HomeMy WebLinkAbout25780-Z
FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-26966
Date. 03/0S/00
THIS CERTIFIES that the building NEW DWELLING
Location of Property: EAST
(HOUSE NO.)
County Tax Map No. 473SS9 section 4
END RD
(STREET)
Block 5
FISHERS ISLAND
(HAMLET)
Lot IS
Subdivision
Filed Map No.
Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated
MAY 20, 1999 pursuant to which
Building Permit No. 257S0-Z
dated
JUNE 7, 1999
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 ONE FAMILY DWELLING WITH AS APPLIED FOR & AS PER ZBA 14677.
The certificate is issued to STEPHEN & JENNIFER SCACE
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL RIO-9S-0160
02/25/00
ELECTRICAL CERTIFICATE NO.
PENDING
03/03/00
PLUMBERS CERTIFICATION DATED
Ol/lS/OO MARIO ZANGHETTI
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Rev. l/Sl
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Form No. 6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN BALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
A.
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.
Final Approval from Health Dept. of water supply and sewerage-disposal(S-9 form).
Approval of electrical installation from Board of Fire Underwriters.
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 buildings
and installations, a certificate of Code Compliance from architect or engineer
responsible for the building.
6. Submit Planning Board Approval of completed s~te plan requirements.
2.
3.
4.
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 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.
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 Buildine - $100.00
3. Copy of Certificate of Occupancy - $20:00
4. Updated Certificate of Occupancy - $50.00
5. ,Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00
Da te ..~:-. Y. : P:o. . . . . . . . . . . . . . . . . . . . ... . . . . . . .
New construction...~...... Old Or Pre-existing Building.................
Location of property............f ~~.T.. .fi~p. ... .?-fJ.':l.Q.................. ......... .........
House No. . Street Hamlet
Dnwer or Owners of property.~c.p..h.E:-n...t:.~."J<~;f~r.-...~~~~.e........Cf~I~~!lLl.
County Tax Map No 1000, Section........"." .Block.... ,,'!=:....... .LOt.....~.............. ..
Subdivision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Filed Map........... .Lot.. . . . . . . . . . . . . . . . . . . . .
?ermit No. !'?!>.? '!.~...... .Date Of Permit..4 /.7.f. '1~.... .APplicant..~ .~.~.c:.~...... ... .......
Health Dept. Approval......................... .Underwriters Approval........... ...............
?lanning Board Approval........................
lequest for:
Temporary Certificate........... Final Certicate....~......
Rae.. S7S~1
Cll-'e. 2'1'(,
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APPLICANT
,ee Submitted:
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.
25780 Z
Date JUNE
7, 1999
Permission is hereby granted to:
S & J SCACE(PETRILLIl
20 WOOD ST.
WATERFORD,CT 06385
for :
CONSTRUCTION OF A SINGLE FAMILY DWELLING AS PER ZBA APPEAL #4677
AS APPLIED FOR.
at premises located at
EAST END RD
FISHERS ISLAND
County Tax Map No. 473889 Section 004
Block 0005
Lot No. 018
pursuant to application dated MAY
Building Inspector.
20 1999 and approved by the
Fee $
452.20
Signature
ORIGINAL
Rev. 2/19/98
,
I
TOWN OF SOUTBOLD
OFFICE OF BUILDING INSPECfOR
P.0.80}(728
TOWN HALL
SOUTHOLD, N.Y. 11971
C E R T I F I C AT I 0 .
TEL. 765-1802
DB. t~, / / I g / 0 ()
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Building Permit No. 0/.5'1 R-o
Owner 5le f?h.1'\l SC.AC~
. (please print)
Plumbermr'\(.\,'.. Zr'I nJ6hG.TTi
(please print)
I certify that the solder used in the water supply system
contains l~ss than 2/10 of 1% ,lead.
