.S' Filed Map No. 5't ti�, Lot -10 (Name) s �. g Occupancy P 1. State tstin use and occu anc of remises and intended use and occupancy of proposed construction: a. Existing use and occupancy eL..Cs Ly N b. Intended use and occupancy 1 N6 tz F-N^n1 Ly ONM-L', Ny 3. Nature of work (check which applicable): New Building Addition Alteration_,X Repair Removal Demolition Other Work t. Estimated Cost 2zo, Q©O Fee (Description) (to be paid on filing this application) If dwelling, number of dwelling units 1 Number of dwelling units on each floor If garage, number of cars >. If business, commercial or mixed occupancy, specify nature and extent of each type of use. •- Dimensions of existing structures, if any: Front O 3 Rear 12' Depth 5C) Height_2021 t Number of Stories im Dimensions of same structure with alterations or additions: Front los' Rear -7 Co Depth A& -Height---2-8� Number of Stories 2 Dimensions of entire new construction: Front 18 3 ' Rear '1 G Depth b$ Height 2250 Number of Stories 1- Size of lot: Front_ 50 Rear 157 Depth 0. Date of Purchase_ /14000 Name of Former Owner._ ik I ULAAo1Q- 1. Zone or use district in which premises are situated 2. Does proposed construction violate any zoning law, ordinance or regulation: IQ 0 3. Will lot be re-graded 00 Will excess fill be removed from premises: (0 NO $Rl x TURD GAr7 wca rY 4. Names of Owner of premises s46• SPtR4o*Cts Addres - (jaunaDhone No.3(&q'39.5729 Name of Architect 00 1%'O-mo FIZ1 t,m%- Address n!10RO, MP•m7uCX_Phone No_29 -15 3 Name of Contractor Pevpo W_ Address Phone No. 5. Is this property within 100 feet of a tidal wetland? *YES NO X • IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE REQUIRED 6. Provide survey, to scale, with accurate foundation plan and distances to property lines. pLA'(' PLPN ON 7. If elevation at any point on property is at 10 feet or below, must provide topographical data on,surrvey. TATE OF NEW YORK) S: 'OUNTY OF&9 being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, 3)He is the NRqA11'_ (Contractor, Agent, Corporate Officer, etc.) f said owner or owners, and is-duly authorized to perform or have performed the said work and to make and file this application; iat all statements contained in this application are true to the best of his knowledge and belief; and that the work will be -rformed in the manner set forth in the application filed therewith. worn to before me th' d 4 daday of 20 Notary Public Signature of Applicant LYNDA M.BOHN NOTARY PUBLIC,State of mew York No.01606020932 Term alExpires March 8,20- �