HomeMy WebLinkAbout33531-ZFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-33491
Rte: 01/14/09
THIS CERTIFIES that the building ALTERATIONS
Location of Property: 2705 WEST CREEK AVE
(HOUSE NO.)
County Tax Map No. 473889 Section 110
Subdivision
CUTCHOGUE
(STREET) (HAMLET)
Block 5 Lot 3
Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated NOVEMBER 8, 2007 pursuant to which
Building Permit No. 33531-Z dated NOVEMBER 15, 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 WINDOW REPLACEMENT, HEAT AND ELECTRICAL UPGRADE IN AN EXISTING ONE
FAMILY DWELLING.
· ~ne certificate is issued to ROBERT & LINDA KEN-NEY
(OWNER)
of the aforesaid building.
COUNTY DEPART~rr OF HEALTH APPROVAL
ELECTI~ICAL u~KTIFICATH NO.
PL~EI{S c~TIFIC~kTION DATED
N/A
3061375 05/08/08
N/A
Authorized Signature
Rev. 1/81
Form No. 6
TOWN OF SOUTHOLD
BUILDING 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
A. For new building or new use:
1. Final survey of property with accurate location of all buildings, property lines, streets, and um
3.
4.
5.
topographic features.
Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form).
Approval of electrical installation l~om Board of Fire Underwriters.
)llovC~g:
gual na~.~
Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead.
Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate
of Code Compliance from architect or engineer responsible for the building.
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
New Construction: Old or Pre-existing Building:
Location of Property:
House No. Street
Owner or Owners of Property:
Suffolk County Tax Map No 1000, Section
Subdivision
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
(check one)
Permit No. ~ Date of Permit.
Health Dept. Approval:
Planning Board Approval:
Request for: Temporary Certificate
Fee Submitted: ~
Block t9 ~""6 D Lot
. Filed Map.
Applicant:
Underwriters Approval:
Hamlet
Lot:
Final Certificate:
f (check one)
Applicant Signatme
BY THIS CERTIFICATE OF COMPLIANCE THE
NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
40 FULTON STREET ~ NEW YORK, NY 10038
CERTIFIES THAT
Upon the application of
upon premises owned by
Located at
ALAN HUBBARD ELEC.
PO BOX 2241
126 CLOVER PLACE
AQUEBOGUE, NY 11931,
2705 WEST CREEK AVE CUTCHOGUE, NY 11935
BOB KENNY
2705 WEST CREEK AVE
CUTCHOGUE, NY 11935
Application Number: 3061375
Certificate Number: 3061375
Section: Block: Lot: Building Permit: BDC: ns11
'3 5 1
Described as a occupancy, wherein the premises electrical system consisting of
electrical devicee and wiring~ described below~ located in/on the premises at:
First Floor, Attached Garage, Outside, Attic,
A visual inspection of the premises electrical system, limited to electrical devices and wiring to the extent detailed
herein, was conducted in accordance with the requirements of the applicable code and/or standard
promulgated by the State of New York, Department of State Code Enforcement and Administration, or other
authority having jurisdiction, and found to be in compliance therewith on the 8th Day of May, 2008.
Name QTY Rate Rating Circuit Type
Alarm and Emergency Equipment
Sensor 1 0 CarMon/Smoke
Sensor 4 0 Smoke
Appliances and Accessories
Dish Washer 1 0 1.2 KW
Exhaust Fan I 0 F.H.P.
Air Conditioner 1 0 30 Amps
Air Handler 1 0
Furnace 1 0 Gas
Wiring and Devices
Receptacle 29 0 General Purpose
Switch 14 0 General Purpose
Dimmers 12 0
Fixture 36 0 Incandescent
Receptacle 10 0 GFCI
Receptacle 1 0 20a Laundry
seal
I of 1
This ceAificatemay not be altered in any way and is validated only bythe presence of a mised seal atthe location indicated.
FORM NO. 3
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Hall
Southold, N.Y.
(THIS
BUILDING PERMIT
PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
PER~IT NO. 33531 Z
Date NOVEMBER 15, 2007
Permission is hereby 9ranted to:
R & L KENNEY
2705 W CREEK AVE
CUTCHOGUE,NY 11935
for :
WINDOW REPLACEMENT AS APPLIED FOR
at premises located at
County Tax Map No. 473889 Section 110
pursuant to application dated NOVEMBER
Building Inspector to expire on MAY
2705 WEST CREEK AVE
CUTCHOGUE
Block 0005 Lot No. 003
8, 2007 and approved by the
15, 2009.
