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Home My WebLink About33386-z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY Date: 11/29/07 NO: Z-32760 THIS CERTIFIES that the building FOUNDATION REPAIR Location of Property: 20905 CR 48 (HOUSE NO.) COUnty Tax Map No. 473889 Section 96 (STREET) Block 1 CUTCHOGUE (HAMLET) Lot 4.1 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated AUGUST 27, 2007 pursuant to which Building Permit No. 33386-Z dated SEPTEMBER 13, 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 FOUNDATION REPAIR TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR. The certificate is issued to JAMES & LINDA WOLBERT (OWNER) of the aforesaid building. N/A SUFFOLK COUJlTY DBPAR'l'MBH'1' OF HEALTH APPROVAL N/A N/A ELECTRICAL CBRTIFICATE NO. PLUMBERS CERTIFICATION DATIID ~od~ Rev. 1/81 ,;; q g- 5 q i 2. , \oJ ~ ~_~J WI ~ 8 l(~~v..m \W bi..L'J. D~PT. TQ...Wl: QF sr;:JTHO~+D 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: 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 2/10 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: 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 I. 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 Date. !VOU;l Cj, tltJO 7 New Construction: Old or Pre-existing Building: Cry IJr ~fS Street Owner or Owners of Property: ~'1!!2S ~ J.. ( n {\ 14 Lv 0 L t>:e12-r- cJ '?b Block / Location of Property: V J(()CJ05 House No. (check one) (ID rd)(yc;oP/ Hamlet Suffolk County Tax Map No 1000, Section Lot '-/'1 Subdivision Filed Map. Lot: Date of Permit. C( //3/ () '7 Applicant: m 1.J:7l..V,) Permit No. 333 $5 0 Health Dept. Approval: Planning Board Approval: Request for: Temporary Certificate Underwriters Approval: Final Certificate: (check one) Fee Submitted: $ o(l,~ J11 .[u~4~ Applicant Signature ~. 7 3L{f,C <:'.0 ~ 3~ 7C,0 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. 33386 Z Date SEPTEMBER 13, 2007 Permission is hereby granted to: JAMES & LINDA WOLBERT PO BOX 558 MATTITUCK,NY 11952 for : FOUNDATION REPAIR TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR at premises located at 20905 CR 48 CUTCHOGUE County Tax Map No. 473889 Section 096 Block 0001 Lot No. 004.001 pursuant to application dated AUGUST 27, 2007 and approved by the Building Inspector to expire on MARCH 13, 2009. Fee $ 200.00 j/~ CJ./~ I Authorized Signature ORIGINAL Rev. 5/8/02 TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ ] FOUNDATION 1 ST [ ] FOUNDATION 2ND [ ] FRAMING I STRAPPING [ ] FIREPLACE & CHIMNEY [ ] FIRE RESISTANT CONS1RUCTION REMARKS: [ ] ROUGH PLBG. [ ] INSULATION *INAL [ ]RRE~I~ [ ] FIRE RESISTANT PENE1RAT1ON ~~ k~~ /~ ~ ' ... - ~.~.., DATE 11~~~7 INSPECTOR ~~ ~-~~-. }}3 fh Z TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ ] FOUNDATION 1 ST [ ] FOUNDATION 2ND [ ] FRAMING I STRAPPING [ ] FIREPLACE & CHIMNEY [ ] FIRE RESISTANT CONSTRUCTION [ ] ROUGH PLBG. [ ] INSULATION P\f FINAL [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT PENE1RATION REMARKS: b AJ.c Jt r5 I1-rc" ~~ II:-Lf~~ ~,.~tN1-0 DATE 11-'J-F-t/7 INSPECTOR ~.