State of New York)
,CountyofSuffolk) ss;,
Sworn
to before me this
day of Jo.l'\ u.a.n.-(
,
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)4: .2.roO
Notary 'Public,
County
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1000656
I
THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
40 FULTON STREET, NEW YORK; NY 10038
Application No. onftle 1911<;499/99
PAGE 1
Date I1ARCH 10,2000
THIS CERTIFIES THAT
N 517939
only the electrkal equipment as described below and introduced by the applicant named on. the apove application number is in the premises of
JENNIFER SCACE. OFF EAST END ROAD. FISHERS ISLAND, NY
in the following location; fJ Basement 0 1st Fl. D 2nd Fl. Section Block Lot
was examined on MARCH 03,2000 and found to be in compliance with the National Electrical Code. '
FIXTURE RECEPTACLES SWITCHES FIXTURES
OUTLETS INCANDESCENT FLUORESCENT
OTHER
RANGES
AMY. K.W.
COOKING DECKS OVENS DISH WASHERS EXHAUST FANS
AMY. K.W. AMT. K.W. AMY. K.W. AMY. H.P.
7
26
21
5
2
1
F
AMY. K.W.
H.P.
FUTURE APPLIANCE FEEDERS SPECIAL REC'PT. TIME CLOCKS BELL UNIT HEATERS MULTI-OUTLET
SYSTEMS
AMY. NO. A. W. G. AMY. AMP. "AMY., AMPS. TRANS. AMY. H.P. NO. OF FEET
DIMMERS
DRYERS
FURNACE MOTORS
OIL
H.P. GAS
AMY. WATTS
4 F
AMT.
NO. OF HI-LEG
C
A.W.G.
OF HI-LEG
E
TYPE
NO. OF
METER
EQUIP. l' 2W 1 III 3W 3 III 3W 3 III loW
S E
NO. OF CC CONDo
PER.
R
II
SERVICE DISCONNECT
AMP.
OF ~C~C~'ND.
NO. OF NEUTRALS
A.W.G.
OF NEUTRAL
. ;,
OTHER APPARATUS:
MODULAR HOUSE-1
PADDLE FANS F-5
6 CIRCUIT GEN--TRANS,-l
G.F,C.I:-2
SMOKE DETEL~R,-l
,iULi:. C; J /lAM
Per 11
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.
Z & S CONTRS. INC.
P.O. BOX 202
FISHERS ISLAND. NY. 06390
LIC.#4798 E .
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GENERAL MANAGER
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
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Board Of Southold Town Trustees
SOUTH OLD, NEW YORK
PERMIT NO. 'i '3 &-s-'
DATE: ...JO/27/94
ISSUED TO ....AN1:kIQNY. M. .pETRILLI
Autqnrilutinu
Pur.suant to the provisions of Chapter 615 of the Laws of
the State of New York, 1893; and Chapter 404 of the Laws of the
State of New York 1952; and the South old Town Ordinance en.
titled "REGULATING AND THE PLACING OF OBSTRUCTIONS
IN AND ON TOWN WATERS AND PUBLIC LANDS and the
REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM
LANDS UNDER TOWN WATERS;" and in accordance with the
Resolution of The Board adopted at a meeting held on 10/27/94
19 94, and in consideration of the sum of $150.00 paid by
. GlennJ.ust. for..ANTHONY M. PETRILLI.
of ". ..fis4exs..lsl,;md N. Y. and subject to the
Terms and Conditions listed on the reverse side hereof,
of Southold Town Trustees authorizes and permits the following: .
To const.ruct. a single family residence, sanitary system. decki~.
regrade and apply crushed driveway. as per survey prepared "
by Chandler, Palmer & King last dated 11/5/91. Fishers Is!,'
all in accordance with the detailed specifications as presented in
the originating application.
IN WITNESS WHEREOF, The said Board of Trustees here-
by causes its Corporate Seal to be affixed, and these presents to
be subscribed by a majority of the said Board as of this date.
