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HomeMy WebLinkAbout40737-Z , S�Ff®j� OG Town of Southold 6/23/2016 1 o 11 P.O.Box 1179 v' 53095 Main Rd Southold,New York 11971 * CERTIFICATE OF OCCUPANCY No: 38358 Date: 6/23/2016 THIS CERTIFIES that the building ADDITION/ALTERATION Location of Property: 1165 West Rd., Cutchogue SCTM#: 473889 Sec/Block/Lot: 110.-7-2 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 6/1/2016 pursuant to which Building Permit No. 40737 dated 6/1/2016 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: ADDITION AND ALTERATIONS TO AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR The certificate is issued to Rynd Jr,Donald of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 837427/837604 10-13-1987 & 10-14 PLUMBERS CERTIFICATION DATED 06-03-2016 Pace Analytical Autho ed Signatu e Tom" TOWN OF SOUTHOLD �suFFotK jo`� coGy� BUILDING DEPARTMENT TOWN CLERK'S OFFICE 1 o SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 40737 Date: 6/1/2016 Permission is hereby granted to: Rynd Jr, Donald 6 Mill River Rd East Norwich, NY 11732 To: ADDITION TO DWELLING ReplacesB.P.#14531 At premises located at: 1165 West Rd., Cutchogue SCTM # 473889 Sec/Block/Lot# 110.-7-2 Pursuant to application dated 6/1/2016 and approved by the Building Inspector. To expire on 12/1/2017. Fees: PERMIT RENEWAL $107.72 CERTIFICATE OF OCCUPANCY $50.00 Total: $157.72 C( ilding Inspector F011391 NO. f 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) N9 14531 Z Date ..: -: .c.!.a-r4ti.. 7 , 19.X,... Permission is hereb1 granted to: �, /Gear/T .,t v• 5 .ei.hi c, Z c,T c4.. ,V-`% ./117 to e .T .C/C.2- a5.--&57.-/%4 .. L 10 /Q5 �.fgA77 - � ... .4e/y0 at premises located at ./.1. , -st .'E?G 40)-4.4) County Tax Map No. 1000 Section ....// Block Q 7 Lot No. '61O. -, ® pursuant to application dated .. �� e -7 , 19Fnd approved by the Building Inspector. - Fee $ S Zit/ 11 / . 1 Building Inspector Rev. 6/30/80 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 the following: A. 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 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: 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 1. Certificate of Occupancy-New dwelling$50.00,Additions to dwelling$50.00,Alterations to dwelling$50.00, Swimming pool$50.00,Accessory building$50.00,Additions to accessory building$50.00,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$15.00 Date. ------ - - -- -- --- New Construction: Old or Pre-existing� ngBuilding: (check one) Location of Property: ( � 5. �J f%s1 Pd �6i o aL'L'._ House No. Street Hamlet Owner or Owners of Property: DMA! U` k _i not Jr Suffolk County Tax Map No 1000, Section i I' Block Lot Subdivision Filed Map. Lot: Permit No. Li0 7 3-7 Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted:$ 5b -- — —, — — • Appl icant Signature rzl tiC C'.m.x.A..".J__l'Acknm).!C0..CJ_�._:0Gael')_,l' _C"eC' l'omJ_!