~ ))pY'7 TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION REMARKS: l~ r/- d-L r' )"t::h- ~ cWL.cOkJ Q{FOUNDATION 1ST [ ~ FOUNDATION 2ND [ [ ] FRAMING I STRAPPING [ [ ] FIREPLACE & CHIMNEY [ [ ] RRE RESISTANT CONS'IRUC'nON [ riA- .eL- ~ DATE i -/1/07 ] ROUGH PLBG. ] INSULATION ] FINAL ] FIRE SAFETY INSPECTION ] FIRE RESISTANT PENE1RATION " tI- . INSPECTOR rWL t4 FIELD INSPECTION REPORT FOUNDATION (1ST) FOUNDATION (2ND) ~ ROUGH FRAMING & PLUMBING DATE I COMMENTS \J.> ~ .I oX/.-., /1'\ 1.-' . Y::7'J1J ~ ''/ //~----- ~ v l"IJIt I q .I)-1r() I' , , / A>1-- r/-" J f(.... v f/ /1\ / /' /oJ ~ A....~ -.. I I I \.. ------- f-- INSULATIONPERN. Y. Af/f' .. STATE ENERGY CODE /V, LJ , , ~ , , 'I ',....111 -07 A/V --t r 1 .' J/.+.Y ~ 7 ~, .. , P' v '" ADDmONAL COMMENTS , \ I./;L 1\ d"j -" ~A s /./ff ~ ;..J A A" A' ",,'I, ~ ~ ___ I"7""T'\. ~ ., '..!., .An --"'-" L...... ) V // I.-~ ~ / ')... ~ A 'I-- t1'~ c:: ~..,,; .~ ~:z -.09 ~' P'" JO~ ~ ~.., "\> : ~~ I" ~ ~.., 1 li .,." " ~1 ~~ ~~, ~::l ~o :z \ ;J ~ ;! I:;j ~ ... :-' f~ PROFESSIONAL ENGINEER , 3T~ ?c: $'6'(;78 , .,., f 1725 HOBART ROAD I PO Box616 SOUTHOLD, NEW YORK 11971 TEL: 63~ FAX: 631.614.3516 . e-mail: joseph@fischetti.com Date: Reference: August21,2007 20905 RT 48 Southold Building Dept Mike Verity, Building Inspector PO Box 1179 Southold, NY 11971 Dear Mr. Verity, I inspected the existing west block foundation wall for the above referenced home. The wall is currently unsound. It has bowed out from the plumb over 3 inches. I have recommended that the wall be re-constructed with block in-kind. It will be important that this work be completed expeditiously because of its unsound condition. The owner Mr. Wolbert has retained me to monitor the re-construction work but I he will be submitting an application for a building permit for this e ency work. Ir.~J 1r~ .~JJLJ,ml [J U 'I) 3 0 2 ! L!!J I "-_ rr"J:;7-;:T;<~~~v. ~ I '---.. wlIIbmWOlII.<1.: ElOAHD CERTIFIEr.'.! ~;;TRUCTUF\f1,L ENGINEER ALL (,uMHRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YOAKSTATE. CERTIFICATION OF NAIL~G & CONNECTIONS REQUIRED. . (.:. _______"'(C <':\;':",',,' ' ',r' . ',I; , fX;S~;(I~ ('.,.,.,.,."Y1q - 5'/1 ~eAleV' . TeVMI~ sh/q~CG: T'!~,NCY OR /tl'1C"OI' bo I-kUS' :"3 UNLAWFUL W" · IT CERTIFICATE C. ~,\.._I ';NCY New C MtJ ~; lied c;ollJ [tIE: AP~~~~,: N~T;~~ ':: (1-rD-__ BY: ,f)~ 'ie',! 8UILQ,"" 'ocPNlTM::NT Ai , , [,(2 8 Ar::' "Olv! FOR THE " 'I',G INS"[:TIC~S: r.C,V\J;TION ,,'\ REQUIRED oLe, c,,, IqE~-( "ETE 2. ROi./.., ' ,C ;.f., ',',' " PLUMBING 3, INSULA TIC", 4, FINAL - CONS' ,~:;CT")N MUST BE C'JMP,,',' 'c.;,c,.O, ALL CONSThc;CION SHALL ME''', THE REQUIREMENTS OFTHE CODE8 JF NEW YORK STATE, NOT RESPONS'BLE FOR DESIGN OR CONSTRUCTION ERRORS. ~'i.I':>~ es..,CIIIl~ S IJ1;-Io Nek) eX 16 C()Y1w4.< t:'oo~ JOSEPH FISCHETTI, PE 1725 HOBART ROAD SOUTH OLD, NT 11971 631-765-2954 , '\ , " $lJIMY OF DESCRIBED PROPERTY SII1JAIE CUTCHOGUE. TOWN OF. SOUTHOLD SUFFOLK COUNlY. N.Y. A VENUE '. ISO.3I' RAotus ~ 75.0' -- -- SURllEYED FOR: JAIofES D. WOI.BE:RT UNDA M. WOLBERT \ \ \ \ \ \ '\ \ \ \ I ..... () o C 'Z ? ';0 o c ~ ts:1 ~ CP -- -- ~ ~ .2' o '::.! ;;;;;ooc< ~.4' - GUARAHIWl 10: ......ES O. WOlIlERT UNOA. M. WOlBERT TMI 1000-096-0'-004.1 SURVEYED: 28 aUGUST 200~ SCALE ,". 