C~, k~r"
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.'In''4~.. Ib.es /]1W1 dI
9S-20-1 (818n-9d
New York State
"Department of Environmental Conservation
/~
/
o NOTICE
.~
...
...
The Department of Environmental Conservation (DEC) has issued
permit(s) pursuant to the Environmental Conservation Law
for work being conducted at this site. For further information
regarding the nature and extent of work approved and any
Departmental conditions on it, contact the Regional Permit
Administrator listed below. Please refer to the permit number
shown when contacting the DEC.
-
Regional Permit Administrator
Permit Number f~-IJO~~f)tJ'-o
Expiration Date
NOTE: This notice is NOT a permit
:..
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TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N.Y.
NOTICE OF DISAPPROVAL
Date: February 9, 1999
Revised: February 25, 1999
To: Mr. Anthony M. Petrilli (Scace)
East End Road
Fishers Island, New York 06390
PLEASE TAKE NOTICE that your application dated
January 8 . 1999
For permit to Construction of a new sinl!:le familv dwelline with attached 1 car ,:araf;!e. at
Location of Property
House NO.
East End Roa~.
:Stree
Fishers Island. New York 06390
ttamlel
County Tax Map No. District 1000 - Section 4
- Block
5
- Lot
18
Subdivision:
Filed Map No.
Lot No.
Is returned herewith and disapproved on the following grounds:
Nonconforming Lot: Zoning District R-120
[Required Lot Area 120.000 S.F. - Actual Lot Area 73.000 S.F.I+I-l]
Under article XXIV. Section 100-244.. Nonconforming Lots. Lots with areas between
60.000 & 79.999 square feet shall have a minimum front yard set back of fifty five (55') feet.
The proposed front vard setback is indicated as thirty (30'+/-) feet.
"
APPEALS BOAR ~fFOl.t
o,'mdi;,.~~\ " tl'
Lydia A. Tortofa . ' ~. ~
Lora S. Collins: -- ~ ~
G H. BLDG. DEPT. , '''0,... ....~
eorge ommg29.'NN OF SOUTHO~D _..1 ~... l'
QrL:C
Southold Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 11971
ZBA Fax (516) 765-9064
Telephone (516) 765-1809
BOARD OF APPEALS
TOWN OF SOUTHOLD
FINDINGS, DELIBERATIONS AND DETERMINATION
.- .' .......->....--......-- '. "MEETING DP-MAV-.w...J..229
---
Appl. ~4~EPHEN SCACE PARCEL 1000-4-5-18 ~"
STREALITY: East End Road, Fishers Island .)
___ DATE OF PUBLIC HEARING: April 22, 1999 ,._'
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FINDINGS OF FACT
PROPERTY FACTS/DESCRIPTION: The subject land is vacant and comprises approximately 1.67
acres of total lot area. The property has two front yard areas and a large portion of the property
contains freshwater wetland areas which may not be disturbed.
This property officially has two road frontages. It is bordered to the south by a well-traveled,
paved East End Road, which is a privately owned extension of the Town Road named Oriental
Avenue. The property is bordered on the east by another well-traveled but unnamed hard
scrabble, dirt private road. The applicant's property is bordered on the west by CTM Lot 1000-4-
5-17.2 (Dietrick & ano), whose northerly property line also abuts the right-of-way mentioned
below and is the road cited by the Notice of Disapproval.
In addition, the subject lot is bordered on the north by a gravel and dirt dead-end right-of-way
which serves as a private driveway for both the immediate northerly neighbor on the developed
2.5+- acre parcel (CTM 1000-4-5-19.5) and for the adjacent developed 1.7+ acre parcel (CTM
1000-4-5-10). The driveway for Parcel 1000-4-5-19.5 begins 150+- feet from the easterly
beginning point of the right-of-way, and this neighbor's house is located 150+- feet south of said
right-of-way. The other neighbor's driveway on Parcel 1000-4-5-10 begins 500+- feet from the
aforementioned beginning point of this right-of-way, at what is now the westerly end of the
right-of-way.