•apf:ale4::,.4s9.!.otIv _A.:!.L4.,7..Ce e2„,7..7.t_py_l'7.Ges.l.C':LCJ._I"aC'eCp,..n'e7J_C._t" 'mg,14' _L'.A_Cy.i..,imqW�C . t ._, iu0a3� THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY ei.c^ 85 JOHN STREET, NEW YORK, NEW YORK 10038 Y El Date October 13, 1987 Application No.on file 466448/87 g: ►; THIS CERTIFIES THATIP Mg only the electrical equipment as described below and introduced by the applicant named on the above application number in the premises of Y 1 Donald Rynd, West Rd. , West Creek Rd., Culxtogue, N.Y. Ir in the following location; Basement E 1st Fl. LFI, 2nd Fl. Section Block Lot i was examined on - and found to be in compliance with the requirements of this Board. i" .; FIXTURE FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS 1 ! OUTLETS 'ECEPTACLES SWITCHES MERCURY 'A' INCANDESCENT FLUORESCENT VAPOR AMT K.W AMT K W AMT K W AMT K W AMT H P I s' ' 1 y. R1 3a 35 40 35 1 1.2 3 F Iro. 9,El T' DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIME CLOCKS BELL UNIT HEATERS MULTI-OUTLET DIMMERS �Ty-4,AMT K W OIL H P GAS _ H P AMT NO A W G AMT AMP AMT AMPS TRANS. AMT H P NO.OF FEET AMT WATTS I} i r , i:: 1 30 1 600 N — SERVICE DISCONNECT NO.OF S E R V I C E ;T g AMT AMP TYPE EQUIP 1 A 2W 1 0 3W 3,0'3W 3,0'4W NO.OF CC COND AWNO OF HI-LEG AWG NO OF NEUTRALS A W G ' PER A' OF CC CGOND OF HI-LEG OF NEUTRAL Y `-C r -41 ! OTHER APPARATUS: 111y : , 3-2 Ton A.C. Units Ia L®3 Ton A.C. Unit oA n ,y yet- '(' !Y .4!{, a 'iTEc1Di&-1 Ir 1 i-4: n i til 'i r j' V3 d+ — ta lo "3 g ,f......,&i.& --::).40,#/i ..e,- ( E: 13e Bio Electric Stillwater Ave. ,,,0-,,,,. Cutch ue, N.Y.0 11935 lU.0.s 2070EA ,GENERc1MANAGER 1 u�, ; • Per i ,s IPa- r.ti This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified\biy their credentials. ;: la IldAtiAnif UV(AWL Litt vnr1mi/>jlietneit121[led 11fi[tedNit wuleAtt/1etAthninnmtIe9mmflthneuUln>tnth[SEa[itintibfitittAttamrlwmmA#rnIttr\&h\VVV VW lirCit;AtIlAtItiltailiviltlynigleillistNitt .; M R. COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER. Or .-.4"a�-gki %.l%:lIJ..1A..l% kJ.!:0,4:.L/_.P•_L'AAF:X9l,.1_✓:Ael_:'.V.�J!.%a ._l•J_'AtVl_•ll %.;VJ_,'g_S.J::_l• ')J e__l'7.J:9_t_L.l_•_L':lPS 1,..,LAC.A•._l:\J_. !_..J_:':_l�_l'i%.__l%. _')✓:e.4_:el gk,._l•_l.Ine,t:'Y_ r -1.. 1000314 THE NEW YORK BOARD OF FIRE UNDERWRITERS Di t 1; BUREAU OF ELECTRICITY ' i<a 1, 85 JOHN STREET. NEW YORK. NEW YORK 10038 g Date ()amber 14, 1987 Application No.on file 39'439/ 'i N 837504 �r e j 1..!<<; THIS CERTIFIES THAT V. tt tj only the electrical equipment as described below and introduced by the applicant named on the above application number in the premises of la_ Donald, ,crud West ltd® on a. side Peyy" Ave. ,'tc N.Y. = b1'44 ekIW k: .3' F 9 .3' .� -`�`3 �.s SB ' '6s&Y(i6:$S �Ps g LV 14 - � • in the following location; L`mJ Basement ❑ 1st Fl. ❑ 2nd Fl. Section Block Lot i was examined October 1, 1 7 and found to be in compliance with the requirements of this Board. I i }i 14; FIXTURE FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS r RECEPTACLES SWITCHES X. OUTLETS INCANDESCENT FLUORESCENT VAPOR AMT K W AMT K W AMT K W AMT K W AMT H P t .144 j� �i VAPOR _ . S" 1 1 -p ���y ]: 4 DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIME CLOCKS BELL UNIT HEATERS MULTI-OUTLET DIMMERS ,r.'W 0. SYSTEMS i W4 j� AMT K.W OIL H.P GAS H P AMT NO A W G AMT AMP AMT AMPS TRANS. AMT H P NO OF FEET AMT WATTS o' .My P I} ly'� t SERVICE DISCONNECT NO.OF S E' R V - I C E 4 y. AMT AMP TYPE METE 1...RF 1W 1 if 3W 3,9 3W 9,B'4W NO OPERC GOND OF CC GOND NO OF HI-LEG OF HI-LEG NO OF NEUTRALS OF NEUTRAL Y • I 1 200 C13 1 X 1 3/0 1 3/0 „I,OTHER APPARATUS: - a 71 li<1rr 0 - E ,,-,; y B. am Electric .