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Home My WebLink About32561-Z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-32106 Date: 12/28/06 THIS CERTIFIES that the building ADDITIONS Location of Property: 750 ABORN (HOUSE NO.) County Tax Map No. 473889 Section 118 LA (STREET) Block 2 CUTCHOGUE (HAMLET) Lot 11.4 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated DECEMBER 11, 2006 pursuant to which Building Permit No. 32561-Z dated DECEMBER 11, 2006 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 SECOND STORY ADDITION, INCLUDING SECOND STORY DECK, AND PARTIAL FIRST FLOOR ADDITION TO AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR. The certificate is issued to LIZABETH & JENNIFER J. BURRELL (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. N 010614 04/28/88 PLUMBERS CERTIFICATION DATED 12/20/06 PECONIC PLUMBING & HEAT ~"~ Rev. 1/81 . Form No.6 TOWN OF SOUTHOLD Bun.,DING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY 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: I. 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 buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. c . 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings (prior to April 9, 1957) non-conforming nses, or buildings and "p~at3~r~d uses: 1. Accurate survey of property showing all property lines, streets, building and unusual natural-or topographic features. .__' 2. A p:operly completed application and consent to inspect signed by .the appliCatl!.t~:a C7rtific,,!_,: of <:>~c1ffia,!c'y i~ demed, the BUilding Inspector shall state the reasons therefor m wntmg to the ap nr.'- 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 - $.25 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 Date. 12MCJb (check one) ~U-u+-tOWb Hamlet New Construction: Old or Pre-existing Building: A50ruJ House No. Street 0Ebe6& Location of Property: LA-N6 Suffolk County T"f Map No 1000, Section Subdivision Pemlit No. ')'), -;:; 10 )V 1St) e.-liG t./ I . .() , I D Block 2- Lot 11 Owner or Owners of Property: Date of Pemlit. Filed Map. Applicant: Lot: Health Dep!. Approval: Planning Board Approval: Underwriters Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ 7 '5 : ';) v ~ant6 ~-u.-. 7/5!.3 co ~ 3:JIO~ 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. 32561 Z Date DECEMBER 11, 2006 permission is hereby granted to: LIZABETH & JENNIFER J. BURRELL 435 E 57TH STREET #14 B NEW YORK,NY 10022 for : CONSTRUCT 2ND STORY ADDITION & PARTIAL 1ST FLOOR ADDITION TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR. (REPLACES BP #15758-Z) at premises located at 750 ABORN LA CUTCHOGUE County Tax Map No. 473889 Section 118 Block 0002 Lot No. 011.004 pursuant to application dated DECEMBER 11, 2006 and approved by the Building Inspector to expire on JUNE 11, 2008. Fee $ 361.55 ORIGINAL Rev. 5/8/02 Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971-0959 Fax (631) 765-9502 Telephone (631) 765-1802 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATION Date: J '2-/2-0 / -;) 1. Building Permit No. ~ --z..