BASIS OF APPEAL: The Building Inspector's February 9, 1999 Notice of Disapproval (updated
February 25, 1999), which states that under Article XXIV, Section 100-244, nonconforming lots
with areas between 60,000 and 79,999 sq. ft. shall have a minimum front yard setback of fifty-
five (55) feet. Zone: R-120 Residential.
AREA VARIANCE RELIEF REOUESTED: Applicant is requesting a variance from the Zoning Code
to reduce the setback of a proposed dwelling from 55 feet to 32 feet, as a minimum, from one of
the private roads on which this property abuts.
REASONS FOR BOARD ACTION. DESCRIBED BELOW: After consideration of the entire record,
testimony at the public hearing and other evidence, the Board finds the following facts to be true
and relevant:
The uneven topography of the applicant's parcel greatly restricts the ability to properly site a
building because the property contains a large pocket of low elevation and wetlands, particularly
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Page 2 - May 20, 1999
Re: 1000-4-5-18 at F.I.
ZBA Appl. No. 4677 - S. Scace
'T~ '
along south and east boundaries. These constraints have become the basis for the applicant's
request for a variance since the three front yards and substantial wetland areas create two
separate hardships which impact development of this property. This situation, however, does not
make this parcel unusable for a single-family residence, as is reflected by the applicant's
successful acquisition of a valid D.E.e. permit and the Town Trustees' approval of this project.
1) The granting of the setback variance will not produce an undesirable change in character of
neighborhood or detriment to nearby properties because this is a preexisting parcel of 1.67+-
acres in an R-120 Residential Zone District, and the construction of a single-family dwelling on
this site will not change the nature of the sparsely developed, privately owned exclusive
neighborhood located on eastern Fishers Island.
2) The benefit sought by the applicant cannot be achieved by some method, feasible for
applicant to pursue, other than an area variance because the topography of the parcel includes a
large wetland area and does not allow for much flexibility in selecting a building site.
3) The requested area variance is not substantial because the variance is necessary because of
the third front yard. The applicant conforms to the zoning requirements for the other two front
yards, which are more consequential.
4) There is no evidence that the grant of the variance will have an adverse effect or impact on
the physical or environmental conditions in the neighborhood or district. The grant of the
variance will allow for the least possible environmental impact to this property and to neighboring
properties.
S) The alleged difficulty has not been self-created because it is related directly to the existing
wetland areas, and the uneven topography and related characteristics of the land.
In considering this application, the Board deems the grant of the setback variance to be the
minimum necessary and adequate to preserve and protect the character of the neighborhood,
and the health, safety, welfare of the community.
RESOLUTION/ACTION: On motion by Member Horning, seconded by Member Dinizio, it was
RESOLVED, to GRANT the variance, as applied for.
VOTE OF THE BOARD: AYES: MEMBERS
HORNING. Member Collins was absent ( of t
NIZIO, TORTORA,
1000-4-5-18
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ROBERT E WALL
PAGE 01
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aUILDING ~.
INSPECTION
[ ) POUNDATION 1ST [ ] ROUGH PLIIQ.
l ] FOUNDATION ZMD [ ] INSULATION
[ ] FUMING [~
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TOWN OF SOUTHOLD PROPERTY RECORD CARD
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STREET VILLAGE . DISTRICT SUB. LOT
<, ~.6Whj It.. y
,
N EU ACREAGE ~1o
TYPE OF BUILDING
0
RES. SEAS. ;!ll FARM COMM. IND. I CB. I MISC.
LAND IMP. TOTAL DATE REMARKS -+-
....
/
AGE
NEW
NORMAL
BUILDING CONDITION
BELOW
ABOVE
Form
Acre
Value Per Acre
Value
~
rillable 1
rilloble 2
/.c
-4.:. ..... '.!'61
nllable 3
Noodland
,womplond
;rushland
-iouse Plot
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. ~~ JAN 8 19!J}' i
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. '---', TOWN HALL
1'OWN(iF'~~~PT. SOl UIOLD, N. Y.
