HomeMy WebLinkAbout33046-Z
FORM NO.4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
NO: Z-32433 Date: 06/26/07
THIS CERTIFIES that the building AGRICULTURAL BUILDING
Location of Property: 30800 CR 48
(HOUSE NO.)
County Tax Map No. 473889 Section 74
(STREET)
Block 4
PECONIC
(HAMLET)
Lot 4.1
Subdivision
Filed Map No.
Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated
APRIL 27, 2007 pursuant to which
Building Permit No. 33046-Z
dated
MAY 21, 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
AGRICULTURAL STORAGE BUILDING AS APPLIED FOR.
The certificate is issued to THOMAS J HUBBARD
(OWNER)
of the aforesaid building.
N/A
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
N/A
ELECTRICAL CERTIFICATE NO.
PLUMBERS CERTIFICATION DATED
N/A
Rev. 1/81
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Form No.6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
This application must be fllled in by typewriter or ink and submitted to tlie 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 2/1 0 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 $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
(.) f I 2.. I () 1--
Date.
Old or Pre-existing Building:
60bJO U L{ Y
House No.
Owner or Owners of Property: ~ CI./\. u{
li
v
New Construction:
(check on1-\ ,
Te. ('.--0>11 c...
Hamlet
Location of Property:
Street
Suffolk County Tax Map No 1000, Section
-JYJtNYj d ~
Block
L(
Lot If I
Date of Permit.
Filed Map.
Applicant:
Underwriters Approval: i(IJ 0 E (.e <- -1 r c C
Lot:
Subdivision
Permit N~.3 3 0 '-\ to
Hcalth Dept. Approval:
Planning Board Approval:
Request for:
Temporary Certificate
Final Certificate:
(check one)
'1 r-- <n:.J
Fee Submitted: $ ,.< 0
@-t e; J' fiT, .J:::, -~
ApplicaJ t Signature
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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)
PERMIT NO.
33046 Z
Date MAY
21, 2007
Permission is hereby granted to:
THOMAS J HUBBARD
9 LEGGET RD
BRONXVILLE,NY 10708
for :
RECONSTRUCT AN AGRICULTURAL BUILDING AS APPLIED FOR.
at premises located at
30800 CR 48
PECONIC
County Tax Map No. 473889 Section 074
Block 0004
Lot No. 004.001
pursuant to application dated APRIL 27, 2007 and approved by the
Fee $
150.00
Building Inspector to expire on NOVEMBER ,2008.
ORIGINAL
Rev. 5/8/02
3S-&~c
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1ST
[ ] FOUNDATION 2ND
[ ] FRAMING I STRAPPING
[ ] FIREPLACE & CHIMNEY
[ ] RRE RESISTANT CONS'IRUCTION
[ ] ROUGH PLBG.
[ ] INSULATION
[~L
[ ] FIRE SAFETY INSPECTION
[ ] RRE RESISTANT PENETRATION
"
INSPECTOR
DATE f//?7
I -
~10%~
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
[~N~A~~S~E~]!~~~.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING I STRAPPING [] FINAL
[ ] FIREPLACE & CHIMNEY [] FIRE SAFETY INSPECTION
[ ] RRE RESISTANT CONSTRUCTION [ ] RRE RESISTANT PENETRATION
,r.' ...
"
DATE tf~7
INSPECTOR
L
.-
FIELD INSPECTION REPORT
FOUNDATION (1ST)
-------------------------------------
FOUNDATION (2ND)
ROUGH FRAMING &
PLUMBING
DATE I
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COMMENTS
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INSULATION PER N. Y. ~---
STATE ENERGY CODE
FINAL
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ADDITIONAL COMMENTS
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PERMIT No.33O-~ f.,::C
BUILDING PERMIT APPLICATION CHECKLIST
Do you have or need the following, before applying?
Board of Health
_ 4 sets of Building Plans
Planning Board approval
- Survey
Check
Septic Form
N.Y.S.D.E.C.
Trustees
Contact:
TPWJ:,;DF SOUTH OLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, NY 11971
TEL: (631) 765-1802
FAX: (631) 765-9502
www.northfork.net/Southoldl
Approved
Disapproved a/ c
<Ins
Examined
,20-2..
,20L
Mail to: 1716,',- f K r- ,,~.s t.
/
Expiration
,20_
QJ~
Phone: 1 7 (/ - i S' ,/ I
,
J
APPLICATION FOR BUILDING PERMIT
Date
7/.2 7-
, 20 0 t-
INSTRUCTIONS
a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4
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 waterways.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d. Upon approval ofthis 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.