30' UfIJh'~"t2 -..: o.r I'lIlIiI ,.... UfC 'ARE< - 27.857.525 S... 011 0.6.35 ACRES iU.r.s.r OPP"1I'ID'Ilm""--_ - - -i I NOn:: STA'fOlD(T I'r'" JWES 8UNCHUCK SOUO WASJE: c:::ooROI*TOR. TOWN OF $OUTHOt.D I..ANOFILL. >>fAT SURfED ELECJ'RfCAl ~ES HA'JE BEEN.R(- ROUTED OFF T~ WOl.8ERT PROPERJ'Y. Remove Failed foundation wall and replace in-kind with new bleck foundation wall SURVEYED fJY STANLEY J. I.SAKSEN. JR. P.O. BOX 294 NEW SU. OLK. N.Y. 631-73 .5835 ,- ~}\r~ _ ~ ~ \!] ~ \ ;}- ~ ~ 0 JOSEPH FISCHl::;TTI. PE '.\..1 \ PROFESSIONAL ENGINEER l_-- 1725 HOBART RD I PO BOX 6~6 1 SOUTHOLD. NY 11971 . . 631-765-2954 .' ..-'1.....' TUTHILL A VENUE S 54'33"40-E 150.31' RADIUS COHC. "- ~ SUfFOU< COUNTY lIQH. AfOMJAjENT ~ -to \ \ to \ C'l \ l') \ ~ ~ \ \ \ \ \ \ \ \ \ I \ / \ / / / / / ~ I . / ,.. <0 '/ 6.0' a, / I /'''' ~ / / ..; L /."oOP. Z - -I ~U - ~~ c> ~ "'0 6' .~ 6'. SUFF'OU< COUNTY WONUiAENT 35.4' -- SURVEY 0, DESCRIBED PROPERTY SITUATE CUTCHOGUE, TOWN OF SOUTHOLD SUFFOLK COUNTY, N.Y. SURVEYED FOR: JAMES D. WOLBERT LINDA M. WOLBERT GUARANTEED TO: JAMES D. WOLBERT UNDA M. WOLBERT ~ ~ (') o d 'Z ~ ~ ';0 o d ~ t!1 SURVEYED: 28 aUGUST 2003 TM# 1000-096-01-004.1 ~ r-- :;; o o o o i--- ~ CO AREA = . UTIUTY POt.E #.,2 POlE O.S' fROM PROP. UHE ~ SCALE 1"= 30' 27,657.525 S.F. OR 0.635 ACRES 3.7' OFF PROPERTY UHr-- -... - ~uARANTEES INDICA TED HERE ON SHALL RUN lNL Y 10 THE PERSON FOR WlHOM 1HC SURVCY S PREPARED, AND ON HIS BEHALF TO THE mE COMPANy' GOvemuENTAt AGE'NCY. ENDING 1NSlInJT1ON. IF' USTED HEREON. ANO \) THE ASSIGNEES OF' THe LENOING INSTITUTION. :uARANTEES ARE NOT TRANSFERABLE TO 'DO/T1ONAJ.. INSTlnJlIONS OR SUElSCOUENT OWNeRS. - - -- -- NAUTHORlZED At TERA T10N DR ADOI11ON TO rHlS .. UR~ IS It Wa.A 710N or SECTION 7209 OF - J./E NEW YORK S1A TE' EDUCA T10N LAW. OPffS OF 1HIS SURW:Y MAP NOT SCARING J.ff LAND SVR\IC)"Qlf$ EIIBOSSED SEAL SHALL - or 8C CONSIDER8J TO BE It VALlO TRUE 'JPy 215.00 -- -- "I I NOTE: STATEMENT BY JAMES BUNCHUCK SOUD WASTE COORDINATOR. TOWN 0, SOUTHOLD lANDFlLL. THAT BURIED ELECTRICAL UNES HAVE BEEN RE- ROUTED OFF THE WOLl/ERT PROPERTY. SURVEYED BY STANLEY J. ISAKSEN, JR. P.O. BOX 294 NEW SUF OLK. N. Y. 631-73 -5835 .> :5 3 y~ 6- 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: TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL .' . SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 www.northfork.netlSoutholdJ PERMIT NO. Examined r fi 3 , 20 ~ APproved~, 20fl Disapproved alc Mail to: Expir . , 20o!!- n ~ ~~W~fJ Phone: APPLICATION FOR BUILDING PERMIT Date flufolJST ~ ,20~ 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 oflot 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 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 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. (Signature of applicant or name, if a corporation) ~ tjo/.>~. //tJY7f)Vt)t, /J'/ /lfS'd{ (Mailing address of applicantf State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder owpc:r{L Name of owner of premises T/hf<c:--s 'D /HJb /.-.IIJiJAH LlJo~~ (As on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer ~/A- (Name and title of corporate officer) Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. 1. 