TEl.: 765-1802
FORM NO. I
N 01' SOUTIIOJ.D
ING DEPARTMENT
BOARD OF IIIlAJ.TII ...............
3 SETS OF PLANS ...............
SURVEY ........................
CIIECK .........................
SEPTIC FORM ...................
NOTIFY:
/ -8l"o-ljl/~:;f)33S'
1'1V5 ::Set:< c.L
CAU. ..................
ClI.v................... .
. .. .............................
11971
F..xamined................., 19....
ApprCNed.....fP. ;j......., J9j. ~ Pennit lb. .. f!..~. ?J.7g..
Disapproved alc .1:139~!.~~l).S€leA~..... . !J
.......................................... .... ..... flJi2t,. .~.s ~:<<:::::.IO~PP6A~ +'-/(p 1?
Ouilding Inspector)
PLICATION FOR BUILDING PERMIT
'Date.lo}1~........ ,197.?.
INSTRUCTIONS
a. This application DlJ8t be ~letely filled in by typewriter or in ink and subnitted to the Building Inspector witl:
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, relstionship to adjoining premises or ","'lic
"freets or areas, and giving a detailed description of layout of property l1J.I8t be drawn on the diagrllJl ",bid, is part of
this application.
c. nle >lOTi< CCNered by this application ""'Y not be CCJ1I12nced before issuance of Building Pennit.
'. d. Upon a[1{lTCNal of this application, the Building Inspector "ill iS8lJe a Building Pennit to the applicant. Such
penni t shall be kept on the premises available for inspection throoghout the work.
e. lb building shall be occupied or used in .A1ole or in part for any purpose whatever mtil a Certificate of
Occupancy shall have been granted by tile Building Inspector.
Al'l'LICATIrI'l IS IERllllY tWE to the Building IJeparl:ment for tile issuance of a Building Pennit pursuant to the
Building Zone Ordinance of the Town of Southold, Suffolk Cwnty, New York, and other applicable laws, Ordinances or
Regulations, for tile construction of buildings, additions or alterations, or for TellDI1al or deoolition, as herein
described. TIle applicant agrees to ~ly with all applicable laws, ordinances, h,ilding code, housing code, and
regulations) arwl to adnit authorized inspectors on premises and in building for necessary inspectioos.
......7. f.~.. .~~~':I.. .:!.'~:.................
(Signature of applicant,lbr name, if a corporation)
?.C!. /1r;f.. .cil/?r-9... G~.. B:4l':e. .11)( .t!f-!yt)
(Mailing address of applicant)
State WletlleT applicant is CMleT, lessee, agent, architect, engineer, general contractor, electrician, plumer or builder.
............... ....... ...... ..~~~J.. ...Ca.,~b ..... ..................... .....................................
NlIlIe of owner of pr8Dises ........ .~.~...kYl.:!:.. -:;k.:1i,f.,.... SC^".~..........................................
(as on r~<tax roll or latest deed)
If aPlZ~ a corpora~ion, signature of ~ly authorized officer.
.(~ and tit'#rf!:ffe.~ffi~.......
~
Builders License lb. .. .1..J.e?Y.?l.............
Plumers l.icense No. ..... ..5:s:.'I............
Electricians Li~ lb. .... ~7.9:?'.........
I.
Other Trade's License No. ..............j'....
location of land on w,ich proposed work l.ill be done.....~v.'..~..?."f.'..................................
............................. _.................................................... ;;;~.. ..:1i!~. tY.f.........
Hoose tbIber Street Hanlet
Cwnty Tax Map lb. HXXI Section ....QQ'i...... Block ......:l.:... Lot ./If...........
SuIxlivision ...................................... Filed Map lb. ............... tot ...............