-. ~ f.o I '--- Owner: GCJ{L6c5 {3 u(0CCC--- (please print) Plumber: fe~OVl f~C '. f/~ h ~ J- H~'ii-6IVz (please pnnt) ~ I certifY that the solder used in the water supply system contains less than 2/10 of 1 % lead. ~l;;~. Sworn to before me this VV ~ Ir- daYOf~ ~, 20D~ l ~L0 ~~' d J?upt-z , Notary Public, County ~L'" 1lllIIJ~~1Ittl '~illSulIGlk~ a.....iISlDnEJqlireS 110 1---------------- 1"'1/1"7 THE NEW YORK BOARD OF FIRE UNDERWRITERS f'AGF: I. lOn1O'l3 BUREAU OF ELECTRICITY I APRIl, Z8,] '18~ 85 JOHN STREET. NEW YORK. ~~J!1~\V~f38 Ii nJO~14 DatI' Application No. onlil(> THIS CERTIFIES THAT only the electrieal equipment 03 deacribed below and introduced by eke opplieant named on the above opp'reotion number in. tIN pre",._ oj GEROGF. BURnl, NASSAU POINT ROAD CU'rCBOGUF: , N.Y. in theJollowinR loc"A'PRoiJ,f..l Q. !,~nt 6 IJiltFl. 0 2nd H. .~tion Block Lo. was examined on ondJound to be in compliancf> with the requiremenlfC oj this Board. RXTUR. IECEPT ACIIS I FIXTURES IANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS OUTLETS SWITCHES INCANDESCENT FlIJORESCENT M:~l /OMT. ICW, /OMT. K.W. /OMT. K.W. /OMT. I.W. /OMT. H.P. 45 ~5 1B 45 1 " DRYERS RlRNACE MOTORS FUTURE APPLIANCe FlIDEIS SPECIAL REC'PT TIME CLOCKS IILL UNIT HEATERS MULTI.otJTlET DIMMERS /OMT. K.W. H. P. GAS TRANS. SYSTEMS OIL H.P. /OMT. NO. A.W.G. /OMT. /OMP. /OMT. AMPS. /OMT. H.P. NO. OF FI!T /OMT. WATTS (, F I 1O seRVICE DISCONNECT NO. Of S E R V I C E METER NO. OF CC. COND. A.W.G. A.W.G. A.W.G. /OMT. /OMP. TYPE EQUIP. l,12W '.8'3W 3.8'3W 3,1AW PERk OF CC. COND. NO. OF HI-LEG OF HI-LfG NO. OF NEUTRALS OF NEUTRAL OTHER APPARATUS: ]'!()'l'ORS: [.-1. ~ H.P. l>:J,~T, WATER HEAn:RS: :1-4, , K. VI. " G.!' C.T:-4 S ~IO n: D.;Tf.\,TOR: -I - GARY TJOROSK! ~~~ 425 MONSEl,L i,V":. CU1'\,HOGOE, NY, 11 <13'1 ~ ';"JAGER p" . f,' This certificate must not be altered in any manner; return to the office of the Board if incorred. Inspectors may be identified by their credentials. -----. 11 , I I i I IE = ;;; i ~ lE = = 5 ~ I i = ii I = !i = ! i :I! I COPY FOR BUILDING DEPARTMENT. THIS COPY Of CERTIFICATE MUST NOT BE ALTERED IN AMY Mo\NNER. _I 3 ?-S"G I z- TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ ] FOUNDATION 1 ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING I STRAPPING r>1 FINAL [ ] FIREPLACE & CHIMNEY [] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONStRUCTION [ ] FIRE RESISTANT PENETRATION REMARKS: ~--~ ~d V I~ ~ ~J; e~ c/--f~ CPAZ .~\i, c DATE /;}- -;;U r () ~ INSPECTOR ~ ~ l_ u .3;2-st.1 Z ~~ I S- "'IS'! ~ -7 I ' ~ TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ ] FOUNDATION 1 ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING I STRAPPING P<( FINAL [ ] FIREPLACE & CHIMNEY [] FIRE SAFETY INSPECTION [ ] RRE RESISTANT CONSTRUC11ON [ ] RRE RESISTANT PENETRAnoN REM~RKS: ~ ~ ~;/-;. ~),,--jWt. ~, ~~ ~~'~~{~J F,~,.ikJ O~~ ~ ~. ~ C)~ , C!!:. \'-'~ ".it).~ !J---IJ--dt ~~ DATE INSPECTOR I ' ~ <:I (j Z !I z A. 0 - 52 z 5 c:J ::>> ::>> ..I 0 fI) c la ... I: Z Z - =~ ... ... c:J U .z ~ ! is III '-' '-" =A. Iii a z icn ... N Z Z Z .0 0 = - =c - c:J a a z z z - ::>> ::>> ! t e e ~ ... .