`'� il-r I Stillwater Ave. . 4 !'l Cutchogue, N.Y. 11935 lics#t 267 4 GENERAL MANAGEk ,,. r: ir . Per *' az ; 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 r a:x ,s,,rveyY\,YY,Y\;%Y.,Y`CYY;rv.-r-n--. YY1'Y,YYYTMF-Trwi-di•YYrr-ilYYY YY(-i•:,iY+YYYYYYYYMfr.YYYYYYYYYYYnYYiYYYY,YY.Y',1'1'YYYYYYMY'T,FYIY7`,,YYY`'n Ei COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER. Sir Sample Information: Type: Solder ceAnalytca LABORATORY RESULTS Origin Distribution 575 Broad Hollow Road, Melville,NY 11747 Routine TEL(631)694-3040 FAX (631)420-8436 Results for the samples and analytes requested The lab is not directly responsible for the integnty of the sample before ®��ri NYSDOH ID#10478 www.aacelabs coat receipt at the lab and is responsible only for the certified tests requested HARRY GOLDMAN WATER TESTING Lab No. : 1606356-001 A 8700 MAIN ROAD MATTITUCK,NY 11952 Client Sample ID. :SUE NAHILL/DONALD RYND (2 -'I�1�,,A _\, Attn To : 1165 WEST ROAD,CUTCHOGUE Federal ID • SOURCE(TOILET BOWL-NEXT TO Collected : 06/03/2016 12:00 AM Point No KITCHEN)GRAB BY CUST. Received : 06/03/2016 2:20 PM Location. CnllPntPd Rv• AF99 Analytical Method: SW6010C Prep Method:SW3050B Prep Date• 6/9/2016 7:50 00 AM Analyst JA Parameter(s) Results Qualifier D.F Units Limit Analyzed Container Lead 0.04 1 % 0 2 06/10/2016 8:30 PM Container-01 of 01 D [SCENE 1 D JUN 1 6 2016 BUILDING DEPT. TOWN OF SOUTHOLD Result(s)reported meet(s)NYS Regulatory Limit(s). Result(s)flagged with * Exceed NYS Regulatory Limit(s) Limit noted. Qualifiers E=Value above quantitation range,Value estimated. I9•44^0 B=FFound in Blank91. 22, D.F.=Dilution Factor D=Results for Dilution c=Calibration acceptability criteria exceeded for this analyte.Value estimated Sr.Project Manager: Stu Murrell H=Received/analyzed outside of analytical holding time J=Estimated value-below calibration range Test results meet the requirements of NELAC M-,M+=Matrix Spike recovery below/above control limit unless otherwise noted. N=Indicates presumptive evidence of compound This report shall not be reproduced except in full, P=Duplicate RPD outside of control limit without the written approval of the laboratory. r=Reporting limit below calibration range Value estimated. S=Recovery outside of control limits for this analyte +=NYSDOH ELAP does not offer certification for this analyte/matrix/method Date Reported• 6/13/2016 Page 1 of 3 • PACE ANALYTICAL 575Broad Hollow Road f2eAnalytical Melville,NY11747 Sample Receipt Checklist TEL:(631)694-3040 FAX•(631)420-8436 o Website:wwwpacelabs corn Client Name HGO Date and Time Received: 6/3/2016 2:20:00 PM Work Order Number: 1606356 RcptNo: 1 Received by Lloyd Olsen Completed by: - Reviewed by: V Wif/t/te:.....1., Completed Date: 6/3/2016 4.42.21 PM Reviewed Date: 6/4/2016 11:10:44 AM Carrier name: PACE Pickup Chain of custody present? Yes 0 No❑ Chain of custody signed when relinquished