(NlIlIe )
2. ~State.ex:sting use and occupancy of premises and, int~~ use ~nd .oc~ of proposed J'struction:
a. F..xlStlng use and occupancy ...... ..:~J ...~. J ...Y..CA.GQ.. .... ...I.<:1f.!.....................
b. Intended use and occupancy ....~~~..~j~.......................................................
....
I..
iJ_U~_U,
/ !
New Iklilding .......... Additi'rt';.......,..,Alt~ration ..........
llennlition ............ Other Work .......:.. ........................
(Ilescription)
fee ................(1 ,q,............:............
(ro be paid on Ii'ling thi~ awli""tion)
5. If dl....lling, ....'."'r of dwelling .mirs ............ tu,ber of (k....lling .mirs on each floor ................
).
"hlllre of work (dleCk ...lid. applicable):
(lepuir ............ Raooval .............
Estill..red Cosr ....<?~.~..~......
.
6.
7.
If garage, rl..I1lber of cars _0..0.................................
If business, canrercial or mixed occupancy, specify nature and extent of each type of use................. 0:'"
Dimensions of existing structures, j f any: Front................ Rear ............... Depth .................
l1eight ......................... NJJber of Stories ......................
Dinensions of saoo structure with alterations or additions: Froot ............... Rear ...............
Ilepth .................... \leight .................... to,ber of Stories ...............
-:::1
8.
niuEnsions of entire new constructioo: Front................ Rear................ Deptll ..............
lleight ......................... NJJber of Stories .....................
9.
Size of lot: Front .................... Rear .................... Ilepth
10. Ilate of I\m:hase ..................... Nare of Fonrer O....er ..................... .,. . . . >. . . . . .. . . . . . .
II d. . .... 'eIl' . ed I ,. ,
. Zone or use tatrlet In 11 prenllses are SttJ.Jat ................. ~....... ~ ~. ~ .L.-..;... ~ ~ ~....... ~.... ..~~........-J _.
12. lhes proposed construction violate any zoning law:. ordinance or regulation: ........... ~............
I). Will lot be regraded .................... Will excess fill be renuved [T(JII premises:
YES
to
14. Nares of Owner of premises ........................... Address .............................. Phone No. .........)....
Nare of Ard.itect .. ........ ........ _....... .......... Address........................ ...... Phone No.
Nille of f.ootractor ................................... hklress 7.......................... .Phone No.
Is this property within ](X) feet of a tidal wetland? "YF.8.......... to..........
"IF YES, lnmDJ) 'RUl1\1\JSlEE.'l PElMff MAY BE RF.lplRlID.
.
. . . . . . ~ . . . . . . .
.
,
15.
I'I.OT DIAGRAM
locate clearly and distinctly all buildings, Ioilether existing or proposed, and indicate all set-back dinensions
fruu property lines. Give street and block rumer or description according to deed, and show street nares and indicate
whether interior or corner lot.
SI',,:m (H' "HI \'lHlK,
(UJNIY (J! ......;?~~~....... SS
... - -. -..... .l~~... ..::;['... Shi.lJ~. _......... _..... .beir~~ dilly swum,
(Nate of irxliviulJal signing contract)
alXNe I)("'B..I,
deposes and says lh.-"lt he i 5 the applicant
lie is the ................... .~!'t"!~l... .~~t<f:k........................ .........................
(Contractor, agent, corporate officer, etc.)
of said owner or """lers, and is duly authorized to perfono or have l'er[om1ed the said work and to...ke and file this
awlicati...; that all stat ,ts contained in this awlication are tme to tile I",st of his knowledge and belief; 1IIK1
that the work will I", pe in the IIl8"'ler set forth in the application filed Ulerewitl,.
...~.... ,Akd....
1'1l0MAI " DClHI"fY IN,
NOlllry Public Stlt. of N.w V.'k
No. 4S0e5st
QUlllfl.. 10 Sutfolk C'lJ.Illy
Tlrm Expire. 12131/"
(Signature of ^