HomeMy WebLinkAbout33094-Z
FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
Date: 02/01/08
NO: Z-32863
THIS CERTIFIES that the building ADDITION & ALTERATION
Location of Property: 3050
(HOUSE NO.)
County Tax Map No. 473889 Section 110
GRATHWOHL RD
(STREET)
Block 8
NEW SUFFOLK
(HAMLET)
Lot 8
Subdivision
Filed Map No.
Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated
MAY 10, 2007 pursuant to which
Building Permit No. 33094-Z
dated
MAY 31, 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 ADDITION & ALTERATION TO AN EXISTING SINGLE FAMILY DWELLING AS
APPLIED FOR.
The certificate is issued to CAROL G. DINDA & JOHN R. EMERY
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
N/A
ELECTRICAL CERTIFICATE NO.
127476
12/11/07
PLUMBERS CERTIFICATION DATED
12/20/07 DENNIS FRANKS
~i~
Rev. 1/81
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'.
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Form No.6
13'1-55'-11
11 FEB
UU:
L.
TOWN OF SOUTHOLD
BY\LDlNG DEPARTMENT
J TOWN HALL
765-1802
L'
.,.....,~ ..
(-"-.-',:'.,"
APPLICATION FOR CERTIFICATE OF OCCUPANCY
.....~L-
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 foml).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Swom statement from plumber certifying that the solder used in system contains less than 2/1 0 of I % lead,
5, Conunercial 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 therelor in writing to the applicant
Old or Pre-existing Building:
iii
Location of Property: _1iJ S (, C1 [+Vn-'l..<-I,\~I I-
House No. Street
Owner or OVv'ners of Propel1y: (' 1\1\'{L.c. i.- (~1' )~ , N'>A ...... Sc l~ to
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 Certilicate of Occupancy - $50,00
5. Temporary Certificate of Occupancy - Residential $15,00, Commercial $15.00
Date. ~J~~'J'.'i-.''-'f 3;.,:)<('<(
( check one)
f.J k.,.; ~.)0 F Fill-K..
Hamlet
./
TeL.
New ConstlUction:
J2.. [:\"C 1'-'1
Suffolk County Tax Map No 1000, Section
Block
Lot
Subdivision
Date of Permitn.\ A 'I .':\ J
Filed Map.
,k,c '7 Applicant:(~ I~ <~
,
Lot:
,
IV} 'j
\,,c\. "N},,\
'~', G i-l ."
Permit No, .:> ') (' l' \ "----
::S;,tlrV k, ><, ,,()Ie '(
Health Dept. Approval:
Underwriters Approval:
Planning Board Approval: .
Request lor:
Temporary Certificate
Final Certiticate:
(check one)
Fee Submitted: $
-, ,
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t.. u- .t{'.~. C~
ApplicaptjSignat e
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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.
33094 Z
Date MAY
31, 2007
permission is hereby granted to:
C DINDA & J EMERY
PO BOX 17
NEW SUFFOLK,NY 11956
for :
ADDITION & ALTERATION TO AN EXISTING SINGLE FAMILY DWELLING
AS APPLIED FOR
at premises located at
3050 GRATHWOHL RD
NEW SUFFOLK
County Tax Map No. 473889 Section 110
Block 0008
Lot No. 008
pursuant to application dated MAY 10, 2007 and approved by the
Building Inspector to expire on NOVEMBER 31, 2008.
Fee $
451. 60
L~, (2L(_.
f Authorized Signature
ORIGINAL
Rev. 5/8/02
LONG ISLAND ELECTRICAL INSPECTION SERVICES, INC.
670 MIDDLE COUNTRY ROAD
ST. JAMES, NEW YORK 11780
(631) 265-3075
Fax (631) 265-6057
Agent:
Address:
Owner: Dinda Emery Residence
Address: 3050 Grathwohl Rd.
