HomeMy WebLinkAbout32695-Z
FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
NO: Z-32620 Date: 09/24/07
THIS CERTIFIES that the building INGROUND SWIMMING POOL
Location of Property: 685 KOUROS
(HOUSE NO.)
County Tax Map No. 473889 Section 117
RD
(STREET)
Block 6
NEW SUFFOLK
(HAMLET)
Lot 9
Subdivision
Filed Map No.
Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated
FEBRUARY 5, 2007 pursuant to which
Building Permit No. 32695-Z
dated
FEBRUARY 5, 2007
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 IN THE REQUIRED REAR YARD WITH FENCE
TO CODE AS APPLIED FOR.
The certificate is issued to JAMES H & JOAN A JACOBS
(OWNER)
of the aforesaid building.
SUFFOLK COUlllTY DEPAR'nmIIT OF HEALTH APPROVAL
N/A
ELECTRICAL CERTIFICATE NO.
N389378
06/21/96
PLUMBERS CERTIFICATION DATED
N/A
Rev. 1/81
..
Form No.6
TOWN OF SOUTH OLD
BUILDING DEPARTMENT
TOWN HALL
765-1802
;;:-_.~
.
'1
(>
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:1
,
APPLICATION FOR CERTIFICATE OF OCqUPANCY i
I - I
This application must be filled in by typewriter or ink and submitted to the Buildi;;g-Department with the foltow1ng:
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 2/1 0 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:
I. 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, Additions to dwelling $25.00, Alterations to dwelling $25.00,
Swimming pool $25.00,J\ccessory building $25.00, Additions to accessory building $25.00, Businesses $50.00.
2. "-ttmiucale 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. '3 - ':i - (.) 7
New Construction: Old or Pre-existing Building:
Location of Property: to g s ok () VL eo <, 12 D
House No. Street
1/
(check one)
A.Juv S.vF"-,:::DL-\<"
Hamlet
Owner or Owners of Property: -.J ~ ,,-,,,,cD _ \ 0 p,,u j A- LOQ;, .::,
Suffolk County Tax Map No 1000, Section 41?> BB'1 ) 11'7 Block ODOr",
(
Lot 0(')'/
Subdivision
Filed Map.
Lot:
jol"t-0...Jf1co/3:::'
Permit No.
3~ t:1q G'
Date of Permit. ;)- "5' -07
Applicant:
Health Dept. Approval:
Underwriters Approval:
Planning Board Approval:
Request for:
Temporary Certificate
Final Certificate:
V'
(check one)
Fee Submitted: $
d5 DO
()t~
~~-7?1109
CO -b 3.2bJ6
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.
32695 Z
Date FEBRUARY
5, 2007
permission is hereby granted to:
JAMES H & JOAN A JACOBS
PO BOX 115
NEW SUFFOLK,NY 11956
for :
INSTALL INGROUND SWIMMING POOL WITH FENCE ENCLOSURE AS ACCESSORY
IN REAR YARD AS APPLIED FOR. THIS PERMIT REPLACES BP 23071.
at premises located at
685 KOUROS RD
NEW SUFFOLK
County Tax Map No. 473889 Section 117
Block 0006
Lot No. 009
pursuant to application dated FEBRUARY
5, 2007 and approved by the
Building Inspector to expire on AUGUST
5,2008.
Fee $
150.00
!n~
I/~' ,
Yl" 0"
iI oriZ~{ S'n~tC1re
ORIGINAL
Rev. 5/8/ 02
THE NEW YORK BOARD OF FIRE UNDERWRITERS
1185077
I
PAGE 1
BUREAU OF ELECTRICITY
85 JOHN STREET, NEW YORK, NY 10038
,-lppllca.ion /lIo. on Jil* 11907296/96
N 389378
0..* JUNE 21,1996
THIS CERTIFIES THAT
only the electrical equipmen.t _ clacribed below .nd' i,,'rocfueed' by d.. opjallcant ...med' Oft. the .bove .""ue.tioft. number in d.. premiN. oj
JAMES JACOBS. 685 KOUROS ROAD. NEW SUFFOLK. N. Y.
in .IoeJoIlo..inW ""'arion, 0 _.....n. 0,.. Fl. 0 %nd Fl. OUT .'i<<rion Block Lo.
