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BRUCE R. FOLEY
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-- ,�LCURcTTA "1vi0UfgA1U'k.N.; :M.S.N
Associate Public Health Director
Director of Patient Services
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
Environmental Health (845)279-6130 Fax (845) 278 - 7921
Nurs[ng Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early intervention (845)278-6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648
ADDITION APPLICATION (RESIDENTIAL ONLYI
STREET V �S% �la�,c. TOWN ►0 TX M" - o�
NATNIE W- f PHONQW5- --2.6' D 9/ L P CHD#
MAILING ADDRESS. /a2 1��0�/051� p /acc. %YJlL`ip,�ift� I�V�
DESCRIPTION OF ADDITION
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NGIVIBER OF EXISTJ[NG BEDROOMS ' PROPOSED # OF BEDROOMS /V0i�Ce�,J
(FROM CERT. OF OCCUPANCY OR
CERTIFICATION FROM BUILDING INSPECTOR)
*Any addition which is considered a bedroom requires formal approval of plans (Construction Permit)
prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the
Putnam County Sanitary Code.
K ° Please- submit tliis form and the following to Putnam County Health Dept., 4 Geneva Road, Brewster, NY
10509, Phone 278 -6130.
1. Certified check or money order for $100.00. .
2. Sketches of existing floor plan (drawn to scale, all living area including basement)
'*Non-professional sketches are acceptable.
3. Two sets of proposed floor plan (drawn to scale, with name, street, and tax map fr)
*Non- professiomd sketches are acceptable.
4. Copy of survey showing well and septic location, to the best of your knowledge. Include date of
installation if known. Label all wells and septic systems within 200 feet of the property line.
Contact this office with any questions:
5. Copy of Cert. Of Occupancy from Town or Certification from Building Dept: with legal bedroom
count of dwelling..
OFFICE USE
Comments 1r��
Bthouseguidelines
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BRUCE R. FOLEY
Public .. Hf'aft �
LM AM' R-N.; M.S.N.
Associate Public Health Director
Director of Patient Services
DEPARTMENT OF HEALTH
I Geneva Road
Brewster, New York 10509
Environmental Health (945)279-6130 Fax (845) 278.7921
Nursing Services (845)279-6559 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention (845)278-6014 Preschool (843)27a-6082 Fax (845) 278 - 6648
Putnam County Dept. of Health
4 Geneva Road
Brewster, NY 10509
Gentlemen:
Re: FP A5",
1►
Residence
Tax Ma
Town
According to r cords maintained by the Town, the above noted dwelling
_ ._ ... =S NOT
Town et t r bedrooms d i
Incompliance with To n code and the total number o f b d ooms on record s
This information has been obtained from:
CERTIFICATE OF OCCUPANCY:
ASSESSORS RECORD:
OTHER
Building Inspector
BFhouseguidelines
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PR-0 VOS T Mocodom� PACE
SURVEY OF PROPERTY
I ' PREPARED FOR
JOHN F. 8 DOROTHY L. KEE VAN
1 ; S/TUATE IN THE •:.
TOWN OF PUTNAM • V,4LLEY 4 `
PUTNAM COUNTY
NEW YORKo,
' I SCALE / in. s 40 fl. ✓ULY 28 '198.3
e We hereby certify that the survey shorn hereon.
Was completed by as on ✓u /y 28 , 1983, that 1' E
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