Municipality: New Suffolk NY
OwnerPhone
License#:
Agent:
Application No.:
Permit Number:
127476
33094
Lot:
Block:
Section
Triangle Electric
Post Office Box #61
St. James NY
trian
SIZE No. ITEM SIZE
o SubFeeds:
o Timers:
1 Transformers: Bell
2 ACEquipmentCentral: 3D/3D
o ACEqulpmentWlndow
o MotorsbyHP:
o Generators:
40/40 1 WhlrlpoolHotTub: 20 A
1 Microwave:
o WaterHeaterElectric:
5 Smoke Detectors:
o TrackLIghtlngStrlp:
o ElectrlcHeat:
o PumpMotor:
2 Disconnects:
o FutureOutlets:
LOCATION OF WORK : ~ Basemen vl FirstFloor 0 SecondFloo ~ Outside [J Addition
Comments New Residence Final 12/07107
I Additions
No. ITEM
49 Switches:
59 Receptacles:
10 GFCI Devices:
0 Dimmers:
64 MedlumBaseFlxtures;
0 FluroescentFlxtures:
0 HID:
2 RangeOvenCookT op:
1 DryerElectric:
3 ExhaustFans:
4 CeillngFans:
1 OW:
1 Laundry:
3 HeatingEquipMotors:
0 ExltSlgns:
0 EmergencySlgns:
UG ;"': Amp: 200
Phase: 1
Voits: 240 WireType: AL Conductor 4/0
# Meters: 1
Member I.A.E.I.
Certificate Issued on:
Issued to
Electrical Certificate
12/11/2007
Dinda Emery Residence
3050 Grathwohl Rd.
Address:
New Suffolk
NY
Triangle Electric
Post Office Box #61
St. James NY 11780
No. ITEM
0 PoolsAbvBlo:
0 PoolslnGround:
0 Pools Filter:
0 Pools Lights:
1 CO Detectors:
0 Disposal:
0 Metal Halide Lamps:
2 RefrlgUnits:
0 WalkinBox:
0 ExhaustUnlt:
0 SteamShower:
0 BreadWarmers:
0 GarbageOisp:
0 CentralVac:
0 ChandellerLlfts:
0 ElevatorLlfts:
11780
SIZE
CLlI
Survey !\ZJ New Canst.
Certificate No.
127476
LONG ISLAND ELECTRICAL INSPECTION SERVICES, INC.
THIS CERTIFIES THAT OUR LOCAL DISTRICT
INSPECTOR CONDUCTED AN INSPECTION OF THE
VISIBLE PORTION OF T LECT CAL
INSTALLATION DESCRI D ER IN ND IS
COMPLIANT WITH THE UR E NA IONAL
ELECTRICAL C .
IAEI Certified Inspector
Town Hall, 53095 Main Road
P.O.. Box 1179
South old, New York 11971-0959
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
CERTIFICATION
Fax (631) 765-9502
Telephone (631) 765-1802
Date: \7..\ ">-0\.""
Building Pennit No. 53 0'1 tf z:.
Owner~c,- c:: ~i "IDA "" ~ ((_ ~~ ~~cj
(Please print)
Plumber: -j)&-"l-0~ ff/'?-.1//CS
(Please print)
lead.
I certi fy that the solder used in the water supply system contains less than 2/1 0 of 1 %
~~~
Sworn to before me this ~;;)._
day ofD~~=_, 2UI;)_"l_
c--.. " ,,';
~<~--
Notary Pubhe.. '::,~~"---_ County
-~....-
c..._.A~~
~ sJ'9CJ--..-v1P
(Plumbers Signature)
3?d 7f,?::-
;(~
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1 ST
[ ] FOUNDATION 2ND
[ ] FRAMING I STRAPPING
[ ] FIREPLACE & CHIMNEY
[ ] FIRE RESISTANT CONSTRUCTION
[ ] ROUGH PLBG.
[ ] INSULATION
t\[FINAL
[ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT PENETRAnON
REMARKS: -1 ~~
F~ ~~CJK,
~~~,
DATE /;;. - 'J... 7 - 0 1
INSPECTOR
*~
3301fL
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1 ST
[ ] FOUNDATION 2ND
[ ] FRAMING I STRAPPING
[ ] FIREPLACE & CHIMNEY
[ ] FIRE RESISTANT CONSTRUCTION
[ ] ROUGH PLBG.
~ INSULATION
[ ] FINAL
[ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT PENETRATION
REMARKS:
~~e~
~ Oft ~
DATE
cr-n--01
INSPECTOR ~~
3)011(-7-
TOWN OF SOUTHOlD BUilDING DEPT.