APPLICA nON IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Town of South old, 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.
t1Lt~~ /~- d (/.
(Signanfre of applicant r name, if i corporation)
J7'/o ..s/~v~k Lc..~"- C_f-.Lh''JJe..
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
Q,9 r v"- .{.-
Name of owner of premises -r AD ........a <" J-/", to he::. ref!
(As on the tax roll or latest deed)
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.
Other Trade's License No.
I. Location ofland on which proposed work will be done:
l\.....~ ~&
House Number Street
Pel-C,,,,
Hamlet
<-.
County Tax Map No.1 000 Section
Subdivision
-, L'
T I
Block 6 L(
Filed Map No. Cf L; ( f.
Lot
Lot
7' /
,
(Name)
^~
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy r: tL r "'^
b. Intended use and occupancy ;<e/lIc.L<" 100..,,,, ~\.....,(.,. h"r~,,<j t€u._- ',,,, 'oi,
,
3. Nature of work (check which applicable): New Building
Repair Removal Demolition
Addition
Other Work I? "p I"" ""
Alteration
inqrV"\
(Description)
.. 4. Estimated Cost
/.J SoQ
.
Fee
5. If dwelling, number of dwelling units
If garage, number of cars
(To be paid on filing this application)
Number of dwelling units on each floor
6. Ifbusiness, commercial or mixed occupancy, specify nature and extent of each type of use.
7. Dimensions of existing structures, if any: Front
Height Number of Stories
Rear
Depth
Dimensions of same structure with alterations or additions: Front Rear
Depth Height Number of Stories
,
8. Dimensions of entire new construction: Front LiD
Height / S' ( !? " Number of Stories
Rear
70'
Depth
3 (1 I
/
9. Size oflot: Front
Rear
Depth
G -5- q /
10. Date of Purchase
Name of Former Owner Ill, ( lo. .-. Ie. s
111.'0.....11
II. Zone or use district in which premises are situated
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_NO ~
q /.. ~9!j ~ of- /!.e.
tI vb b" d'Address 13.--, ~ .... lie, N Y
Address
Address
14. Names of Owner of premises 11.0''''4''
Name of Architect
Name of Contractor
Phone No.
Phone No
Phone No.
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 REQUIRED.
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.
STATE OF NEW YORK)
COUNTY OFS.;f$~~
~\~~ \
\/0
(Name of individual signing cont
~ ~ being duly sworn, deposes and says that (s)he is the applicant
ct) above named,
(S)He is the
Q~~
(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.
Notary Public
BARBARA ANN RUDDER
Notlry Public, State of New York
No. 4855805
Quaiified io Suffolk COUOID",( 0
Commltlion Elplrea Apr1l1~
COMPLY WITH ALL CODES OF
NEW YORK STATE & TOWN CODES
AS REQUIRED AND CONDITIONS OF
SOUTHOLD TOvVN ZBA
SOUTH OLD TOWN PlANNING BOARD
SOuTHOLD TOWN TRuSTEES
NYS. DEe
~
AP R VED AS NOTED
B.P. # 8'5c::LJ Go?
FEE: B~ (j.~12
NOTIF BUILDING DEPARTMENT AT
765-1802 8 AM TO 4 PM FOR THE
FOLLOWING INSPECTIONS:
1. 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 OFTHE CODES OF NEW
YORK STATE. NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS.
ALL CONSTRUCTION SHALL
MEET THE REQUIREMENTS OF THE
CODES OF NEW YORK STATE.
OCCUPANCY OR
USE IS UNLAWFUL
WITHOUT CERTIFICATE
OF OCCUPANCY
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AL KRUPSKI
2790 SKUNK LANE
CUTCHOGUE NY 11935
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DATE: ./09/07
KOWPS.
ae:VATlONS
A.2
I~ 40'
8' 7' ~ 10' ~ 7' 8'
[l] [l]
t-- r---
30' X 40' X 10' 4" POST & FRAME GARAGE
fm 0-18" X 8" CONCRETE FOOTINGS (TYP.) II)
~ ("" LB CAP, 3200 LB COlU"N WI) W~
2 -10 X 10 SLIDING DOORS Z'"
2:5;:
3 2-W1NDOWS SUPPLIED BY CUSTOMER ~~Z
:;)zw
'ixJ 181 -4X6 TREATED POSTS 8' OC.(TYP.) OJ a::;):;)
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2X6 TREATED SKIRT BOARD .,JCI.lO
c(o:C
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2X4 SPRUCE WALL GIRTS & ROOF PERLlNS 24" OC. "'"I-
0 F 0 N:;)
n n u
2-2X10 #1 SYP TRUSS CARRIERS 08' SPANS
(692 PLF CAP; 640 PLF ROOF LOAD)
PRE -ENGINEERED ROOF TRUSSES-
'ixJ 4/12 PITCH, 48" OC, 30-5-5 LOADING OJ
12" EAVE OVERHANG WI VENTED SOmT & FASQA
FLUSH GABLES
"..