-. ~. ,....., '-' '-' ~. '-' .........,~ , \>\ J ~ ~ ; fI) z - -- III =c a :~ . CD II Z Z ... L 0 - 0 z 5 t CD ... ~ ~ - 0 fI) C N! I- Z ~ Z - - II. ! CD U ,....., ,....., iZ LII '--' '-' '-" ... ~ A- t; a Z icn .. N Z Z Z 0 0 ~ - ~ CD - a a Z .. Z Z - fI) . ~ ~ ~) 12 ~'{ = ,....., ! = ...... '-' u . , ...... I: 'J, a " ~ ~ Z II Z E 0 ~ - t2 z s Q c:J ::I ::I .... N'" I- 0 en ~ III: III: Z !: U - ii: ~ ......., ......., 'Z ......., !2i III '-' ... '---J '---J A. =A. Ii; a en z z icn ... N - Z Z 0 - = - c:J a z z - .. ~ I en ::I lII: .. ~ ; ~< ,....., ~\ ,....., '---J ... ~ ..~ '---J III: ... '"""' . = a _:.l.1J ...u.::...;:.""'....v.. l!""l1....:. II ""'v.....;;.:... ........ . . -- . . . .. J . .. ~- . .. /' '.,4 QUrlDA'TIO~1 ( 1 - - -- OUNDATION (2nd) OUGH FRANE & PLU!1BING , " :NSULATION PER N. Y. STATE ENERGY CODE FI:1AL o/t.- ""'. '" '" 3: H o-j "" ~ ~ c: ~ ~!1i ~~ (III ~ J "'r ADDITIONAL CO!1!1ENTS' r z, '", ~ 0J J' .,. - '" C ,. r- ~ o-j :I: <::1 '" '" o-j . "" . , . - -- -~-'-"='.'~ /ooc> -j/?-j-. 7 Idtld - /1~'S'I2.. OWNER I ~.I TOWN OF SOUTHOLD PROPERTY RECORD CAi'" - STREET 1- Lvt N LAND IMP. - Soo AGE NEW FARM NORMAL Acre Tillable Woodland Meadawlond House Plot I Total S TOTAL - ~ 0 'fA '. RoADS FARM DATE BUILDING CONDITION BELOW Value Per Acre ABOVE Vclue .... ~ VILLAGE Cu le/ '() q UL~" E B - D - W COMM. CB. MICS. DIST. SUB. REMARKS NPt' If NO'."',S'9.3 S ",L [) "liI'< :'0", 9~' 9..-. tlf..-ID"" FRONTAGE ON WATER FRONTAGE ON ROAD DEPTH BULKHEAD DOCK s Q.SC~ FIIOIl/' 10 ,7 ),23 .:s 7, r;; b-' Butffff , ... - ,. I .5 - rAl'i SO (3,0 '01 , ---- ., .,. ' .. . ~OLOR ~<<.u TRIM ~ < ! - '-- -- - . I . Ji:( l/ VI-' I' , I I I I i I I I i , i -. < ..s rl Sv 3 3> -=- '-f r;d ----.-J ~...., ...... M. Bldg. !;o .;2.- EXtension Extension Extension O. B. ~ i jlO Foundation Bath I Dinette I Basement Floors 'K. Ext. Walls Interior Finish LR. I Fire Place Heat IDR. Type Roof Rooms 1 st Floor SR- , I Recreation Room Rooms 2nd Floor FIN. B Dormer Drivewoy J3( Porch Breezeway Garage Patio Total Ilk' .'~ . .~ . - . -. ~ _ ~ 'TOWN' OF SOUTH OLD ~OPERTY RECORD' CARD' OWNER STREET I 60 VILLAGE DISTRICT SUB. '''\ . . "J..J 1'41be.>Vh L. If ~n.' --~I!.JL-. FORMER OWNER T bo( f\ ~ /~ I" 16 E I/~ ,y LOT 94 poy+ 93 ~ N tES. S,SoC, ,.:-~,) .i S W ACREAGE I I TYPE OF BUILDING CB. , MISe. i("J LAND TOTAL DATE COMM. I IND. REMARKS VL. FARM t? aa Q'T() r-t'> a (CEIL / ~ 0.1' {p .I .- "" /ry' ~b d I S:c-<;.- adch/ .lf4!Jif,'....... 4~ . -to 5urrell If aM) , - , c.. , -. AGE ~ {,,_.,._"'---.;.l ./ .J ,,) -:~E\Yc) .+ -;'4" '''''J'~ (I-I..'.c 1<-. ,'", Farm Acre \ "",' ,'/ i \ ,/ ./ .r -\.de , iIIable illable 2 iIIable 3 loodland ~"I";: J ,-..... " ! Q ,X~:\' Nampland rush land /1"(' c"c -'3d ~ L",.:: . ,::;}.- <; ------ 1..1....' , 1-:-' t.'," ___~...2.,_~) louse Plot ~ I . '_~-'---7 .. I I --,. , I r f 2. I;:; ('AUC'"'" Dtal -', L.--" f- / 1,..-' . I I I I ^. Bldg. I ! Foundation i Both I I i xtension \ Basement Floors ;xtension I Ext. Walls Interior Finish extension Fire Place Hem Porch Attic I Porch Rooms 1 st Floor lreezewoy Patio Rooms 2nd Floor 3arage Driveway J. B. I " " - .. -----,.~"~- Ilk- . , fl;:;" f~. [ - :,' ':"', I /- .._ Ai I ~ ;' '. ,.\-'.y' ...._-~:-::-""'-, 'F'A>f!: . '" ~,', '-1 'l'c" '1 !. '; \ll, ~I,,'~crl ' I' ~~" ~ ,h~~ . ~ i , " , ;:i,' ~ ,".'.' ,,",",J h,.~",' .., ~, ~' ..-' ..,' ---- ',' I', '~:;;~>c~;:;>.', p> ;,..,,,,,,.