765.1802
INSPECTION
] FOUNDATION 1 ST
[ ] FOUNDATION 2ND
[~MI~ STRAPPING
[ ] FIREPLACE & CHIMNEY
[ ] FIRE RESISTANT CONSTRUCTION
y>(ROUGH PLBG.
[ ] INSULATION
[ ] FINAL
[ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT PENETRATION
..
DATE
9--- ~-o 7
INSPECTOR
~~
33D9+-Z
TOWN OF SOUTH OLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1ST [
[ ] FOUNDATION 2ND [
rp4' FRAMING ('SrRAPPIN.Y [
[ ] FIREPLACE & CHIMNEY [
[ ] FIRE RESISTANT CONSTRUCTI~ [
REMARKS: &~---)
] ROUGH PLBG.
] INSULATION
] FINAL
] FIRE SAFETY INSPECTION
] FIRE RESISTANT PENElRATION
DATE
7-7~() 7
INSPECTOR ~~
J309'fz.
Jf~
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1 ST [ ] ROUGH PLBG.
o FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING I STRAPPING [] FINAL
[ ] FIREPLACE & CHIMNEY [] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRucnGN [ ] FIRE RESISTANT PENETRAnON
REMARKS:
DATE
"6-;.0-07
INSPECTOR ~~
330?~
TOWN OF SOUTH OLD BUILDING DEPT.
765.1802
INSPECTION
Ifo-ttJ..![~UNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING I STRAPPING [] FINAL
[ ] FIREPLACE & CHIMNEY [] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION. [ ] FIRE RESISTANT PENETRATION
REMARKS: ~~ cY/c '
i
DATE
INSPECTOR
FIELD INSPECTION REPORT
FOUNDATION (1ST)
FOUNDATION (2ND)
ROUGH FRAMING &
PLUMBING
DATE I
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COMMENTS
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STATE ENERGY CODE
FINAL
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ADDITIONAL COMMENTS
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CUAPANlEE51NDICATf:O HrHE ON SI/A1L PUN
ON/YrQIHEPER5ONFORWliOMfHESIJI!V/."Y
I5PR[PAI?ED, AND ON HIS BUIAtF TO THE
nilE CO.WANt UO"'-RNI'ENTAI AC[NC~
LENDIN(;IN5"rimON,II"U5rWHERfON, AND
WrIi[A$SI(;N[[sorTH[UNDINGINsmUflON
GUARANr"';AFlFNormANSFERABlE TO
AODlnONAIINsnrunrwS0ll5UfJSI-OU,NTO>W[P5
UNA(ir!iORIZEOA,rrRA[J()NOPADOITIONTO rHIS
$IJRV[Y/SA VlOI..ArlONOF SEC7ION 7209 OF
Tilf "EW YORK STATf [OU(;AnQN LAW
COPIE~; (IF rHl,,' SUR",,. MAP NO T BORING
THE LAND SURVlYOR5 fM80S5fO SEAL SHALL
NOT8E CONSlDERW WBE: 4 VAliD TRUE
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(RES"LJEI\'CE)
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C!JR',EY UF
DESCRIBED PROPERTY
SITUATE
NEW SUFFOLK, TOWN OF SOUTH OLD
SUFFOLK COUNTY, N. y,
SURVEYED FOP, JOHN R. EMERY
CAROL G. DJNDA
TM# 1000-110-08--008
GUARANTEED TO
JOHN R EMERY
CAROL G. OJNOA
NOTE ALL CONTOURS SHOWN HEREON ARE IN 1925 NGVa
,"'LOOO lONE DATA SHOWN HEREON IS FROM FIRM
PANE:... SOT OF 1026 MAP NUMBER IS 36103C0501 G
EFFECTIVE DATE IS MAY 4, 1998
SURVEYEO 18 MARCH 200S
SCALE 1 - JO'
AREA 19,781 S.F
OR
0454 ACRES
SURVEYED BY
STANLEY J ISAK~)[N, ,)R.
P.O BOX 294
NEW SU FOLK
631- 7
390
James F. King, President
Jill M. Doherty, Vice-President
Peggy A. Dickerson
Dave Bergen
Bob Ghosio, Jr.
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
May 4, 2007
Mr. John Emery & Ms. Carol Dinda
P.O. Box 17
New Suffolk, NY 11956
RE: 3050 GRATHWOHL ROAD, NEW SUFFOLK
SCTM# 110-08-008
Dear Mr. Emery & Ms. Dinda:
The Southold Town Board of Trustees reviewed the survey prepared by Stanley J.