..... e.amiRft/ on JUNE 18,1996 ondfound w be in complUutce with the NaJionol Electrical Code.
"XIUII
OUTIITS
"XTUIIS
NCANDlSCI!NT 'lUOlt!5C!NT
ACIIS SWDOlIS
1
1
1
OTHER
IANGIS
NAT. IC.W.
OYl!NS
ANlT. I.W.
DISH WASHIIS IXHAUST 'ANS
AMr. K. w. AMY. H. P.
COOliNG DICKS
AMY. I.W.
AMY. K.W.
H.',
JlUTUH APPUANCI PlIOIIS SPICIALIIC'" TlMlCLOCKS IILL UNITMIAll1S MULTt-OUTLlT
AMT. NO. A. W. G. AMT. AM', AMT. AMPS. TtANS. ANlT. H. P. ~~~~
AMY. WATTS
DIVIIS
_HACR MOTOIS
OIL
H.', GAS
PI_lIS
1 20
I Y
....w.o.
Of ce. COND.
C
A.W.O.
Of HI.LEG
...W.O.
Of NfUTlAl
E
NO. OF NfUTIAlS
AMT.
.....
NO. Of S E
MITH
IQUIP. l.1%W l':rw 3':rw 3,,14W NO.OFPEi<j.COND.
NO. OF H!-LEG
SlIVlCI DI5CONNICT
.....
0-' _lATUS,
SWIMMING POOL-l
TIME CLOCKS-!\MP.40-1
G.F.C.I-l
G.F.C.I,-l
* (SWIMMING POOL) This certificate
covers compliance at the date of
:lnspection only. Because of unusual
environments it is advisable to
have frequent test/and or repairs
<<< Continued on Page 2 >>>
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This certificate must not be altered in any mannerj retum to the oHio of the Board if incorred. Inspectors may be identifted by their credentials.
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE HUST NOT BE ALTERED IN ANY MANNER.
THE NEW YORK BOARD OF FIRE UNDERWRITERS
Oa.. JUNE 21, 1996
THIS CERTIFIES THAT
only CM .-trieeleq..ip".."c .. "-enbed beIcnP .,." introduced by 'M.""ue.n.t...mecI on 'he.boDe ."plietltioft. number in tIN premlN. oj
1185077
I
BUREAU OF ELECTRICITY
85 JOHN STREET, NEW YORK, NY 10038
11907296/96
Application No. onJiI..
PAGE 2
N 389378
JAMES JACOBS, 685 KOUROS ROAD, NEW SUFFOLK, N. Y.
i.. .Ioefollowi..~ ,,,,,..,..., 0 _........ 0 I.. Fl. 0 'nd Fl. OUT .'iHtlo.. 81""k Lo.
.... ...ml.."" Oft JUNE 18, 1996 and foand '0 lH1 in complu."ce with the Notional Electrlcol Code.
f1xrun
OUTllTS
"XTUlH
TAQIS 1Wn0llS INCANDeSCI!NT 'lUOltESCfHT
OTHER
IANGES
NAT. IC.W.
COOICING DICKS OVENS
AMT. !C.W. AHo.T. (.w.
DISH WASHERS EXHAUST FANS
AMY. ItW.
""'T.
H.P,
DRYERS
AMT. !C.W.
A. W. Q. AMY. AM', AMT. AMPS.
IIU UNIT HIATEIS MULn..ouTLIT
TUNS. AMY. H. Po ~~~':t
AMT. WAtTS
RlINACI MOTORS
fI/TIlII APftIANCI _IS SPICIAL IIC''' nMl CLOCKS
co,
H,P, GAS
H.P,
""'T.
NO.
SERVlCI DISCONNECT
NO. Of S I
MItH
IQUIP. 1,#7W 1,3W 3,3W 3"~ NO. OfniC,COND.
R Y
A.W.O. NO. OF HHfG
Of ce. COND.
""'T.
M\P,
.....
0'''' APPARATUS;
made by a qualified person.
11,- G-'1
ROSLAK ELECTRIC
P.O.BOX 164
CUTCHOGUE, NY. 11935
-
.-,~, . -, -
r""~ .;-.;.,~.