~ 29 GA. G-100 PAINTED STEEL ROOFING & SIDING ,
IllI
12" PAINTED STEEL RIDGECAP
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i TRUSS CARRIERS _M__
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40'
FLOOR PLAN D.\TE: 1,./09/07
,.......
"""" PL<H
SCAlE: 3/16" = 1'0" A.1
BUILDING DESIGN NOTES AND DETAILS
F:XCAVATlON
FOOTINGS SHALL BE CIRCULAR (UNLESS NOTED OTHER"'SE) AUGERED TO THE
DEPTH AND DIAMETER SPECIFIED, WITH ALL LOOSE FILL REMOVED BEFORE
CONCRETE FOOTING MATERIAL IS PLACED,
FOOTINGS
STANDARD DEPTH FOR FOOTING EXCAVAllON IS 44~ FROM FINSIH FLOOR HEIGHT
FOOTINGS SHALL BE A MINIMUM OF 36" DEPTH FOR FROST PROTECTION OR;
LOCAL BUILDING CODE DEPTH REQUIREMENTS FOR fROST PROTECTION WILL BE
FOLLOWED.
DRY MIX CONCRETE "'LL BE USED UNLESS OTHERWISE SPECIFIED.
ERAM!llli.
LUMBER FOR SIDEWALL GIRTS AND PERLlNS SHALL BE #1 SPRUCE OR
COMPARABLE.
LUMBER FOR SKIRTBOARD. POSTS AND BEAMS SHALL BE #' OR BETTER
SOUTHERN YELLOW PINE.
LUMBER FOR TRUSS CARRIERS SHALL BE #' OR BETTER SOUTHERN YELLOW
PINE.
ALL GROUND CONTACT LUMBER SHALL BE TREATED TO AWPA STANDARDS .60
ACQ OR CCA MINIMUM USING #' OR BETTER SOUTHERN YELLOW PINE.
ROOF TRUSSES
TlRUSSES SHALL BE PRE-EN~NEERED "'TH A ENGINEERED STAMPED PLAN
ATTACHED TO BUILDING PLAN.
GROUND SNOW LOAD. DRIFT LOAD. COLLATERAL LOAD. AND WINO LOAD ARE TO
BE IN ACCORDANCE "'TH LOCAL BUILDING CODE REQUIREMENTS.
TlRUSS ERECTION AND BRACING SHALL BE DONE ACCORDING TO TRUSS PLAN.
FRAMING CONNFCTlONS
FRAMING CONNECTIONS SHALL BE OF A SIZE AND DESIGN TO MEET DESIGN
LOADS SPECIFIED
FASTENERS/ CONNECTIONS NAILS USED IN .60 Aco/eeA TREATED WOOD SHALL
BE 120 HOT DIPPED GALVANIZED; ASTM A 153 PLATED 1.2 MIL SCREWS, AND A
65 CLASS G 185 HARDWARE. THE MINIMUM AMOUNT OF 120 NAILS IN 2X4 ROOF
PERLlNS IS 2. THE MINIMUM AMOUNT OF 120 NAILS IN 2X4 WALL GIRTS IS 3.
TlHE MINIMUM AMOUNT OF 120 NAILS IN 11" STRUCTURAL BEAMS IS 1 PER 1".
METAL SIDING AND ROOFING
METAL SIDING AND ROOFING SHALL BE INSTALLED WITH #9 WOODGRIP, i" HEX
HEAD, METAL AND RUBBER WASHERED GALVANIZED COLOR MATCHING SCREWS
Of SUFFICIENT LENGTH TO PENETRATE THE WOOD TO A DEPTH OF 1 N.
METAL SIDING AND ROOFING SHALL BE WARRANTED #1 GRADE COORUGATED 29
GAUGE PAINTED STEEL PANELS GALVANIZED TO A MINIMUM OF G-100.
METAL SIDING AND ROOFING SHALL BE TRIMMED WITH CORRECT FLASHINGS AT
ALL EXPOSED EDGES, ROOF ENDS, CORNERS, DOORS. WINDOWS AND RIDGES.
EXCEPT; LOWER SIDING EDGES ON SOME OPEN STYLE LEAN TO'S, AND BOTTOM
EDGE OF STANDARD ROOFING MATERIALS.