Isaksen, Jr., last dated March 18,2005 and received on May 2,2007, and determined
the proposed construction of raising the roof lines over the entire house, incorporating
the present garage area into living space, proposed porches, construction of a two-car
garage and modifications to existing driveway to be out of the Wetland jurisdiction under
Chapter 275 of the Town Wetland Code and Chapter 111 of the Town Code.
Therefore, in accordance with the current Wetlands Code (Chapter 275) and the
Coastal Erosion Hazard Area (Chapter 111) no permit is required. Please be advised,
however, that no construction, sedimentation, or disturbance of any kind may take place
seaward of the tidal and/or freshwater wetlands jurisdictional boundary or seaward of
the coastal erosion hazard area as indicated above, or within 100' landward from the
top of the bluff, without further authorization from the Southold Town Board of Trustees
pursuant to Chapter 275 and/or Chapter 111 of the Town Code. It is your responsibility
to ensure that all necessary precautions are taken to prevent any sedimentation or other
alteration or disturbance to the ground surface or vegetation within Tidal Wetlands
jurisdiction and Coastal Erosion Hazard Area, which may result from your project. Such
precautions may include maintaining adequate work area between the tidal wetland
jurisdictional boundary and the coastal erosion hazard area and your project or erecting
a temporary fence, barrier, or hay bale berm.
This determination is not a determination from any other agency.
2
If you have any further questions, please do not hesitate to call.
Sincerely,
J!:; K;:p20,
Board of Trustees
JFK:eac
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, NY 11971
TEL: (631) 765-1802
FAX: (631) 765-9502
www.northfork.net/Southold/
PERMIT NO.
3)0 9'rr r-
BUILDING PERMIT APPLICATION CHECKLIST
Do you have or need the following, before applying?
Board of Health
4 sets of Building Plans ,/-
Planning Bol)l'd approval
Survey ./
Check-:#' 2.~ I (p
Septic Form
N.Y.S.D.E.C. /'
Trustees /
Contact:
Mail to:
Phone: 7 3l(- '55 'f 1
,/ ~/f ~
I Building Inspector
'.Ot[
APPLICATION FOR BUILDING PERMIT
Date )}/ ft,Jz'?1 ,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 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 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
issires 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 premises and in building for necessary inspections.
~<~
0,0 ~ i,.", . v.{
i . . _ J 1 l'--Jc-v_>.-A.) r-,-C:1\- K. k"
(Mailing address of applicant) ',\ 'I S<..
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
OCUlJff2...S
Name of owner of premises Utli1l- Q.1il0!:;f'j < ,L1H..; fJ f;rJ..6Ic'I
(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 of land on which proposed work ~~ll be done:
BoSo (~CATHl..LXt+k iceA!:,
House Number Street
~\LlLj ;5 U (C Po ,-i<-
Hamlet
County Tax Map No. 1000 Section
Subdivision
lie:
Block 0 ~
Filed Map No.
In)! VIlli A/J.!.!"_ ') ....
.....*'~~
-~. :: :,,,
,.uo:'~\ - -. "t: ~", .,,+,,~_ ,,0 .
~ - ;\1'''': - - " - - """.<
(Name)
2. State exist!ng use and occupancy of pr9J1ises and integ4ed use and occupancy of proposed construction:
a. EXlstmg use and occupancy -Vr2...\ V Ale: (C~S I :D ~Nc.. &
b. Intendeduseandoccupancy VR-I VA-r(:; 5Zc:Sfb&Nc..C
3. Nature of work (check which applicable): New Building
Repair Removal Demolition /"
Addition ./
Other Work
Alteration /"
(Description)
4. Estimated Cost
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 1-8' ("
I. "
Height I;J,.L, Number of Stories I
Dimensions of same structure with alterations or additions: Front 1s:. /"
Depth L. 3. ?; Height 16. i L. Number of Stories
Rear
48'3"
Depth
5J'3-
Rear '-If:'
I (}i'
8. Dimensions of entire new construction: Front
Height Number of Stories
Depth
Rear
10. Date of Purchase
i03. 3~
1/c21/03
f '
Dept&)1 f 3 '11- {.i)~lJ 4. S 3
Name of Former Owner C/2ow t;
f(JSI 06tJ-rft L
lo-v.