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LIC.#3677E
DIMMERS
C E
C:. ~:&fG NO. Of- NEUTIlAl.5
A.W.G.
Of NEUTRAL
LlL
G.I1I.~ _
11
liliP" /
This certificate must not be altered in any manner; return to the oHice 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.
3 2~ 9,s- e--
TOWN OF SOUTHOlD BUilDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1 ST
[ ] FOUNDATION 2ND
[ ] FRAMING I STRAPPING
[ ] FIREPLACE & CHIMNEY
[ ] FIRE RESISTANT CONS1RUCTION
REMARKS:
[ ] ROUGH PLBG.
[ ] I~ULATION
[Y(FINAL k f~
[ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT PENETRATION
,
DATE q If Cf( 07
INSPECTOR
3~1S:2-
TOWN OF SOUTH OLD BUilDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1 ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING I STRAPPING P<(FINAL
[ ] FIREPLACE & CHIMNEY [] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRAnON
REMARKS: f'~ F ~ ~
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DATE
INSPECTOR ~,~
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HHIl;1I FHMm &
PLlJtllll I'll:
- NSH1.ATl ON PER 1'1, y,
STATE EIIEHGY
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OCCUPANCY OR
USE IS UNLAWFUL
WITHOUT CERTIFICATE
OF OCCUPANCY
"IMMEDIATELY"
ENCLOSE POOL TO CODe
UPON COMPLETION
BEFORE 'WATER"
71 lie
.fIle
(7...~
Ir'
/200. - 117-
OWNER
TOWN OF SOUTHOLD P4tOPERTY RECORD
5
v t- 6.J I? os i jt.) e w Jurn / /(
N ILKe./A E, 'i ~""al'lf'hr'c.(;
S kllVI-O.l /?oad ~t1. H'iK'K/lvS
FARM COMM. , IND.
DATE REMARKS J6/r/
~ ?;x.')' II +-:-- ''...J
CARD 11 -.J
STREET
VILLAGE
DISTRICT
SUB.
LOT
Jah-ev Jde.d dJ' 'i-?VJ"
FORMER OWNER
""'/.r
ACREAGE
/)ac,
I '1tfl
SEAS.
VL.
Est. Mkt. Value
~ I'//d '"
{Esf/ tJ
LAND
J8./1 ,,/::-It'"
IMP.
TOTAL
c.. f ,
_~ 3 tJ &
rop
~
606 36 a 6
?oo ,S""1.'-'0 S' ~ CJ 0'''(
AGE BUILDING CONDITION
NEW NORMAL BELOW ABOVE
Farm I Acre Value Per Acre Value
FRONTAGE ON WATER
FRONTAGE ON ROAD
BULKHEAD
DOCK
tfd :6 ~
[illable 1
I iIIable 2
Ii liable 3
tI,
Noodland
;wampland . r
~rush~d_
louse Plot
l;.,...
otal
~~E-' il_'ill~jj7f:.___
E~~~~ /YXl4-~"-jJ!Q_L_~
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I.{ t{ I ()
Foundation
;' Basement
._.-!f_f.~
Ext. Walls
Extension
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Floors.
ood riJ. Interior Finish
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Heat
HW.
Extension
Fire Place 11/7
. __. _.____~~__ ._______~ _ ___~z..---
Parch
Roof Type
Breezeway
Garage
~~1J<j_=-36.~__ ..i..I! tl
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V
, .
Patio
O. B.
3 () ~ Driveway
-..--
:;. S- /
S-/ 9~
v
Rooms 1 st Floor
Rooms 2nd Floor_~ Sm ""I L L. ) -'57'7"""--~~-~----- ___
Dormer .' r r
-~-- -. - -------~--I--- ---- ~---~-- ----
"....)
FORM NO.1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD. N.Y. 11971
TEL.: 765.180:!
Examined.... /r?. .,19~r- ~"~J,,/1S
Approved... .I.'O/I.?..., 19%ermit No.~-C-
Disapproved ale ................................:....
BOARD OF HEALTH ........
) SETS OF PLANS ........
SURVEy.................