~"" ~'./>"" _>~i'*,~--_.;*:': ~ '&:- _...-~-w- '. ,.,..:.;... f '\~"""; i ~", "- "'A 7;' r ' </) I"" "'- ~ .. /: it ~ \l} '~ '" t I'" ~I>,) i \-. \ c Vi \ ," __~.~..~~L:':~ ~ ~ / ~ -...L M, B'~7 ;,SK3Y;- 95tJ' '//7i.J S~ t~S7 Exttn1ion IlfX I' ::. ~.;l 'f _ r i Exte5:f{f'1';;~'{: l~~ t ISPl .3~ S5"'1 Extension 1'/)( ~ 2- = 5 ! t .J I~ K 1.// ::.l.ff;t,"), ~ ~ /~.... ~~.., ,., ~ tll$l... ~~ ~r".~ ttr) .. Breezewoy :3 co.. Garage ''J-, 1C,30 -- 6 i}t) 0, B. ,...,...,- c..(l.A.~ jJ . . . -;z.c.J "~c."" , . ",-,'l ,f:j"- ,~ z:;S' /~ '-!_-----" ~- ^~ I. \ F ,t 1,1)'- I i " ~ _: ~ / 1.' 4 -< ;;:.1- ~.::i 'I. i.1 ,-/" h 111U I'l, WV'I'''") '-r" :1_ ' " ':>~ J III~ '11-' Foundation C;.ffi Basement Pa... r Ext. Walls .PL Y tNl>D D , " Fire Place L:t I/', Porch 2..(' rf Porch Patio 7 ~ 0 Driveway ,- I 3 ~.s 2.- I" 1,3: 1/7 L I, g7!,/~ 1.( ~()~;.,;p,~" .._~~-'1:_....a.:;.."?,,~fu\iA~, > ," Both ,Floors I~terior Finish , Heat , Attic Rooms I ~ Rpoms ""; , , , , {I I" ~ "" '; ~ ~ -lJe J , FORM NO.1 TOWN OF SOUTHOLD BUILDING'DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Irn\@~@Jgjl!~lL~;[l1i i' ~Xl MAA I 01987 i I; :. hI U L;'.=_."." ~,,~/ Examined .'W)~. J.;;:., 19~] Approved :h1M<J.!l. .1<., 19}i'? Pennit No.).;; 7. 9.~.-C :j.' Received.. '" .. . . . . ,19.. . .3~-~ Disapproved alc ................ . . . . . . . . . . . . . . . . . . . ... .... ........ ..... .............. ............... f.. wLw (3.p. ~ ~ v:. ...... . .... .~........... CM.e 73 '1- '>-;J.~ (Building Inspector) APPLICATION FOR BUILDING PERMIT Date .YY!S'ff.< k . . . . . . . ., 19ff? INSTRUCTIONS a. 1l1is 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 Pennit. d. Upon approval of this application, the Building Inspector will issued a Building Pennit to the applicant. Such pennit 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 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 neces~~. ~~ . . .? ~. . . . . . . .. ....... (Signature of applicant, or name, if a corporation) . . ?llll.w?-. T~'r. .A.lI:':}. ~.V;t-.~. 7!f-;~. . . . . . . . . . . (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. . . . . . . . . . . . . . . . . . . . . . ~ !ol".~ h Y". . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nam~ of owner of premises .<9.~?X',~" .l?j);('(I?Il..................................................... (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No. . (0. 'l. '1~/:-:--: N ..7:. . . . . Plumber's License No. . P~P.O:l<l !~e.. . .Ft:~>'1 10, ;~. El t.. 'L' N <;-e...y tq 'f')_ ~ $ V,' ec nClan s Icense o. .......:.).. .1./..., . . . . n . '..,." I. Other Trade's License No. ..................... 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 .....f? ~s,.d.% T c;th . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .. b. Intended use and occupancy .... R ~ s./d~Tq. t., ,.. . ./ ~. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. 10. 11. 12. 13. 14. - ftJJ,1Tf"Ir4- ~hJ Pt."cr- 3. Nature of work (check which applicable):" New ~uilding . . . . .'. . . . . Addition. V. . . . .. Alteration .......... Repair .............. Removal . . . . . ;... . .. . . .. Demolition .............. Other Work. . . . . . . .. . .. . . . i (Description) 4. Estimated Cost. . . .