and received? Yes 0 No❑ Chain of custody agrees with sample labels? Yes 0 No❑ Are matrices correctly identified on Chain of custody? Yes 0 No❑ Is it clear what analyses were requested? Yes 0 No❑ Custody seals intact on sample bottles? Yes ❑ No❑ Not Present 0 Samples in proper container/bottle? Yes 0 No❑ Were correct preservatives used and noted? Yes 0 No❑ NA ❑ Preservative added to bottles: Sample Condition? Intact 0 Broken❑ Leaking ❑ Sufficient sample volume for indicated test? Yes 0 No❑ Were container labels complete(ID, Pres, Date)? Yes 0 No❑ All samples received within holding time? Yes 0 No❑ Was an attempt made to cool the samples? Yes 0 No❑ NA ❑ All samples received at a temp.of>0°C to 6 0°C? Yes 0 No❑ NA ❑ Response when temperature is outside of range. Sample Temp.taken and recorded upon receipt? Yes 0 No❑ To 3.3° Water-Were bubbles absent in VOC vials? Yes ❑ No❑ No Vials 0 Water-Was there Chlorine Present? Yes ❑ No❑ NA 0 Water-pH acceptable upon receipt? Yes 0 No❑ No Water ❑ Are Samples considered acceptable? Yes 0 No❑ , Custody Seals present? Yes ❑ No 0 Airbill or Sticker? Air Bil ❑ Sticker❑ Not Present 0 Airbill No: Case Number: SDG: SAS: Any No response should be detailed in the comments section below,if applicable. Client Contacted? ❑ Yes ❑ No 0 NA Person Contacted: Contact Mode: ❑ Phone. ❑ Fax: ❑ Email: ❑ In Person' Client Instructions: Date Contacted: Contacted By Regarding: Comments. CorrectiveAction: Page 2 of 3 aceA tal lca 575 Broad Hollow Road, Melville,NY 11747 TEL (631)694-3040 FAX (631)420-8436 I NYSDOH ID#10478 www.nacelabs corn WorkOrder: 1606356 Certifications STATE ! CERTIFICATION # NEW YORK 10478 _ _NEWJERSEY NY158 • C 0 NNE C TIC UT P H-0435 MARYLAND 208 MAS SAC HUS ETTS M-NY026 NEW HANP S HIRE 2987 RHODE IS LAND LA000340 PE NNSYLVANIA 68-00350 Page 3 of 3 7684802 BUILDING DEPT. • 5 * ECTI * [ ] FOUNDATION SST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ ] FINAL w R REMAKS e■ ✓�G LA��T DATE 7 1-7 INSPECTOR e-- ----/A=7 • 765-1802 BUILDING DEQ. INSPECTI . N [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ ] FINAL REMARKS: DATE 'VO--C/ INSPECTOR 14C/d4 ' /191'1 I t *; 0€ TOWN- OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLUMBING [ ] FOUNDATION 2ND [ ] 1 LATION [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: // �' C.°- "e4.% ®- DATE 0/6-A INSPECTOR ` 1/17 4pF SOW.; i* * u, = ,yoourm,��'. TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLUMBING [ ] FOUNDATION 2ND [ ] IN ULATION. [ ] FRAMING / STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATI • N [ ] CAULKING REMARKS: ` �. aeCerwt DATE o� �i 1p INSPECTOR ' - - --- -- -- - --- - -- --- ------ --- Fa8LD INSPECTION DATE COMMENTS I� 1 . FOUN-: ION ( 1st ) 1110,/ iTI / / U, FOUNDATION ( 'd ) — 2 . // //e e9 ,4 c ROUGH FRAME & . 