CHCCK ...... _ . . , . . . . . . . .
SEPTIC FORM ............
!lOTI F'f : '2Jtf.'.f6o'
ChLL .................................
HAIL TO:
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
.................................. ..
................................:...~~~~~...
APPLICATION FOR BUILDING PERMIT
Date... (bl::....... .,I9t.(
. .
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with:
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 street,
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 Permit.
d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such 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 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 necessary inspections. ' , , '
, '.. ./l.: fl.t?u.'t ~ ..J {J.~~... me:. ..... .. . .. ..
(Signature of applicant, or name, if a corporation)
.19...'?'?~. ~.: f!1.'77:n.~.)v.~7... !(.rJ,-:...
. (Mailing address of applicant)
Ii
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
. . . . . . . . . . . . . . . . . . . . . .Q 61tI6"'P.-'.~.' . . .~JI:,,77Jrt.. . . . . . . . . . . . . .'. . '. . . . . . . . . . . . . ..' . . .. . . . . . .
Name of owner of premises ....... .J?J:7J':I.'/:iT r.. . .:;r.~~ . . .,l1.. . . . ~.CO.a.s. .. .. . . . . . .. . . .. .. . . . . . .
' (as on the tax roll or latest deed)
If ap' ica is a corporation, 'gnature of duly authorized officer.
.... ,",........ .....
Builder's License No. . ~.f..:)'8.1. Jif.. . . . . . . . .
';-~r~ @ [~ ~~j,1
I . - 5 ne>::; ..
j
I
BL:JG. CL T
TOWN OF SC..if'V""
.,-,~_.,_..._..-
Plumber's License No. ...... ~.. .. .. . .. .. .. .
EI .., L' N 11 <>St.-'7t< Cd C.-<'I"""< c:...
ectnclan s Icense o. ./-'-:..... ".t' . . . . ... . . r:'"f.
Other Trade's License No. .....................
I. Location of land on which proposed work will be done.
....... ......... .., ..... ...... ...................
. .. .G.8"[ .. .. . .. . .(<(,)y1..0~.... .ll.o.J!f.I'J)' . .. .. . . Al.~. .~.~(.;F.Q.Cf<'.. /.1( ~.'.. ..... ..... . . ..
House NUIll ber ,Street Hamlet
County Tax Map No. 1000 Section ...:.//.7......... Block..... C. . . . . . . : . .. Lot...... y. . .. . . . . . . .
Subdivision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Filed Map No. .............. Lot...............
' (Name) .
~, State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy........... (l,-.t;;:~~~77.a-:L......... i;,.:~f',~..............
, fl{;;JI,-)n-..ro1L iN .~~;tiii';
b. Intended use and occupancy ..................... y;;. . . ... . '" . . .~,.....................
- . fWIY1-\.""'-II'\Ic. f%oL
. ' -, . /~/:F XJ ~r
'3. Nature of work (check which applicable): New Building.......... Addition.. . .,. . ... Alterationl.....:..
Repair .............. Removal . . . . . . . . . . . . " Demolition ....:......... Other Work. . . . . . . . . . . . . . .
. - ,P. '. " (Description)
4. Estimated Cost. . . . . .. " . . .1l.om"~' " . . . . . . . . . .. . .. Fee. . . . . .. .. . . . . . . . . . . . . . . . . . . . . . . .. .. . . .
(to be paid on filing this application)
5. If dwelling, number of dwelling units. . . . . . . . . . . . . .. Number of dwelling units on each Door. . . . . . . . . . . . . . . .
. If garage, num ber of cars ...........................:.............................................
6. If business, commercial or mi,xed occupancy, specify nature and extent of.each type of use " . . . . . . . . . . . . . . . . . . .
7. Dimensions of existing structures, if any: Front. . . . . . . . . . . . . . . Rear .............. Depth...............
Height ............... Number of Stories. . . . . . . . . . . . . . . . . . . .. .. .'. . . . . . . . . . . . . . . . . . . . . . . . " .... . .
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: Front . . . . . . . . . .' . . . . . . . . . ,: .. Rear.............;........ Depth ......................
10. Date of Purchase ............................. Name of Former Owner .............................
11. Zone or use district in which premises are situated. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12. Does proposed construction violate any zoning law, ordinance or regulation: .............................. ~ .