9. Size of lot: Front
Rear
II. Zone or use district in which premises are situated
~
12. Does proposed construction violate any zoning law, ordinance or regulation? YES_NO L
13. Will lot be re-graded? YES_NO -/ Will excess fill be removed from premises? YES_NO_
14. Names of Owner o1:remisesC.OI/IJl>fT ~ .T.tMEkfAddress.(6. 601,( I 1\ "k:w.:5'f1h~rleINo. /., 3/-13 i-f -55 i-f'i-
Name of ArchItect -rQltKf-.,lUt-.HVA I\J AddressKAToNA f\ I\jY. Phone No q 1'-\ -..., /, t-of?31
Name of Contractor Address ' Phone No.
...
IS 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)
SS:
being duly sworn, deposes and says that (s)he is the applicant
amed,
(S)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
\0 dayof ~"".
,
20~
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Notary Public
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c..niUion . SIpl. .z.-..
04/30/2007 15:10
531-734-7010
CUTCHOGUE LIBRARY
PAGE 02
EXEMPTIONS:
A. Doeg. this projeclmeet the. minimum standards for classification as an Agricultural Project. _
,Hote: If you anlWtted YH, \0 any of tile ebovt. . Storm-wet.r, Grading, O.einage & erollon Control, PIIn II not required,
Erosion. Sedimentation and Storm-water Run-off Control Plan ASSESSMENT FORM
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ACTIONS REQUIRING THE SUBMISSION OF, A STORM-WATER, GRADlN<; D~r::~~E ~ROSION
CONTROL PLAN CERTIFIED BY A DESIGN PROFESSIONAL IN THE STA'I:_ 0_ --YO_
Item Number:, (A Check Mark (J) for each queslton is required for complele application} ~ ~
I. Will this project retain all Stonn-Water Run-off generated on Site'!
(This Will include all nm-llff created by site cleanng andlor canslruCllon activities as well a8 all
Site, Improvements and !he permanent creallon of Impervious surfaces.)
2. Will this, project, require lilY land filling, gradmg or excavation where there, is a change to the
natural existing grade involving more than 200 cubiC ya.rds of matenal within any p"",el7
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3. Will this application require. land disturbing aCllvjt,es encQmpass!!1g an area
of five thousand (5,000) square foet of ground surface or more'!
4. Is there. a Natural Water course ruMing through the SIte or IS IhlS project Within
One hundred (100) feet afwetl.nds or a heach?
5. Will there be sIte preparation on slopes whIch exceed fifteen (15) feet orverlieDI rise. to
One hundred (100) feet of horizontal distance?
6. Will driveways, parking areos or other Impervious surfaces d,.ree! Storm-Water Run-off
into and/or in the direction of a Town Right.or-Way?
7. Will this applicotion require the placement of mat en ai, removal of vegetation andlor the
construction of any item within lhe Town Right-of-Way Or ,oad shoulder area?
(lhl.llem does. n.llnelude theln.lollalion 01 driveway aprons,)
8, Will there be Slle preparation within the one hundred (100) yea, floodplain of lIJIY watercourse?
Note: II. any answer t. qu..t1on. one through e'Vhl II answer.d wilh a ehec~ merk In the 80x, a Ston""..t.r. Gredtnv.
Drainage & Erosion Cont.ol P1en I.. required and musl be eubmllted 'or review prior to.I'.uonee 01 eny butldlng. permit.
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That I. ..
...'.:.p~;!fi.~..{i~'"'- ::ing duly ,worn, deposes and ..ys that belshe is the applicant fa, Pennit,
Documem) -:":'.:,:.":"~
(Owner, CQnlTlIClof. A&enl, CorplJrJ;te Q(fj~ef. t(<;,)
Owner and/or representative of the Ovmer or Owner's, and is duly authorized to perfonn Of have per.f9ntJed the SBld work and 10 make
aod file thi5 applicatjon; that all StatementS contained lD rrns applu;ation are lrue to the best of his knowledge ~nd belier~ and that the
work sill be performed 'I) the lJlillD.er sef forth in the appHcahon filed herewith.
Sworn to before me this:
Notary Public; C>. '
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CalnmiSSiOn Expira Sept 25. <-=. ,~