1/ ver Hamlet County Tax Map No. 1000 Subdivision J..J /,q. (Name) ~ction , o?C? ~9ck. ".a / ; I Lot (!) 0 t:/. / ,.. ". 1. " " ." ,d "c....,. ; ", JIq;l;~ilP:1'{ll.;..J ; ". '/'; v Lot '-'- . ,. ~ , -'~ . ;:' " ", f ,'....~:....~,"..<1I,:,~.~-l'. !~.:!,:;..".J . 'i;;"'f~ r, .,... ,1>; ,~~' ,>o!t,.r.:..:i .....' :;'.p"T:":',>..i' 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy .I? t:!> I J>e1.J c.e- . . 0- b. Intended use and occupancy $;fNe~ 3. Nature of work (check which applicable): New Building Repair I V Removal Demolition l(FIJt.Au: 4. Estimated Cost Addition O~el Work Alteration ?fi" ~p; ~ 'I4Jt wl4(.L. (Description) . ~ (,,'5' ()t::J - Fee 5. If dwelling, number of dwelling units P /11- If garage, number of cars (To be paid on filing this application) Number of dwelling units on each floor 7. Dimensions of existing structures, if any: Front ;!.I/ Height 1<' $' ., Number of Stories Rear O,ucr ;!.'1 .AJ/A- Depth .1ft) / i/fp / 6. Ifbusiness, commercial or mixed occupancy, specify nature and extent of each type of use. Dimensions of same structure with alterations or additions: Front 2!- ..; Depth J...f tJ / ~ & Height / $"" 1? tI Number of Stories , .~ ) 1 Rear Z, cj i!!:'"v~ Depth 8. Dimensions of entire new construction: Front fJ / A Height Number of Stories , 9. Size oflot: Front ? I + A-/U.. eI r- Rear /32... ~ b '0(,.7(, . 10. Date ofPurchase---1tt~ a-- Name of Former Owner Rear Depth 2--1:> / I ~'(::) ,3 c / -r Ii-V L.t::JR- e- s 'nth;;: II. Zone or use district in which premises are situated f! t?'S / b c!;)J'n A--L--- 12. Does proposed construction violate any zoning law, ordinance or regulation? YES_NO V 13. Will lot be re-graded? YES_ NO_Will excess fill be removed from premises? YES_ NO v" 14. Names of Owner of premises J+-t.. WOr...8~ Address ",,1J-'rI"f'1)~ NY. Phone No.(P3{-2-9Jl-~7Ji/v Name of Architect ;:roc F?"~eTTi Address S,,""/7/-0 c..b . Phone No 711 S- - 2,95"-tf- Name of Contractor <r;rLJJ-,: 13a~'; Address -:;OiJ'THt!J~ Phone No. fJo'l- ~ z..o 15 a. Is this property within 100 feet ofa tidal wetland or a freshwater wetland? *YES_NO V- * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE RE-9UIRED. 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_NO V- * IF YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF 5~ -::r-J9/I1 t::7 J, W 6146'~being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)He is the &t:O'u~/<- (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~fore me this ,ift- dayof A,.,6v,sr- 20~ tfJ-'-: 4~ Notary Public NOT.""" PUfEB1lIVC' STEWART "" r . Slate of ork No. 52-46633485 Clu8Nlled In SuIloIIc County CammInIon Expiree Nov. 30, 2QKJ Signature of Applicant ~ jT~;vc: $C'd8 PROFESSIONAL ENGINEER 1725 HOBART ROAD I PO Box 616 SOUTHOLD, NEW YORK 11971 TEL: 631.765.2954 . FAX: 631.614.3516 . e-mail: joseph@fischelli.com Date: Reference: September 6, 2007 20905 RT 48 Southold Building Dept Mike Verity, Building Inspector PO Box 1179 Southold, NY 11971 Dear Mr. Verity, Please find attached 4 copies of the new wall section for the Wolbert foundation repair. If you have any questions regarding this matter, please do not hesitate to call. Ir;::~~,~-,.