13. Will let be regraded ...........~............... Will excess fill be removed from premises: @ No
14. Name of Owner of premises " . .J).9;.:..06.J........ Address.. ~J.Li.f(,!>!-t.~... Phone No. ...........,...,
Name of Architect '" 'AI' . . . . i4if . . . . ~ " . . . Address. . . . . . . . . . . . . . . '( . . Phone No. . 'u;l'~(j r . .
Name of Contractor. . ! I. l ~.r;. . . . . t-:f.. . . . . . . . . Address. . /J1 tf-m ~ .. Phone No. .. . . . . . . . . . . . . .
15.' Is this property within 300 feet of a tidal wetland? - *Yes........ No......... '
. *rf yes, Southold Town Trustees Permit may be required.
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 corner lot. . .
fo;
!JtrJJ;e/fc;'n
...J I..( ft.(; (.-"1
1I1:DER'NRITERS CERriFICI\1E
hEQ;;lilED
"IMMEDIATELY"
ENCLOSE POOL TO CODE
UPON COMPLETION
BEFORE 'WATER"
APPROVED AS NOTED .
DA~ /tX9r8.p.# hr;:/.c- "
FElr/ r ,0;.;--- BY: A -4
NOTIFY BUILDING DEPARTMENT AT
765-t802 9 AM TO 4 PM FOR THE
FOLLOWING INSPECTIONS:
L FOUNDATION - TWO REQUIRED
FOR POURED CONCRETE
2. ROUGH - FRAMING . PLUMBING
3 INSULATION
4: FINAL - CONSTRUCTION MUST
BE COMPLETE FOR C.O. .,
'ALL CONSTRUCTION SHALL. MEET
THE REQUIREMENTS OF THE N.Y.
STATE CONSTRUCTION . ENERGY
CODES. NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS
OCCUPANCY OR
USE IS UNLAWFUL
WITHOUT CERTIFICATE
OF OCCUPANCY
TATE OF NEW YQRK.- ~ S S l
OUNTY OF " . .J~(:-(:Q':-~<;.. . ,
. , . . . . . . .J.(Q~~.11lv. . . Il... . /,?{(l,~ ~ .If.. . " .~ .'. .. being duly sworn, eposes and says that he is the applicant
(Name of individual signing contract)
love named.
~ is the. .\.... . .... .. . . . '. . ........ ... . .~7!:?~ . . . . . . .. . . . '" . ...... . . .. ......... ...... .
' (Contractor, agent, cor'porate officer, etc.)
said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this
plication; that all statements contained in this' application are true to the best of his knowledge and belief; and that the
)rk will be performed in the manner set forth in the application filed therewith. .
10m to before me this ~
fie,S .NY __\
Comm. =--~ '. .. ... '" ............ ... (S. a ~;; ~i ~;;Ii~~'t) ,
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\
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)
3 :J,l.cqs (l2-fL
"2'3'W1 Z
Date ............./t:?/I...7.......................... 19.9.:r.
N~
Permission Is hereby granted to:
/1.~~...~~:E",.~~(.....~...~,[..!f. JAc.o,s5
......l..!l......1.P.I.(...9.. t........................... ... ........ ............
.........I!!:1trJ~~.....-1!.y.......!!.9..Q.~........
to .~{D1//...........&................/~~~J)..........~~~~!.~........&.L
..WI/..7.t.......#d.~..........&.t;/q,!.:.41.'t~..........dF.........~......t:1..~~1f.Qp.~
../..~........~.......&:t.4......;Y~,J.............d.[..........~~~C(4,d........~~../
........,.....................................................................,...................................................................................
~~.~r~~I~~~.;:~;=.~~........................6.;;.........."jb.~~;,.............&...................................................................................................................
............................................................~~...~/.:.~.q<.........................................................
County Tax Map No. 1000 Secflon .......11.7......... Block .......I!~.......... Lot No. ......t?~............
pursuant to appllcaflon dated ..............~..:....f..................... 19...!~" and approved by the
Building Inspector.
Fee $...Im.:..":.....
~/L~m
Rev. 6{30{80