~ ./ J,.5yPP~. . . . . . . . . . .1. . . . . . . . . . . . . Fee. . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . ' .'-'- "(to be paid on filing this application) 5. If dwelling, number of dwelling units. . . . . . " ~ . . .. Number of dwelling units on each floor. . . . . . . . . . . . . . . . If garage, number of cars ................:....................................................... 6. If business, commercial or mixed occupancy, specify nature and extent of each 1ype of use . . . . . . . . . . . ,. . . . . . . . . 7. Dimensions ofexistin1ptructures, if any: Front... .~<?:-:31.'... Rear. j;{J. :'!:i'!..... . Depth .3.7. .?/.~..... Height ....... lv. . . . . Number of Stories .. .i. . . . . . . . . . . . . '" Y' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dimensions of same ptIJ.!.C}pre with alterations or additiofs: Front ... G cr~ . :$.~(. . . . .. Rear.. t;.O~ .~:~. . . . . . . . Depth. . . . . . J...i.~. . ~ : . . . . . . . Height. . . . . .":1-.11. . . . . . . . . . . . . Number of Stories. . .?'. . . . . . . f' . . . . . . . . 8 D. . f t' t t' F t /'.. r5 I 3. I . R r,.,' .3 I. D th f. (# s- . unenslOns 0 en lfe new cons rue IOn: ron .......... ...... ear..."" ..,.. . . . . . . .. ep . .'7. . . . . . . . . . . . Height ........ .1. ,. . . . Number of Stories. . . .:r::. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Size of lot: Front . . . . . . . . . . . . . . . . . . . . .. Rear...................... Depth ...................... Date of Purchase ............................. Name of Former Owner .. .(;rj."> ~ "'~t". . . . . . . . . . . . . . . . . Zone or use district in which premises are situated..../h.f\:e. slcl....>I.1A,,~................................ D?es proposed construction violate any zoning law, ordina~ce or regulation: . No.,. . . . . . . . '.' . . . . . . . . . . . . . . :a\ Will lot be regraded ... N.CJ..:i' ......... '.:!li.i:h;,,:,l1 W1l1 excess fill be removed from premIses: Yes ~ Name of Owner of premises .\j-:~!S:-C1~' . .J7'lM~ddress .q..lI--r<;.~p.r".~..... . . Phone No. 73f.;-......... Name of Architect .. . . . . . . . . . . . r7 . . . . .. . . . . . . Address . . . . . . . . . . . . . . . . . . . Phone No. 17 . . . . . . . . . . . . . Name of Contractor Q.e,q':f.t~. . ~ ~.I\T M~...... Address .QI-<.{Qk'?f0-.~.... Phone No. /~fl:7. !i:!.~. r 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 whether interior or comer lot.- ~ S.5 'U'- 1-' C) 11 T ~ -~ -~r--- . . .-..--.-- ~ \.) ~ ------. CY\i\.e... STo'f'') AdJ.,,'on ~- /pO( r ?C)O 1 I () "" '.t,., ~ ~ ~ (50...5 \. \ \' y ..=-- STATE OF NEW YORK, COUNTY OF .. . . .. . .... . .. ... S.S ., ... .... .........-.............. ..... ... ........ being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) 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 make and file this application; that all statements contained in this application are 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.... .l!Y/.~......., 19{.7. 'oWy P"bli"~H .'II.f),.Jj&,. H . . .. C'~"A~p 1?'.4';;JH . . H H H . H HnfNltDEVOE .....rf"" IlOfMY I'UIlUC, SlIItal.... M (Signature of applicant) No. 410711~ cr".r:7 Tn Expires 30, 1