STRUCTIJRAI DF~IGN PARAMfTERS
STRUCTURE IS DESIGNED FOR A MAXIMUM WIND LOAD OF 90 MPH (3 SECOND
GUST). AND 70 MPH (10 SECOND GUST) UNLESS NOTED OTHERWISE.
SOIL BEARING CALCULATIONS ARE BASED ON 3500 PSI. SOIL BASE CONDlTION
C4B" BELOW GRADE UNLESS NOTED OTHERWISE.
30 PSF(L1VE) MIN. SNOW; S PSF BOTTOM CHORD & S PSF TOP CHORD LOADS
MISCELLANEOUS NOTES
THESE PLANS ARE DESIGNED IN ACCORDANCE WITH THE fOLLOWING BUILDING
CODES:
1996 BOCA CODE
1999 BOCA CODE
2000 IBC CODE
2000 IBC CODE - NJ ADDITTION
2003 IBC CODE
DESIGN REFERENCES
2004 APA - THE ENGINEERED WOOD ASSOCIATION
1997 SOUTHERN PINE COUNCIL (SOUTERN PINE JOISTS & RAFTERS)
1998 SOUTHERN PINE COUNCIL (SOUTERN PINE HEADERS & BEAMS)
THE AMERICAN INSTITUTE OF TIMBER CONSTRUCTION
WARRANTY NOTES
ANY DESIGN MODI FICA TION OR ANY STRUCTURAL MODI FICA TlON BEFORE, DURING, OR
AFTER CONSTRUCTION TO BUILDING BY ANY PERSON(S) OR COMPANY OTHER THAN
WORK PERFORMED OR APPROVED BY SHIRK POLE BUILDINGS LLC WILL VOID ANY
AND ALL WARRANTIES PROVIDED BY MANUFACTURERS AND/OR SHIRK POLE
BUILDINGS LLC.
SUCH DFSIGN MODI FICA TlONS AND lOR STRUCTURAl MODI FICA TIONS INCLUDE:
DRILLING. REMOVING. CUTTING. SAWING, SPLINTERING OR DAMAGING ANY
STRUCTURAL MEMBERS INCLUDING FOOTINGS, POSTS, GIRTS, BEAMS, TlRUSSES,
PERLlNS, PANELS, WINDOWS. DOORS. NAilS. SCREWS. AND BOLTS.
~lJCH nF~IGN MODIFICATIONS ANn/OR ~TRUC:TIJRA! MonWICATIONS Al ~O INCt UDE'
ADDING ADDITONS, SNOW DRIFT LOAD FROM ADDITIONS, LEAN-TO'S. ATTIC
STORAGE. CHAIN HOISTS. OPENINGS. SKYLIGHTS, ROOF VENTS, AND LOUVERS.
~H1RK POI F Run DINGS L L r: WIll NOT AF IIARI f FOR ANY FAlIlJRFS RFSUI TING
FROM THOSE MODIFICA liONS USTFD AROVE OR FROM ANY OTHER MODI FICA TlONS
NOT APPROVFD BY A CERTIFIED ENr.INFER.
CONTRACTOR LICENSING
NJ 13VH02705800
MHIC 92197
HILL TOWN TWP 2006-240
TRI-CQUNTY COG 2006-0410
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OATE: 4/09/07
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DETAILS
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A'RTTMPFOUR
GRANl'OR'S RIGHTS
4.01 Own....hln
Subjoot 10 the provisions of ARTICLE TIIRBE, Grantor shall retain an oth... customary
rights of OWI1OIIlbip in tho Proporty, some of which .... more particularly described in this
ARTICLB FOUR.
4.02 p"",,,-inn
('1faftttrr RIWI oontinue to have the right tn exclw:;ivc pclAAeAAion of the Property.
4.03 Use
GranlOT shall have tho right to use tho Propony in any II1lIIIIl8r and fur any purpose
com1su:m with and 110( prohibited by d1lI !!asemcm: as wcu as sppUcable local, N~ yOIttSt.a.a;
or federal law.
4.04 J .smiIouo,=amJt9 Activities
Grl:n.tM IhAll hAv~ ~ right to c.oODtittue the ~ ~ o.fl:a:t1(k~Apis1s:, pt'UW:09 tid
!'.olvwar.lb ......:..~'D1IodU\tC uu (be P"a"lJQlY. (IJ.uW.l ~ ......Vg die 1I~1u. l.u lClIN~C VI IGltWI'Cl' U:gw,
tbrub.. or othar vogotation when doad, disossed, docayed or damsged.