Fee $ 200.00
Authorized Signature
ORIGINAL
Rev. 5/8/02
- tgo. E~ ,'7
TOWN OF SOUTHOLD BUILDING DEPT.
765-1802
INSPECTION
[ ] FOUNDATION 1ST
[ ] FOUNDATION 2ND
[ ] FRAMING / STRAPPING
[ ] FIREPLACE & CHIMNEY
[ ] FIRE RESISTANT CONSTRUCTION [
ROUGH PLBG.
INSULATION
FINAL
FIRE SAFETY INSPECTION
FIRE RESISTANT PENETRATION
REMARKS:
DATE, / --- ?- o ?
FI~,I,D°IkN'SPECTION REPORT [ DATE [ CONEVIENTS k J3
FOUN]DATION (IST)
FOUNDATION (2~)
ROUGH F~G & ~ ~
PL~G
LNSU~ATION PER N.Y. ~ ~
STATE ENERGY CODE
-
~DITION~ COUNTS
TOWN OF S. OUTHOLD
BUILDING DEPARTMENT
TOWN ItALL
SOUTHOLD, NY 11971
TEL: (631) 765-1802
FAX: (631) 765-9502
SoutholdTown.NorthFork.net
Examined I((f ,200 J
Approved l(/If ,2007
Disapproved a/c
Expiration
PERMIT NO.
BUILDING PERMIT APPLICATION CHECKLIST
Do you have or need the following, before applying'?
Board of Health
4 sets of Buildthg Plans
Planning Board approval
Survey
Check
Septic Form
N.Y.S.D.E.C.
Trustees
Storm-Water Assessment Form
Contact:
Mail to:
Phone:
Building Inspector
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
Date /~b/ 7 ,2007
a. Tlfi~apphcatxon IVlrOST--be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4
sets of plgfi}, accurate plot plan to scale. Fee according to schedule.
b. Plot plan showing location of lot and of buildings on promises, relationship to adjoining premises or public streets or
areas, and waterways.
c. The work covered by this application inay 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 the Building Inspector
issues a Certificate of Occupancy.
f. Every building permit shall expire if the work authorized has not commenced within 12 months after the date of
issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the
property have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the permit for an
addition six months. Thereafter, a new permit shall be required.
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 promises and in building for necessary inspections.
0GCUPANGY 0R (~Sig~atu~re °~-~f aL~e' if a~c °rati°n)
USE IS UNLAWFUL ?c z?;uXS'/g,
WITHOUT CERTIFICATE (Mailing address of applicant)
State whether applicant is owner, les~a~[9~tj~N~¥neer, general contractor, electrician, plumber or builder
Nameofownerofpremises , ,, /9 ,d
(As on the tax roll or lat~:~- t~,: ~
NOTIFY BUILDhN¢ 5L?;,;~Tr¢ZNT AT
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. ALL C0.NSTRL?
Other Trade's License No. MEET THE REQU' OFTHE
OD S EW YOh, STATE.
1. Location of land on which propose~;wor~ willie done:
House Number Street
765-1802 8AM TO ." '~d FOR THE
FOR POUF~ED C~:I;Ci~E'TE
2. ROUGH - FRA?;G & FLUM~iNG
3. INSULATiOr4
4. FINAL- COXS'FL'"~:.~4 MUST
ALL COi4S;5, LF:~ ,;[ 5~-,.:L fd~25~ THE
REQUIREMENTS OF; 2 C:2:.:ES OF NEW
Y~RK STAT~NO'[ RE&O~;S;SLE FOR
Hamlet
County Tax Map No. 1000 Section //
Subdivision ~(e ~
(Name)
Lot
Lot
2. State existing use and occupancy of premises and in½ende~use
a. Existing use and occupancy
b. Intended use and occupancy
3. Nature ofwork.~check which applicable): New Building_
Repair v' Removal_ Demolition
4. Estimated Cost ~ ~;;.DOD. Fee
I
5. If dwelling, number of dwelling units
If garage, number of cars 5/,.--
,ccupancy of proposed constmcti~)n:
Addition Alteration
OtherWork /~/O.,~ (,,O/,~2)c)/.,tJ
(Description)
(To be paid on filing this application)
Number of dwelling units on each floor
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use.