7 PLUMBING _ rP - � ��✓ �/LS � �/� dS-'�r ��f7 ��� �/� USI. 3 . Coil/ INSULATION PER N . Y. _ ,4 J ~' STATE ENERGY CODE c Air •� ,� 1 , FINAL i ADDITIONAL COMMENTS : & • . .. re- Ye I, 10 to 1 -5 ea' wl a • 4 tdi [h r; c. H • FORM NO. 1 i TOWN OFSOUTHOLD �EC - 91985 BUILDING DEPARTMENT 1\ ry a TOWN HALL !] SOUTHOLD, N.Y. 11971 `TOWN OF OFSOUTHOLD TEL.: 765-1802 Examined . .4/7 , 19 .S Received , 1 9 . . Approved 277453 , 1 A . Permit NI. . . . Do vim. 3 - hge."4,,e Disapproved a/c ( (Building Inspector) APPLICATION FOR BUILDING PERMIT Date"_`—' 7 , 19 INSTRUCTIONS a. This 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 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 inspecti s. (Signature of applicant, or name, if a corporation) ��.& D'• • AO l#- / 7 VO 4 (Mailing address of applicant) //97/ State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises e= Y/77) (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. /4/7s-r 47 * ' /1 // Plumber's License No. Electrician's License No. (( IL Other Trade's License No. 1. Location of land on which proposed work will be done. f9r57 a� �r /-/a House Number Street Hamlet • County Tax Map No. 1000 Section //0 Block C e5 7 Lot Z Subdivision Filed Map No. Lot (Name) 2. State existing use and occupancy of premises and intended use and occupancy/Z; proposed construction: a. Existing use and occupancy 5-/AD fee,p.2 "'`�' ✓ r' v b. Intended use and occupancy ;C..1 3 :.Sri 3. Nature of work (check which applicable): New Building Addition Alteration Repair - Removal Demolition Other Work (Description) 4. Estimated Cost D`d � Fee . 2 l�J_ I (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 type of use 7. Dimensions of existing structures,if any: Front 3 6 Rear 3 z Depth 4 Height 3 I Number of Stories 7-6t) 9 Dimensions of same structure with alterations or additions: Front Rear -3 z Depth 4D Height 3 f Number of Stories Z.— Dimensions Dimensions of entire new construction: Front Rear Depth Naioh+ Niimha_r pf Q+nriao 1 9. Size of lot: Front 2 a-e7 / Rear 3 Depth 5 Z-4 10. Date of Purchase Name of Former Owner /60 ® - 11. Zone or use district in which premises are situated /4 .v c-ut rude—IA_ 12. Does proposed construction violate any zoning law, ordinance or regulation: . . . .eit., 0 13. Will lot be regraded /L-'' ca Will excess fill be removed from premises: es No 14. Name of Owner of premises ty'o Address r ite fes Phone No. 734 `cies Name of Architect ;,--/e--4../vf Address a'7" Uz Phone No. 765.--515 Name of Contractor rVo S• Address Phone No. - 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. • • STATE OF NEW YORK, COUNTY OF . . . .. u f )f-tc-: S.S z2 zr- A. 57—/t.-Ar-ta�• 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 - day of ` , 19 Notary Public, te-/-•°--,41 ate- County HELEN KlEDOE IARttPlsuc.StateeiKevi (Signature of applicant) lyre Esp—Ifim 1 �.� . . r • 0 if iesamt=eleMULIMILIMIR • • W t S T Fe ® A 40 �aNccv � 1.2. et 7Q•V N. [�.S°�..1, / `fU/�C, 200. 0 Ma va t Crrn//l rP7 O , e Nye } . \-,9 dr di/C ' L' i _ 661/®fir I \ . . . r) 1N. 0 w •, -o I NN 6 _• r\Irizor0 'av 'Z, AvO r ri-v• w 161 -/ ' ralt...'_ ' .' r .. r tiro., '.k. •r { , /�z. F�. 3. r.. 4 J f'P?c1d A t LI L L /t7.7,• I I d N. /C �'wraPhe/ •Ju `1'!1 I �o✓;roz.f`- • A 1 115:11 16) . ti' P 1 •i A4.1 P OF P/9210PE F'7"Y 11 i owNe_v aY in/i LL /Am H Ho L DEN )1/1 S/ rvITE ,4 r 5urvcyr,/ for' .Irl c:c•rt,/.c'c1 FLEETS NECK — CUTCHOGUE /-/Q, E TITLE IN.5uf,1 /Ac;t �r�"� r 4 .5.a/© 4O ft .r I in ( l' ✓ 4< 64.4.(,, / z ;c;en,'4i Sit i r v L i