-c. -"-"----'- . ~, :,~ I' I ~ \lr. R '" ',"1 I ", ' " . ";' I " :, ~. I... i .c:r:-p I 2 ('7 wlIlbtrlwall.tl:ti(RI,OOc BO;\RD CEr;TIFiEL) STPUcrURI\L ENGINEER Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATION, S.C.T.M." THE FOLLOWlHG ACTIONS MAY REQUIRE THE SUBMISSION OF A /1fJ(Jt)1 1li1t. -12L ~I/, I STORM-WATER, GRADING, DRAINAGE AND EROSION CONTROL PLAN DI.trlct S..Uon Block Lot CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. ---------------------------------------------------- Item Number: (NOTE: A Check Mark (~) for each Question is Required for a Complete Application) Yes No 1 ---------------------------------------------------- 2 3 4 5 6 7 8 9 Will this Project Retein All Stonn-Water Run-0ff Generated by a Two (2") Inch Rsinfall on Site? (This Item will include all run-off craated by site clearing and/or construction activities as well as all Site Improvements end the pennenent creation of Impervious surfaces.) Does the Site Plan and/or Survay Show All Proposed Drainage Structures Indicating Size & Location? This Itam shall Include all Proposad Grade Changes and Slopes Controlling Surface WaterFlowl 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? Will this Application Require Land Disturbing Activities Encompassing an Area In Excess of Five Thousand (5,000) Square Feet of Ground Surface? Is there a Natural Water Course Running through the Site? Is this Project within the Trustees jurisdiction or within One Hundred (100') feet of a Wetland or Beach? Will there be Site preparation on Existing Grede Slopes which Exceed Fifteen (15) feet of Veriical Rise to One Hundred (100') of Horizontel Distence? Will Driveways, Parking Areas or other Impervious Surlaces be Sloped to Direct Stonn-Water Run..Qff into and/or in the direction of a Town right-of-way? Will this Project 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 will NOT Include the Installation of Driveway Aprons.) Will this Project Require Site Preparation within the One Hundred (100) Year Floodplain of any Watercourse? v [d ,,/ [d [d V b] V- b] V- b] V' - b] v' b] V b] ~ 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 SubmlUed for Review Prior to Issuance of Any BUilding Permltl 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 Requlredl v' ---------------------------------------------------- STATE OF NEW YORK, COUNTY OF .......f5..\"I.o.LIk....... SS That !, ........d..'f!fl.J.iJ.$....:l:J.......@.t;?.c"I1.~ being duly sworn, de~oses and says that he/she is the applicant for Penni~ (Name of individual signing Doroment) ~ And that he/she is the (Owner, Contractor, Agent, Corporate Officer, etc.) Owner and/or representative of the Owner of 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 bes~MfJ~ and belief; and that the work will be performed in the manner set forth in the application filed herewith. NOTAlYPU8UC.Slllt~NewM Sworn to b~re me this; No, 52..<<.6)345 ........J.?:..:::...................... '" of .....fIr.,.QM,!!i.L............ ,,,0.'1 . ~ ...............~'u~................................. ................................. ................................... (Signature of Applicant) FORM - 06/07