~~ .oho11 hav.th.";QftUn Dn~oG#O",4Jl ~ nFn,gri"..ltr.......l
c\!llivalion of crops, Iivostock and 6vostocli: prod""", as sot
c..tdLo1d.T--.Coclo,,~x-doI'Y'A.& .~p&"It .
conduCted'irr8CCOrdanoewiththe~t1fthi:llP..MleMeot anc1tnl . nnt r:r~r.timu{~
forth in this coi!serwUon e&$OO1OD( (or deed of developmcnt rights), including bul not limited (0,
the reotriodons SOl fuJth in Soction 3.01 ~ Tho use of tho Property 8hal1 be restricti>d 10
' '8ctuany USC<l in bona fide agricultural production.,
5 ,. "C-
t6. \ kCc.~
"'.06 ~~tur-
Gnmtor ~ hova tho risbtto oroct and mai:ata.U1 the fc;,11~ llOIl~d~
impIOvemonls on the Property thst are necesasry to and consistent with the agricultural uses as
permitted In SectioIl4.0S h=oof; with the plior writton consent of Grantee:
(i) The existing barn and liomed shed on tho proporty may be renovsled and/or
rebuilt with 0 footprint not to ox"""" 15~ of the origittal fuolprint Any
l"CIlOVation and/or rebuild of said bam and said shed, shall take place within tho
existing location of said structures, as DOted on a survey ds1ed July S, 2002 and
prepared by Peconic Smveyors. In DO evant shall the shed and/or the barn be
"'located to a different site with out tho prior written consent of Grantee.
(ll) A.ccesa drivoa, 10 provide "C<S8 to the improvements permitted by Ibis Section
4.06; andmust be pmneable waocs.
(Iii) Und.rground facilities ustd to supply utilities, """lie system.. leaching field.,
irrigation oystoms. and weU., and control stormw_ runoff flum the
impIOvemonto permitted undor the terms of Ibis SoctiOu 4.06.
s
Erosion. Sedimentation and Storm-water Run-off Control Plan ASSESSMENT FORM
Yes No
EXEMPTIONS:
A. Does this project meet the minimum standards for classification as an Agricultural Project.
Note: If you answered Yes to any of the above, a storm-water, Grading, Drainage & Erosion Control Plan is not required.
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ACTIONS REOUlRING THE SUBMISSION OF A STORM-WATER. GRADING, DRAINAGE & EROSION
CONTROL PLAN CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK.
Item Number: (A Check Mark (J) for each question is required for complete application)
1.
Will this project retain all Storm-Water Run-off generated on Site?
(This will include all run-off created by site clearing and/or coristruction activities as well as all
Site Improvements and the permanent creation of impervious surfaces.)
Yes
No
,g
bd-lL
B~
Q~
bJv
BJL
QL
bd-lL'
Note: If any answer to questions one through eight 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 permit.
2.
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 material within any parcel?
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3.
Will this application require land disturbing activities encompassing an area
of five thousand (5,000) square feet of ground surface or more?
STATEOF~~~F_5~H\'::::::HH .H"H"H" ss
That I. HHHA.\.~C~HH\<::{~.~.~ . being duly sworn, deposes and says that he/she is the applicant for Pennit,
(Name of individual signing Document)
And that He/She is the HHQ'lf~<y<HHHHHHHHHHH.HHHH......H.
(Owner, Contractor, Agent, Corporate Officer, etc.)
Owner and/or representative of the Owner or Owner's, 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 belier; and that the
work sill be performed in the manner set forth in the application filed herewith.
~t:.4r'l.
(Signature of Applicant)
4.
Is there a Natural Water course running through the site or is this project within
One hundred (100) feet of wetlands or a beach?
5.
Will there be site preparation on slopes which exceed fifteen (IS) feet of vertical rise to
One hundr~d (100) feet of horizontal distance?
6.
Will driveways, parking areas or other impervious surfaces direct Storm-Water Run-off
into and/or in the direction ofa Town Right-of-Way?
7.
Will this application require the placement of material, removal of vegetation and/or the
.construction of any item within the Town Right-of-Way or road shoulder area?
(This Item does not include the installation of driveway aprons.)
8.
Will there be site preparation within the one hundred (100) year floodplain of any watercourse?
Sworn to before me this;
,;J 'I ~
............................q..daY9f.......... ..
. '~~LLO
Notary Pubhc: ..ItARBARAAMt4RUDDER.. ...... ... ..........
MOtlry Public, State o! Mew York
Mo. 485S80o
Qualified in Suffolk COu"~O
CommiS6lon Expires April 14,
........200~
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