7. Dimensions of existing structures, if any: Front c//~. /Rear cF/,2 ~ __Depth (-fi4 /
Height. Number of Stories
Dimensions of same structure with alterations or additions: Front /t~o C~,4-,V~-~ Rear
Depth. Height Number of Stories
8. Dimensions of entire new construction: Front
t~ear .Depth
Height Number of Stories .~-
9. Size of lot: Front (q~6)' Rear ~'7 ' Depth (gO /
¢/~2--/7 Name of Former Owner
10. Date of Purchase /--
11. Zone or use district in which premises are situated iq.P--4 c (,,/¢,t4 ! ,a~
12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO
13. Will lot be re-graded? YES__ NO ~/'Will excess fill be removed from premises? YES__
14. NamesofOwnerofpremises 3~./~K~..'T ~t/~tddress ~o/~,)( ~'/~ /~P,ho/n¢I~o.
Name of Architect (Address Phone No
Name of Contractor Address Phone No.
NO J
15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES __ NO __
* IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE ~3EQUIRED.
b. Is this property within 300 feet of a tidal wetland? * YES NO
* IF YES, D.E.C. PERMITS MAY BE REQUIRED.
16. Provide survey, to scale, with accurate foundation plan and distances to property lines.
17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey.
18. Are there any covenants and restrictions with respect to this property? * YES
· IF YES, PROVIDE A COPY.
NO ,/"
STATE OF NEW YORK)
SS:
COUNTY OF )
"'/~g>t.~""~7~-----/~"~'-/b/A} ~"-/~ being duly sworn, deposes and says that (s)he is the applicant
(Name of individual signing contract)f above named,
(S)He is tt~
(Contractor, Agent, Corporate Officer, etc.)
of ~1 owner er v- __~ers, 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
'1~5'{-j- day of Ix,3 C9~ .
20 07
Signature of Applicant /
JAN-16-2009 11:28 LEGAL AID 6318521655
LEGAL AID SOCEITY OF SUFFOLK COUNTY, NY
CRIMINAL DIVISION
ARTHUR M. CROMARTY COURT COMPLEX
First Floor
300 Cemer Drive
Riverhead, New York 11901
(631) 852-1650
P.O01
FAX TRANS~T~ COVER SHEET
CONFIDENTIAL
The pagesI comprising this facsimile transmission contain confidemial information intended
solely for ~ by the individual named as the recipient hereof, if you arc not thc intended
recipient, be aware that any disclosure, copying, distribution or use of the contents of this
~ion is prohibited. If you have receivcd this transmission in crcor, please notify us by
telephone immediately.
~, .
TO: ~'q / C
There is/arc page(s) being forwarded to you, including this transmittal cover sheet. If
you do not ireceive all copies, kindly contact our office.
BLDG. DEPT.
TOWN OF SOUTHOI. O
JAN-16-2009 11:28 LEGAL AID
01/18/2B~9 11:~0 63~-65~-~019
Pitier1 ~I~[iIi[ATIOI(~
&M¥95 Dm~]m~s
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6318521655 P.O02
MIIIN ~ TO (IIKIE In~$
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JAN-16-gO09 11:28
al/15/2ea9 ~l:3e
LEGAL AID
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Customer:. UNIT SPEC REPORT Proieot: Bob Kenney
Salesperson: Chris Wilt IQ Version: 7.1
Today's Date: 11/06/2007 Quote No: 0151Bg
Report: Ar~lersen Unit Spec Report Date Quoted: 10/30/2007 Page: 2 Of 7
DisclaimarlNotes
Itom
0002
Unit SLze
2846
Unit OperaUon
AA
Dimensions:
Unit:
Rough Open.g:
Max. Cir. Open:
Subfloor to Sill Stop:
Projection:
Operating SpeclflcaUons:
Glass Area:
Vent Ama:
Max. Cfr. Open:
Extension Jambs:
Location Arm: NIA
WId~ Height
2'9 5t8" 4'9 114"
2' 10 liB" 4' 0 1t4"
2'6 11116" 2' 0 1/2"
2'4 1t8"
9.47 SO FEET
5.26 SO FEET
5.22 SQ FEET
High Pe~form~mce Low-rcA glass will be avaitable as a running change on Andersen Architectural Specialty Windows, See order acl~owledgsment to verily glass {ype, '
Cus~comer:
Satesperso~n:
Repolt:
DIsclaimer/Notea
Chris Wilt
Andersen Unit Spec Repod
UNIT SPEC REPORT
iQ Version: 7,1
Today's Dale: 11106/2007
Date Quoted: 1 OI30,"2007
Projecl:
Quote
Page:
Bob Kenn~
015189
3 ~7
OO03
Unit ~ize
3046
Unit Opera,on
AA
Dlmertelona:
Unit:
Rough Opening:
Max. Cir. O~e~:
Subftoor to $111 Stop:
Operating Spe~lficaaona:
Glass Area:
Vent A~ea:
Max. Clr_ Open:
Extenalo~ Jambs:
Lo~atlon A~m: N/A
Width HelgM
3'1 5/8' 4' 9 1M"
3' 2 118' 4' 9 114"
2' 10 11116' 2' 0 1/2"
2'4
n/a
10.80 SO FEET
5.95 SO FEET
5.90 SO FEET
* Higtt Pe~fo~manss Low-E4 glass will be available as a running change on Andersen ,~N'chlteCturel $1~ecleltyWIndows. See order acknowledgement to redly glass type. *
Salesperson:
Chris Wilt
Andersen Unil Spec Repor~
UNIT SPEC REPORT
IQ Veraten: 7.1
Today*s Date: 11/0812007
Date Quoted: 10f30/20D7
Pro, ecl: Bob Kenney
Quote No: 015189
Page: 4 Of 7
DlscJalmerlNotes
OO05
Unit Size
2442-3
Unit Oporatlo~
AA-AA-AA
Dimensions:
Unit:
Rough Opening:
Max. Cir. Open:
Subfloor lo Sill Stop;
Projection:
Operating Spe~ltcaliorts:
Glass Area:
Vent Area:
Max, Cir. Open:
Extension Jambs:
Locaflo~
Width
7' 5"
7'5 112"
2'2 11116"
2'8 1t8"
n/a
Arm: N/A
Height
4' 5114"
1' 10 1/2"
22.38 SQ FEET
12.60 SQ FEET
4.17 SQ FEET
z
cD.
High Performance Low-EA glass will be available as a running change on Andersen Arcfniteclural Specially Windows. Sas order aclmowledgement to verily glaas ~.ype. '
Customer: UNIT SPEC REPORT proJect: Bob Kenney
Salesperson: Chris Wit1 IQ Version: 7.1
Today's Date: 11/06/2007 Quote No: 015189
Report: Ande~en Unit Spec Repori Dale Quoted: 10/30/2007 Page: 5 Of 7
DleclaimerfHotes
0OO6
Unit Size
2052
Ualt Operation
AA
Dlmer,~lons:
Unit:
Rough Opening:
Max. Cir. Open:
Subitoor to Sill Stop:
ProJect[on:
Operatlag Specifications:
Glass Area:
Vent Ama:
Max. Cir. Open:
Extension Jambs:
Lo~atlon AJ'm: NIA
Width I'lelght
2' I 5/8" 5' 5 1/4"
2' 2 t/8" 5' 5 114"
1' 10 11116" 2'4 1/2"
1'81/8'
n/a
7.94 SQ FEEl'
4.52 SO FEET
4,4g SQ FEET
* High Performance Low-E4 gla~s will be avallalde as a running change oe k~ders~o Architectural Speclatty Wlndows. See order a~knowled~ement to verify glass type.
Salesperson:
Report:
Disclaimer/Notes
Chris Witt
Andersen Unit Spe~ Report
UNIT SPEC REPORT
IQ Version: 7.1
Today's Date: 11/06/2007
Date Quoted: 10/30/2007
Project: Bob Kenney
Quot~ No: 015189
Page: 6 Of 7
Item
0007
Unit Size
2432-2
Unit Opsratlon
AA-AA
Unit:
Rough Openl~j:
Max. Cir. Open:
Subfloor to Sill Stop:
Projection:
Operating Specblcaflons:
Glass Area:
Vent Area:
Max. Cir. Open:
Ex't~nslo~ Jambs:
Location
Wi~h
4' 11 5/16'
4' 11 7/8"
2' 2 11116'
3' 8 1/8'
nla
Arm: N/A
Height
3' 5 114'
3'51/4'
1'4 1/2'
10.84 SQ FEET
6.18 SQ FEET
3.06 SQ FEET
z
High Performance Low-E4 glass wilt be avalhddo m a running change on Anti.sen Aashltectural Speclali. y Wind--. Se. order ~cknowled~ernenl to verily glass
Cu$ res'tar.
Sale, person:
Report:
Disclaimer/Notes
Chris Wilt
Andersen Unit Spec Report
UNIT SPEC REPORT
iQ Version: 7.1
Today's Date: 11/06/2007
Date Quoted: 10130/2007
Project: Sob Kenney
Quota No: 015189
Page: 7 Of 7
z
00OB
Unit Size
24310-2
Unit Oper='tlen
AA-AA
Dimensions:
Ur~t:
Rough Opening:
Max. Cir. Open:
Subltoor to Sill Slop:
Projection:
Operating Spect flcatlo~:
Glass Area:
Vent Area:
Max. Cir. Open:
Extension Jambs:
Loca'~
Arm: I~A
Wldlh Height
4'11 5/'~6" 4'1 114"
4' 11 7/8' 4' I 1/4"
2'2 11/16" 1'8 1/2"
3'0
n/a
13.56 SQ FEET
7.66 SQ FEET
3.80 SQ FEET
z
· High Petfozmance Low-E4 glas~ will I~ available as a rlmnlng ctlange on Andersen Architectund Specialty Windows. See order acknowledgemenl to vm, lfy glass lyp.. '
. Town o_ f $outhold
Erosmn, Sedimentation & Storm-Water Run-off ASSESSMENT FORM
PROPERTY LOCATION: S.C.T.M. #: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A
~ ~)~z~IL ~.~ ! ~)/I STORM-WATER, GRADING, DRAINAGE AND EROSION CONTROL PLAN
District Section Block Lot CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK.
It. earn Number: (NOTE: A Check Mark (~) for each Question is Required for a Complete Application)
Yes No
1 Will this Project Retain All Storm-Water Rue-Off Generated by a Two (2") Inch Rainfall on Site? -L// D
(This item will include all mn-off created by site cleadng and/or construction activities as well as all Site
Improvements and the permanent creation of impervious surfaces.)
2 Does the Site Plan and/or Survey Show All Proposed Drainage Structures Indicating Size & Location? D
This Item shall include all Proposed Grade Changes and Slopes Controlling Surface WatenClowI
3 Will this Project Require any Land Filling, Grading or Excavation where there is a change to the Natural
Existing Grade Involving more than 200 Cubic Yards of Matedal within any Pamel?
4 Will this Application Require Land Disturbing Activities Encompassing an Area in Excess of r~
Five Thousand (5,000) Square Feet of Ground Surface?
5 is there a Natural Water Course Running through the Site? r'~
is this Project within the Trustees jurisdiction or within One Hundred (100') feet of a Wetland or Beach?
6 oneWill there be Site preparation on Existing Grade Slopes which Exceed Fifteen (15) feet of Vertical Rise tOHundred (100') of Horizontal Distance? E~ __
7 Will Driveways, Parking Areas or other Impervious Surfaces be Sloped to Direct Storm-Water Run-Off
into and/or in the direction of a Town fight-of-way?
8 Will this Project Require the Placement of Material, Removal of Vegetation and/or the Construction of
any Item Within the Town R ght-of-Way or Road Shoulder Area? --
(This Item will NOT include the Installation of Driveway Aprons.)
9 Will this Project Require Site Preparation within the One Hundred (100) Year F oodp a n of any Watercourse? r~
NOTE: If Any Answer to Questions One through Nine is Answered with a Check Mark in the Box, a Storm-Water, Grading,
Drainage & Erosion Control Plan is Required and Must be Submitted for Review Prior to Issuance of Any Building Permitl
EXEMPTION: Yes No
Does this project meet the minimum standards for classification as an Agricultural Project?
Note: If You Answered Yes to this Question, a Storm-Water, Grading, Drainage & Erosion Control Plan is NOT Required! --
STATE OF NEW YORK,
That I ..................... ~./~. ........... %.~./~...~.O~t~ .......... being duly sworn, deposes and says that he/she is fl,e applicant fo,-PenaaiL
(Name of individual signing Docoment)
(Owner, Contractor, Agent, Corporate Offoer, etc,)
OwDer and/or representative of the OwDer of Owner's, and is duly authorized to perform or have performed the said work and tD
make and file this application; that all statements contained in this application are tree to tile best of Iris lmowledge a~ld belief; and
that the work will be perforated in file maturer set forth in file application filed here,~4fll.
Sworn to before me tiffs;
...... .............
FORM. 06/07 ~o.
(Signature of Applicant)